Saturday, May 1, 2010

ERC: Elective Repeat Cesarean/Early Removal Complications

We wrapped up a great Cesarean Awareness month this April - lots of wonderful birth stories being shared, lots of activism, lots of great media attention to the situation. Just in the past week, I was made aware of an excellent newish blog that you should all run over and check out immediately: Natural Birth for Normal Women. In fact, you could probably skip the rest of this post, as it's primarily dedicated to ganking her content (in the most flattering, props-giving way possible), but if you'd like a Cliffs Notes commentary to some choice selections, read on.

By the way, note her url: I prefer it to the official title, actually.

Anyway, Ms. Use Your Vagina does a fabulous job of summarizing the real story with VBAC risks here. This is the kind of post I wish I had written myself, it's just spot-on, and echoes many of the thoughts that spring up for me when reading arguments that overstate concerns about VBAC while glossing over the risks of ERC, and ignoring the risks that that first cesarean introduces to subsequent pregnancies, period. For example:
What is without question is that any pregnancy following a cesarean delivery carries significantly greater risk than a pregnancy in an unscarred uterus. Among those risks are higher incidence of placenta problems including previa, accreta, and abruption; higher risk of unexplained stillbirth; greater risk of preterm labor; and not least, uterine rupture. While we most often associate uterine rupture with a VBAC trial of labor, the reality is that even prior to labor, a woman with a previous cesearean delivery has a risk of rupture twelve times greater than a woman with an unscarred uterus having a normal vaginal delivery. The risk is still incredibly small- about 0.2% prelabor rupture for women choosing RCS, 0.4% rupture in a spontaneous VBAC, somewhat higher for induced or augmented VBACs- but without that scar, the risk is only 0.013%. Whenever we talk about delivery options for pregnancies after cesarean, I think it is important to recognize that we're not comparing VBAC (or RCS) to an uncomplicated vaginal delivery. We're comparing the available options, which are VBAC and RCS, and neither option is risk-free for moms or for babies.
Picture me jumping up and down, nodding my head and pointing at the computer, shouting, "OMG! That! Exactly THAT!" The bolding and italicizing is the author's; the obnoxious red is mine - forgive me, but these are the points that had me shouting "YES!" the loudest.

In that same post (please read the whole thing - I could sing the praises of each paragraph all day, but at some point it'll just get embarrassing for both of us), she brings up something that segues into an interesting thought for me:
What about outcomes? Recent studies are showing that women who choose VBAC have better outcomes overall than women who choose RCS. That's not comparing successful VBACs to RCSs either, it's comparing intended VBACs, whatever the outcome, with scheduled repeat c-section. Less NICU time, less respiratory morbidity, and less time in the hospital. Three times lower rates of infant death in the first month of life. Lower maternal morbidity and mortality. And that doesn't even begin to consider the impact of this birth on future pregnancies, an area where VBAC has clear advantages. High risk?
This time, the bolding is mine. I recently had a real-life situation with a client that reminds me very much of this, and it got my wheels spinning. Without divulging confidential information, a cesarean that was originally scheduled for one date got delayed by almost two weeks due to the doctor's reevaluating her case and deciding a vaginal delivery was the better option. Plans were changed, labor was prepared for . . . and then the opinion was rescinded (again, I cannot delve into the details on why), and the surgery was rescheduled.

Mother and baby were both fine, happily. I was so proud of her for being so open to trying different things, and for being such a great sport. And her baby was just wonderful. As I pondered just how healthy and hearty he was, a thought occurred to me: I wondered if he would have done nearly as well if he were delivered on mom's original surgery date, or if that might have been a bit too early for him? We know so much about how important the last few weeks of pregnancy are. Considering this piece of information, that the outcomes of intended VBACS are better for babies even when it still ends up in a c-section, I have to wonder if much of that can be attributed to the fact that the babies were allowed to cook as long as they needed to, instead of being evicted early.

In my client's case, perhaps on some spiritual, energetic or metaphysical level (you can take or leave this part, of course, depending on your beliefs), the whole topsy-turvy ride that was so unsettling to mom, going back and forth between cesarean and vaginal plans, was baby's way of buying some more time in the womb, to ensure the safest and healthiest arrival possible.

Too airy-fairy for you? I understand. But a vital point remains. Let's say a cesarean truly is warranted, and we know this in advance. OR, mom is very well-informed, and has made this choice for herself (because I will always support that as the fundamental principle, even if I would have chosen differently). Whatever the case, we know it will be a surgical birth. Why does it always, always have to be scheduled, and further, why always so early? I'm genuinely asking. I realize that the purported intent is to prevent mom from going into labor spontaneously. But EXCEPT for cases where even early labor can be risky (I'm thinking of a complete placenta previa, where hemorrhaging is a real concern, and of fetal positioning like a footling breech where cord prolapse could happen with even a small amount of dilation), or other pregnancy risk factors like preeclampisa . . . why?

Really, why? I'm asking in earnest, so any professionals out there with insights, please weigh in. Put me in my place if I'm being outlandish or naive. But hear me out a bit more first:

We've ruled out the riskier situations, so let's say it's just a standard repeat cesarean with no other risk factors. First of all, we know how long labor can last, period, and we know that unless mom has a history of precipitous deliveries, early/latent labor can go on for a looooooong time. I will go out on a limb here and say that even if a uterus is going to rupture - very much against the odds - I very much doubt that it would do so in the mildest early labor.

Secondly, isn't the ENTIRE REASON many promote hospital birth as being the safest (leaving that argument aside for now) because cesareans are so readily available? This point is frequently brought up during discussion of VBAC, the salient zinger being that if a hospital isn't equipped to support VBAC, how in the world can you argue that it's equipped to support any birth at all, if emergency facilities are the bottom line?

So, understanding that there can indeed be individual circumstances that warrant scheduling, and even early scheduling at times, I do not understand why scheduling is always the standard, unless it is purely for convenience. Unless the patient prefers it (after being thoroughly informed of all the pros and cons, it should go without saying), couldn't babies benefit from being allowed to gestate as long as they need to? Couldn't a mom facing a known surgical delivery simply tune in to her body, looking for the earliest signs of labor, and then simply let her doctor(s) know as early as possible and head into the hospital, going in much, much earlier than any mom (VBAC or not) would ever be advised to go in unless they either want to be sent home or hooked up for a very, very long, interventive ride. I think it's worth consideration.

WOW, that was some digression. I still have two other mentions for Ms. Use Your Vagina - I promise I won't pontificate* on either one the way I did the first.

First, she questions the oft-cited belief that induction at 41 weeks and beyond leads to fewer cesareans than spontaneous labor with expectant management. This has never really sat well with me, and here's a snippet to explain why:
[W]hile the authors do conclude that "elective induction of labor at 41 weeks of gestation and beyond is associated with a decreased risk for cesarean delivery and meconium-stained amniotic fluid" the VERY NEXT SENTENCE says "There are concerns about the translation of these findings into actual practice; thus, future studies should examine elective induction of labor in settings where most obstetric care is provided." Hmmmm... What in the world does that mean?
It's something that deserves much further examination, in both of our opinions, but I'm glad she took it on.

Finally, the same author guest posts on Andrea Owen's Live Your Ideal Life site, doing a bang-up job spelling out the real risks of cesareans, period, in a very accessible yet thorough way. She parses through what's listed on the consent form (you know, the part where they go "Oh, this hardly ever happens, don't worry, this is just a formality,") and explains what each one actually means. Bookmark this one, everyone. It's a total keeper.

Ms. Use Your Vagina, a.k.a. Pam C, very pleased to make your acquaintance. I haven't pored over all your archives yet, but look forward to doing so. (I was going to say I'd think of you the next time I used my vagina, but that's not quite right, and miiiiiight give you the wrong idea.)

*If you thought this was long-winded, wait until I post on a few recent writings about breastfeeding and medical professionals . . . Hoo boy.


  1. Favorite quote " if a hospital isn't equipped to support VBAC, how in the world can you argue that it's equipped to support any birth at all, if emergency facilities are the bottom line?"

    This is SUCH an important point. Great post!

  2. Doing a great job with your blog! By the way, were you also doulala on cafemom? We used to be friends there! Would love to get in touch again!

  3. I just wondered...a friend who had a (fourth) c-section said that while she was getting sectioned, her doctor said, "Good thing you had a never would have made it through labor/birth with this paper-thin uterus!"

    Now, if the vast majority of the stretching is done throughout pregnancy, then if you made it to full term, would labor still be "dangerous" for ripping apart the uterus? And how does a c-section make the uterus "paper thin"? And how does a c-section help a paper thin uterus?

    I would really, really like to know...hmmmm...

  4. hello, hello! Thanks so much for the link :) I happened to stumble on this while googling myself to see what was out there in my name. Did you know there is a French porn actress named Andrea Owen? Me neither. Anyway, thanks again. And Pam ROCKS, doesn't she?

  5. Well, hello, Anne, it is great to make your acquaintance too! I can't tell you how excited and flattered I was to run across your post this morning- special thanks to Andrea Owen for letting me know it was here! My blog is definitely still in fledgling stage and I really appreciate positive feedback!

    When I chose my URL my husband told me I was going to get hits from really POed porn seekers, so I am (seriously) tickled pink at "Ms. Use Your Vagina."

    I think you make a great point about intended VBACs allowing babies to fully develop regardless of the final delivery method. I know my own 3rd baby (born at 41+6 and my smallest by quite a margin) wouldn't have fared so well at 38 weeks, and we probably all know someone who's had a 38/39 week RCS and a baby in NICU with wet lungs. I have *always* wondered why it was viewed as so critically important to have cesareans scheduled instead of waiting for latent labor, and (except in cases like complete previa, which you already discussed) I can't come up with anything except convenience.

    I suppose I shouldn't turn my comment into another blog of my own! Thanks again for such a glowing review. I appreciate it!!

  6. Hello Andrea and Pam! So pleased to make your official acquaintance. And feel free to comment as lengthily as you like!

  7. (Apologies for the delay, I've been out of town & was taking a mini-break!)