I can't work out why the women
died, they shouldn't. I wonder how much Syntocinon or misoprostol was used,
or how many were from 'anaesthetic accidents' . I've just been reading a
big analysis of VBAC
Hi Carol and all,
just been reading Henci' Goer's critique of the JAMA VBAC study...Mmmm very interesting and how we all need to take a closer look at what 'evidence' is put out there!!!
I've pasted some of her comments below....
Happy reading all
Yours in birth,
Tina Pettigrew
Birthworks
Bachelor of Midwifery Student and Independent CBE
Convenor, Aust B. Mid Student Collective.
http://groups.yahoo.com/group/BMidStudentCollective
[EMAIL PROTECTED]
" As we trust the flowers to open to new life
- So we can trust birth"
Harriette Hartigan.
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VBAC safety: A closer look at the 2002 JAMA study
by Henci Goer
Once again, newspaper articles claim that a study has shown that elective repeat cesarean is safer for babies than vaginal birth after cesarean (VBAC) (14). As with the July 2001 study, using Washington State data, closer analysis reveals no such thing (6). What the new study really shows are the dangers of the first cesarean.
Here's the gist of the study: Scottish researchers collected data on over 313,000 births, excluding pre-term births, breech babies and babies with malformations. They compared infant death rates during labor and up to a week after birth among women having
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trial of labor, planned repeat cesarean, first-time mothers and women with only vaginal births. They got the following results:
13 babies per 10,000 (20 out of 15,500) died in the trial-of-labor group
1 baby per 10,000 (1 out of 9000) died in the planned repeat cesarean group
10 babies per 10,000 (135 out of 137,000) died in the first-time mothers group
6 babies per 10,000 (90 out of 151,500) died in the only vaginal births group
3/4 of the trial-of-labor group birthed vaginally
The study recommended that all women with prior cesareans have a scheduled cesarean at 39 weeks of pregnancy.
VBAC safety: A closer look at the 2002 JAMA study
continued from page 1
What's Wrong with This Picture?The study authors defined "trial of labor" as any vaginal birth or emergency cesarean after 37 weeks of pregnancy. This means that any woman who had a uterine rupture (scar gives way) or placental abruption (placenta separates prematurely from the uterus) during pregnancy and presented at the hospital requiring emergency cesarean would be classified as a "trial of labor." The mortality in such cases would be high because these life-threatening events would occur outside of the hospital. The odds of uterine rupture in pregnancy in a woman with a uterine scar are 2 per 1,000, and the odds of placental abruption are 3 per 1,000 (11). Of course, not every baby would die, and many cases would occur earlier than 37 weeks. Still, do the math on the 15,500 so-called trials of labor, and you will see that several, if not many, of the 20 infant deaths in the "trial of labor" group weren't really trials of labor.
With one exception, the study didn't evaluate the effects of obstetric management. The researchers looked at the effect of inducing labor with prostaglandin E2 (Cervidil, Prepidil) and found no association; however, two other studies have reported strong associations (8,12). Several studies suggest that oxytocin (Pitocin) used to induce labor or possibly even to stimulate stronger contractions poses some increased risk and should be used sparingly in VBAC labors (2,3,13). The study reports that 15 percent of the trial-of-labor group was induced with prostaglandin E2 but does not say what percentage had oxytocin inductions or augmentations. Note: Misoprostol (Cytotec) induction, a potent cause of uterine rupture, doesn't appear to be an issue here (5).
The absolute difference in mortality is small. Even if it is real, which seems doubtful, it amounts to one baby in a thousand. Moreover, the mortality rate differs from the rate in mothers with only vaginal births by less than that and is similar to the rate in first-time mothers. Even one avoidable loss in a thousand matters, but to put this number in perspective, the chance of losing a baby as a result of amniocentesis may be as high as 1 in 200 (9). No one is recommending banning amniocentesis for this reason. A one-in-a-thousand difference isn't enough to justify a policy recommendation, let alone scary articles about the dangers of VBAC. What's more, it's misleading.
Looking at death rates after 37 weeks doesn't tell the whole story. The Scottish study only looked at the tip of the cesarean iceberg. As the number of cesareans increases, so do the odds of infertility, miscarriage, ectopic pregnancy (embryo implants outside of the womb), placenta previa (placenta overlays the cervix), placental abruption, and placenta accreta (placenta grows into and sometimes through the uterine muscular wall) (7). Babies born by cesarean are also more likely to have respiratory problems, including persistent pulmonary hypertension, which can kill (7). A Swiss study of 29,000 women with prior cesareans reported deaths after 28 weeks of pregnancy in normally formed infants. Nine were due to placental abruption, one to placenta previa, and six to uterine rupture, of which one was in the planned cesarean group (11). That same study found that the chance of uterine rupture during pregnancy with a scarred uterus was 2 per 1,000, but it was one per 10,000 ! ! in 226,000 women with no uterine scar (11). That's 20 times more. To repeatedly subject women to the gantlet of C-section risks when 75 percent of them will birth vaginally if given the chance makes no sense. The real take-home message of this study is: "To improve infant outcomes, don't do more repeat cesareans; do fewer first ones."
Page Three: Find out why there seems to be a campaign against VBAC
Page Four: Four things you need to know when making your decision
Page Five: References
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