Study Finds Birth Risk After Delivery by Caesarean
By REUTERS
CHICAGO, May 21 � Giving birth naturally after delivering a previous child by Caesarean carries a higher, albeit small, risk to the newborn, British researchers said today.
A study of five years of Scottish birth records found 20 newborn deaths among 15,000 births to women who had previously had a Caesarean but carried their subsequent pregnancy to term for either a vaginal delivery or an unplanned Caesarean.
The mortality rate for these infants was 11 times higher than that faced by newborns of women who underwent a planned repeat Caesarean, and more than double the rate of babies born to women giving birth naturally for at least the second time. The risk was about the same as that faced by women giving birth naturally for the first time.
Rupture of the uterus was another risk factor faced by women who had a previous Caesarean who have a "trial of labor," or attempt at a vaginal delivery, the study's author, Dr. Gordon Smith of Cambridge University, wrote in The Journal of the American Medical Association.
The report, which was drawn from an examination of 313,000 births recorded in Scotland from 1992 to 1997, noted that most delivery-related deaths among the women with a previous Caesarean occurred at or after the 39th week of gestation.
"Therefore, it seems likely that most deaths could have been avoided by planned Caesarean delivery at the start of the 39th week of gestation," Dr. Smith wrote. "Moreover, planned Caesarean delivery at this time would also avoid exposure to the risk of antepartum stillbirth (occurring before labor) while awaiting the onset of labor."
Many doctors have sought to reverse the trend toward Caesarean deliveries, which have climbed to 23 percent of births in the United States.
"Obstetricians have faced pressure from government and health-care insurers to advocate vaginal birth after Caesarean delivery as one strategy to reduce the overall rate of Caesarean delivery," Dr. Smith wrote.
"The absolute risk of perinatal death associated with trial of labor following previous Caesarean delivery is low," he wrote. "However, in our study, the risk was significantly higher than that associated with planned repeat Caesarean delivery, and there was a marked excess of deaths due to uterine rupture compared with other women in labor."
At 01:41 PM 29/05/02 +1000, [EMAIL PROTECTED] wrote:
Oh no is this going to do for VBACS WHAT THE BL---- BREECH TRIAL DID FOR
BREECH BIRTHS.
I have just supported 2 women at homebirths both were Vbacs and both had
according to obstetricans CPD [based on last birth and post partum
pelvimetry]BOTH DELIVERED WELL Both their babies were bigger than previous
ie 3100-4100 at 42 weeks and 5321 compared to 4800 at 39+5 Both women were
induced with 1st labours at 40+12 and both got to fully dilated but WERE TO
SMALL.
I am glad Ididn't read this article
Here's hoping that the incidence of c/s decreases rapidily. jan
----- Original Message -----
From: Jackie Mawson <[EMAIL PROTECTED]>
To: Birthrites People. <[EMAIL PROTECTED]>
Sent: Wednesday, May 29, 2002 10:28 AM
Subject: FW: VBAC Article
> Thankyou for sending me this, Camille. To share... in frustration
> Birthing Beautifully,
> Jackie Mawson.
>
> ------ Forwarded Message
> From: "Troy and Camille" <[EMAIL PROTECTED]>
> Date: Tue, 28 May 2002 17:22:29 -0800
> To: "Jackie Mawson" <[EMAIL PROTECTED]>
> Subject: VBAC Article
>
> Hey Jackie...Here is the article from the paper. I just can't
> believe it! Our last baby was born in 2000. He was actually delivered by
> his dad on the side of the road. What an awesome birth! Now, I don't
know
> what I'll do! Hope you 'enjoy' the article! Take care! All my
blessings,
> Camille
>
>
>
>
> Spokesman Review, March 19, 2002
>
>
> Hospital forced to limit birth options
>
> Section: MAIN NEWS
> Page: A1
> Author: Susan Drumheller Staff writer
> Illustration: Color Photo
> Caption: Some surprising news. Christi Kuchenski will have her
eighth
> child in November, but it won't be delivered naturally if she has the baby
> at Kootenai Medical Center. Photo by Kathy Plonka/The Spokesman-Review
>
>
> Christi Kuchenski is expecting.
>
>
> ``This is a surprise - it wasn't something we planned,'' said
> Kuchenski, 41, who has donned her maternity clothes for her eighth child.
> Kuchenski had another surprise recently. More of a shock really.
>
> After her initial appointment at a women's health clinic in Coeur
> d'Alene, she learned she automatically would be scheduled for a
> Caesarean-section delivery.
>
> ``My mouth dropped,'' Kuchenski said.
>
> Women's birth choices became more limited in North Idaho in December
> when Kootenai Medical Center adopted a policy to no longer perform vaginal
> births after C-sections, known as VBACs.
>
> The policy was driven by guidelines from the American College of
> Obstetrics and Gynecology, hospital accreditation organizations and a
recent
> study of VBACs in Washington state.
>
> Malpractice insurance rates are among the highest in the field of
> delivering babies, giving obstetricians a big incentive to lower the
risks.
>
> National guidelines suggest that VBACS should not be performed
unless
> an obstetrician, anesthesiologist and operating room staff are immediately
> available.
>
> It's part of a nationwide backlash against VBACs, which had become
> more common in the last two decades.
>
> But with the increase in VBACs came a corresponding increase in the
> number of uterine ruptures, caused by the pressure of labor against the
> incision from the previous C-section.
>
> The recent study of VBACs in Washington found that the risk of
uterine
> rupture was highest in women whose labor is induced.
>
> If uterine rupture occurs, the baby must be delivered by emergency
> C-section within 18 minutes or risk serious brain damage or death.
>
> In women with low risk factors, such as Kuchenski, the chances of
> having a uterine rupture are about 1 in 100, or less.
>
> That's a chance Kuchenski is willing to take, but KMC's doctors
> aren't.
>
> ``We can't cut corners,'' said Dr. Frederick Ambrose, a Coeur
d'Alene
> obstetrician. ``Continuing to do VBACs put us in an untenable situation
from
> a risk standpoint. We felt we were putting babies' lives at risk.''
>
> The Midwives Alliance of North America has voiced concern that the
> recent study, published in the New England Journal of Medicine in July
2001,
> will undo decades of reform efforts to debunk the old medical adage that
> ``once a Caesarean, always a Caesarean.''
>
> ``This is not a simple issue,'' warns Joe Bujak, vice president of
> medical affairs at KMC. ``The community is as much a part of this dynamic
as
> much as anything being unilaterally done from inside the medical
> community.''
>
> For instance, medical malpractice insurance has skyrocketed for
> obstetricians, he said; ``Perfection is an absolute standard. You can't
have
> a bad outcome.''
>
> Last year, a Spokane jury ordered Deaconess Medical Center to pay a
> woman $850,000 after her baby died from a uterine rupture during a VBAC.
>
> Deaconess still allows VBACs, but only if the obstetrician is
willing
> to be on the hospital campus during the duration of the delivery. Sacred
> Heart Medical Center has a similar policy.
>
> Both hospitals are large enough to have an anesthesiologist and
> operating room staff on hand around the clock.
>
> But KMC is smaller, and Kootenai County only has seven
obstetricians.
>
> ``To put an operating room crew on call, an obstetrician on call in
> the house, all the time, and an anesthesiologist in the hospital all the
> time, that's a huge expense for something that might happen two times a
> year,'' Bujak said.
>
> KMC has not yet had a bad outcome with a VBAC, according to the
> hospital's risk manager. But once the American College of Obstetrics and
> Gynecology released its latest position paper on the subject, that made
the
> procedure riskier, from a liability standpoint.
>
> ``If you choose to do them, you're climbing out on a limb,'' Bujak
> said. ``No one wants to climb out on that limb, because it gets skinnier
> every year.''
>
> Kuchenski and her husband, Bob, live in a spacious, spotless home in
> rural Kootenai County, about a halfhour north of Coeur d'Alene.
>
> Two of her children have been delivered by midwife. Her best
> experience was when Aaron, 7, was born underwater in a Northern California
> birthing center.
>
> ``It was really good,'' she said, as she balanced 11-month-old
Robbie
> on her hip and pulled spaghetti out of the refrigerator to feed her
> homeschooled children lunch Monday.
>
> ``It's kind of ridiculous,'' she said. ``You want to make a wise
> decision. I don't want to give birth at home. I'm too far away from a
> hospital.
>
> ``But for me, a Caesarean is not a wise decision, because the risks
> are too high.''
>
> The risks from C-sections include infections and complications from
> anesthesia that can harm baby and mother.
>
> Kuchenski's last child was delivered by C-section because her water
> broke early but labor did not follow, even with labor-inducing drugs.
>
> ``I felt I lost two months of my life because I couldn't do
> anything,'' Kuchenski recalled. ``With natural birth I'm up walking out
the
> door after six hours. It's really hard to take care of a baby when you're
> trying to recover from surgery. I got out of the hospital and I just cried
> and cried.''
>
> Some doctors worry that the new policy may prompt determined mothers
> to deliver by lay midwife at home, when they should be in a hospital.
>
> ``Home-birth midwives, if they're smart, will only take low-risk
> clients,'' said Cathy Weston, a Coeur d'Alene midwife.
>
> Weston said that the highest risk of uterine rupture are in cases
> where labor-inducing drugs are used - an opinion that's backed up by the
> study of Washington state mothers.
>
> Weston said she has about one VBAC delivery a year.
>
> ``You have that `what-if' factor, but you have that any time when
> you're driving down the road,'' she said. ``People should have the option.
I
> think it's terrible that it's fallen on such awful ground.''
>
> A partial solution may be to perform fewer C-sections in the first
> place. Now, about 20 percent of babies delivered at KMC are delivered by
> C-section, which is slightly lower than the national average.
>
> Some C-sections are prompted by indications of fetal distress, which
> may or may not necessarily be accurate. Doctors often play it safe and
> perform a C-section.
>
> Other C-sections are the result of healthy babies growing too large
to
> be delivered naturally. Still other mothers will choose to have a
C-section,
> because they don't want to undergo the pain and difficulties of labor.
>
> ``The issue is as much a social issue as a medical issue,'' Bujak
> said. ``Sometimes medical science ends up trying to sell all the things we
> can do. You generate expectations and expectations run away, and before
you
> know it, you never can get the genie back in the bottle.''
>
> Kuchenski is undecided about what she'll do. She plans to meet with
a
> doctor in Spokane and may deliver there.
>
> ``My biggest concern is that women need to be well-informed about
the
> risks of each,'' she said. ``They need to be given a choice. They weren't
> going to give me a choice, and that's not right.''
> ${Note: }
>
>
>
> ------ End of Forwarded Message
>
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