Exploration of Specific Identified Risk Factors in Healthy Women

Exploration of Specific Identified Risk Factors
in Healthy Women – Breech, VBAC

Ob.Gyn.News Dec 15 2002 * Volume 37 * Number 24

Last 50 Years Show 10-Fold Rise in Placenta Accreta
~ Behind 50% of emergency hysterectomies

“Placenta accreta is a growing cause of postpartum hemorrhage and an increasing cause of emergency hysterectomy, according to Dr. Gary Dildy III. "The incidence of placenta accreta is increasing, and it's thought this may have to do with the increasing rate of cesarean sections since the 1960s," he said at the annual meeting of District V of the American College of Obstetricians and Gynecologists.” (Emphasis added)

Ob.Gyn.News March 1, 2001 Vol 36, No 5

“The rise in cesarean rate over the last several years may portend an increase in the incidence of placenta accreta”, Dr Richard Porreco warned, “I think that with the cesarean rate what it is we are creating a potentially very great problem down stream”.   “The maternal mortality rate with placenta accreta is 7%. Even when physician are prepared and well equipped the condition can be extremely dangerous”, Dr Porreco said. …at his institution a woman who had undergone three previous cesareans was diagnosed with a percreta ….(she) underwent an abdominal hysterectomy and bladder resection. --- the patient ended up going into cardiac arrest during the procedure and had post operative complications that kept her in the hospital for 20 days. (Emphasis added)

Ob.Gyn.News Sept 15, 2001 Vol 36, No 18

“In one study, the rate of placenta accreta in patients with no prior C-section was 5%, 25% with one prior CS, and 50% with two or more prior Cesareans.    Furthermore, … the patient has an 80% likelihood of hysterectomy following delivery. Prepare for a 4-hour surgery with an average 4 liter blood loss, You may need to use up to 20 units of packed red cells and be prepared for ureteral injuries which occur in 2%-3% of patients.” (emphasis added)

Why Cesareans are “in” and normal birth after a prior Cesarean is “out”

In word or two, the answer to the above query is “tort law”. Tort law defines the functional “standard” for any discipline or industry as that which is regularly applied by its members. Only if one violates this industry-identified standard can economic or punitive damages be award by the courts to the plaintive or “victim” in a civil litigation.

The courts look to the obstetrical profession to define the professional standard for obstetrical care. Under the current conventions of tort law, the practice of obstetrical medicine requires that obstetricians (and all hospital-based nurse-midwives) conform their practice to this common-law definition of a ‘community standard,’ – that which is commonly done by other practitioners of the same status under the same or similar circumstances. This is not an evidenced-based concept but rather one of statistical majority and convention -- what is regularly done. In hospitals, the industry-wide standard is to define normal birth as a medical procedure. True to the rules of tort law, the hospitalized childbearing woman has no control over how any “medical/surgical procedure” is accomplished by the doctor once she has consented to the “procedure”, as tort law identifies the physician’s professional judgment as determining what is done, when and how it is accomplished.

Once an industry standard is established, individual professionals cannot be forced to offer forms of care that are, in the professional opinion of the practitioner, “substandard”, as doing so would expose him or her to a judgment of negligent or incompetence in a malpractice suit. This “industry standard” is not required to be cost effective or otherwise to the advantage of the public. In general, tort law cannot compel individuals to bear specific professional risks or provide services for which they may not be economically compensated or that may somehow disadvantage them or their industry.

Obstetricians are quite open about their motives in refusing to provide anything other than cesarean surgery as the management for women with a breech baby, twins or a previous cesarean. They cite avoidance of malpractice litigation and unwillingness to “labor sit” (see LA Times article on VBAC). Once a “surgical procedure” such as vaginal delivery or operative delivery (forceps, vacuum extraction or Cesarean surgery) is successfully completed by the physician, the doctor’s culpability under tort law is concluded and he or she is not liable for complications that may arise at a later date (unless a sponge or surgical instrument was left behind!). For example, long-term complications of forceps such as incontinence or pelvic organ prolapse (see Long Term Pain, Risk of Bad Perineal Tear Higher with Midline Episiotomy, Forceps and Oxytocin use, Ob.Gyn.News Nov 15, 2001; Forceps Double Risk of Incontinence; Ob.Gyn.News Sept 15, 2001, Vol 36, No 18) or post-cesarean complications (infertility, abnormal placentation such as a previa or percreta in a subsequent pregnancy or a uterine rupture and neonatal death or permanent neurological damage) are not deemed to be the “fault” of the physician performing the original medical or surgical procedure. (see Elective Cesarean: An Acceptable Alternative to Vaginal Delivery? Peter Berstein, MD, MPH)

This explains why the standard “consent” for these hospital procedures does not routinely reveal the association between these surgical procedures and the well-known pathological sequelae listed above. For example the previous quote from ObGynNews identifies an overall rate of one percreta/ emergency hysterectomy per 2500 pregnancies (1600 annually). However, this complication is 80% specific to post-cesarean pregnancies, giving the post-cesarean patient a 1 out of 40 chance of a previa and one out of 250 chance of a percreta. Under tort law, the doctor is free from future liability when he puts in the last stitch and writes standard orders for post-delivery/operative care. This principle is similar to the limitations on liability common in product liability law.

While we usually do not think of the late 1800s historical debate about allopathic medicine, the issue of routinely medicalized, mechanized childbirth brings us back to the same issues argued about by our great grandparents. The classical objection to allopathic medicine has always been its use of “heroic” methods, which themselves introduced pain and further complications. This well-known characteristic gave rise to the familiar expression “the cure is worse (or at least as bad) as the disease”. In more modern terms this might be expressed as the medical profession’s preference for surgical interventions in childbirth and the irrational idea that somehow it was more noble to suffer or die from the aggressive over-treatment of obstetrical interventions than the “under-treatment” of physiological management (also known as the midwifery model of care).

Current Philosophy of ACOG Toward Cesarean Surgery

In June of 2001 ACOG president Dr Ben Harer was interview by Diane Sawyer on Good Morning America. Dr Harer was actively promoting the “maternal choice” cesarean, with the less than forthright explanation that there was “really no difference” in the relative safety between vaginal birth and Cesarean surgery. In the last 3 years ACOG has implemented policies that virtually guarantee to replace post-cesarean labors with not-so-‘elective’ repeat Cesareans. This was done under the banner of “freedom of choice” on the part of the childbearing women. ACOG’s story was that HMOs were forcing doctors to provide a trial of labor to all post-cesarean mothers, which they characterized as a violation of the mother’s “right to choose” a repeat Cesarean. (see Rebirth of a Controversy ~ Cesarean section rate rises again as doctors debate the safety of VBAC, July 01, 2002, Los Angles Newspaper Group Website) ACOG used ‘category three’ evidence -- consensus and expert opinion -- to construct such a tight protocol for post cesarean labors that it became more expensive for HMOs to pay for management of a spontaneous labor than a scheduled repeat surgery. This represents an on-going fight for supremacy between HMOs and organized medicine in which ACOG has currently trumpeted the HMO bean counters.

A more recent version of this rationale that favors replacing physiological birth with surgical delivery was aired by National Public Radio on 12/18/02. According to the radio story, the CDC reported the highest Cesarean rate in US history, with the greatest jump in any one year --a 7% increase -- in the year 2001. (see Press Release for CDC - Births: Preliminary Data for 2001; NVSR Vol. 50, No. 10) Physicians interviewed on the radio freely admitted that they are offered reduced malpractice premiums from their insurance carriers for performing “prophylactic” cesareans instead of permitting spontaneous VBAC labors.

Another physician described how doctors had been “forced against their better judgment” to permit VBAC labors and were “burned” by having unexpected bad outcomes for which they got sued. A return to “once a Cesarean, always Cesarean” was identified as the solution to the malpractice problems of the doctor. Sadly, this historical phrase of Dr Craign’s has been taken out of context and is dangerously misunderstood. As used by Dr. Craign in the early 1900 the purpose of this phrase was to caution physicians against the casual use of Cesarean delivery because the initial or primary Cesarean made childbearing women into potential reproductive cripples, and thus cesarean surgery should be avoided in all but life and limb-threatening situations.

A vitally important factor that did not make these newspaper and radio stories is the routine use by obstetricians of aggressive medical techniques that increase the rate of uterine rupture. One of these was the unwise abandonment of double layer closure of Cesarean incisions. In the last decade this time-tested method was replaced by “single layer” closure. It was adopted without any preliminary trials because it reduced the physician’s exposure to HIV infected blood and incidentally, reduced operative time by 6 minutes and saved $12 on suture materials (an important factor in third world countries). What hasn’t been acknowledged is that single layer closure increases the uterine rupture rate 5-plus times. One study reports that out of 1,251 post-cesarean vaginal births women only 0.6% developed symptomatic a uterine rupture rate after a double layer closure. Of the398 women with single layer closure, there were 12 uterine ruptures or a rate of 3%. (see ObGynNews Vol 37, Mar 15, 2002)

Despite the increased vulnerability of inadequately sutured uteri, the standard “management” style over the last decade for VBAC labors included the same casual use of labor acceleration as applied to an intact uterus. Routine administration of Cytotec, prostaglandins and Pitocin, in conjunction with confinement of the mother to her bed, almost inevitably required epidural anesthesia. This further retards the progress of labor. However, the use of prostaglandins and Pitocin in post-Cesarean pregnancies increases the uterine rupture rate by 15 times. Needless to say, these unwise strategies “burned” a lot of people in addition to doctors.

As is true for many conventions of obstetrical medicine, these policies of single layer closure and use of hormones to accelerate labor were not based on scientific evidence. Appropriate studies were never done in many instances or they did not contain the type of data that would permit solidly founded conclusions. One example is that most obstetrical studies do not discriminate between a ‘spontaneous’ and an ‘augmented’ labor when generating statistics on the issue of uterine rupture rates. The category of induction is only applied if the mother has not yet had any uterine contractions. If she is in latent, prodromal or even false labor, then it is considered an augmentation and does not show up in the statistics for Pitocin use. At present, a post-cesarean labor is classified as “spontaneous” even though Pitocin was used in large quantities over a long time. [It should be noted that midwives use NO artificial hormones or other pharmaceutical inducements of labor at all. Spontaneous labor is the safest method to conduct post-cesarean labors (in women with low transfer incision) is statistically better than outcomes for medical management.

A study published in the New England Journal Of Medicine on VBAC labors in July of 2001was given a great deal of publicity in the lay press and media. The public was advises by Dr Michael Green of Massachusetts General Hospital that a repeat Cesarean was “safest for the baby” and that “once a Cesarean always a Cesarean” should become the mantra for the 21st century. The NEJM study on post-cesarean delivery had many serious flaws -- for instance, all data was predicated on ICM codes and those codes did not distinguish between benign dehiscence and catastrophic rupture. Not one of the 91 charts coded for uterine rupture was pulled to check for accuracy, predisposing factors and extenuating circumstances. The study did not contain any new information except for revealing a vastly increased rate of uterine rupture when prostaglandin and Pitocin were used to induce labor in post-cesarean pregnancies (21 times greater than a spontaneous labor with an intact uterus, 18 greater than natural VBAC labor).

The study identified the increased dangers of induction in post-cesarean pregnancies. The dangers of induction, especially with prostaglandins, should have been the study’s big news. Instead of the media promoted the notion that natural labors were extraordinarily dangerous and should be replaced by elective Cesareans. This was predicated on a curious manipulation of the statistics for perinatal mortality in the post cesarean cohort as a direct result of uterine rupture. (see NEJM July 2001 “Risk of Uterine Rupture during Labor among Woman with a Prior Cesarean Delivery” – examination and rebuttal of study at <www.collegeofmidwives.org/news01/nejm01a_vbac_study_npr.htm>)

The non-uterine rupture group included 20,004 women with 100 cases of perinatal mortality or a rate of 0.5 percent. Among the 13,115 women attempting VBAC were 91 uterine ruptures with only 5 perinatal deaths, resulting in a mortality percentage of 0.038. Obviously the one of the most important questions is the relative likelihood that natural labor after cesarean will result in the death of the baby. The answer is that the risk of a baby dying in association with post-cesarean labor was 12 times less than the risk of a baby dying from other cause having nothing to do with their VBAC status.

When the rate of uterine rupture in intact uteri and dehiscence of a benign nature in post-cesarean labors are both subtracted from the generally quoted 1 %, the actual danger of VBAC labor is 0.25% -- that is to say that 99.75% of natural labors will have no problems associated with the mother’s VBAC status. When post-cesarean women learn this, they are frequently unwilling to take on all the associated risks of an extremely medicalized post-cesarean labor in a hospital, which brings with it a Cesarean rate of 25% to 40%. Worse yet, many women find themselves being forced into a repeat Cesarean against their wishes, When the actual likelihood of a normal outcome with a spontaneous labor is 99.75%, women are instead being swept into non-consensual repeat Cesareans, which carries with it a tripled maternal mortality post-operatively and all the long-term complications in a subsequent pregnancy, such as placenta previa, percreta and emergency hysterectomy or uterine rupture.   (Robert Silver, ‘VBAC’ in Ob Gyn Secrets, Helen L Fredrickson and Louise Wilkins-Haug, Ed, 2nd edition)

In one of the most recent and largest studies (Scotland) the neonatal mortality rate subsequent to both induced and spontaneous multip VBAC women is 1 per 1000 -- exactly the same as for primigravida mothers. (see Perinatal Death Risk Term VBAC 1:1,000, Ob.Gyn.News May 1, 2002)

Elective Cesarean increases a woman’s risk of hysterectomy in both the current and future pregnancies (53, 54) and more than doubles the risk of death compared to vaginal birth (55). The placenta previa rate has increased by 10 times and the placenta accreta / percreta rate has doubled since 1950 – a circumstances ascribed to the increase in the use of Cesarean surgery in the intervening years.

The most frequent immediate post-op complication of Cesarean is infection. Other complications include 7.3% incidence of massive hemorrhage (42), blood transfusions in 6.4% (43), ureter and bowel injury in about 0.5% (44, 45) and incisional endometriosis in 0.1 to 1% of cesareans (46, 47). Compared to women who have a vaginal birth, those undergoing Cesareans have twice the rate of rehospitalization for reasons such as uterine infection (2.0 Relative Risk), urinary tract infections (1.5 RR), surgical wound complications (30.0 RR), cardiopulmonary conditions (2.4 RR), thromboembolic conditions (2.5 RR). Several studies were unanimous in finding that women who delivered by Cesarean were less satisfied with their experience than women who had normal spontaneous vaginal births. (49-52)

Severe and potentially fatal placental complications are greatly increased by a history of previous cesarean. Abnormal placentation such as placenta previa is otherwise quite rare -- only a 1/4 of one percent in an intact uterus. It rises to 1.87% after one previous cesarean. (56) This risk rises exponentially so that it is 7.4 xs after two CS, and 6.5x after three CS and an astonishing 45 times greater after 4 previous cesareans. (57) A low-lying placenta is also more likely to lead to the most severe placental complication -- an accreta or percreta. Placental percreta is associated with a maternal mortality rate of 10% and virtually a 100% hysterectomy rate. This catastrophic complication is greatly increased in post-cesarean pregnancies and is cumulative, going up from 5% (for an intact uterus), to 25% for one, 50% for two and up to 70% with four previous cesarean. (60). Placental abruption is also significantly increased with post-cesarean pregnancies with a rate of 0.17 to 0.49 with perinatal mortality of about 10%.

Increased rates of secondary infertility have been reported after prior cesarean and also higher rates of miscarriage and ectopic pregnancy. Babies born by cesarean have triple the rate of developing asthma in childhood and as adults. (see Cesarean Birth Associated with Adult Asthma; Ob.Gyn.News Jun 15, 2001, Vol 36)

Conclusion

Under such politically-dominated circumstances such as currently dominate obstetrical services to women with an identified risk factor such as breech baby, twins or a post-cesarean pregnancy, it is reasonable and rational to provide the childbearing family with all the pertinent facts and then permit the mother to make an informed choice, including the choice to decline prophylactic medicalization.

=================== Documentation ====================

Supportive documentation in a three-ring notebook accompanies this essay on Cesarean and post-cesarean pregnancies. A master copy was provided for the MBC consultant Dr. Pat Chase (Sacramento office).