Canada's Rising Caesarean Section Rate

 A brilliant article that comes clean about Canada's rising Caesarean Section rates.  It doesn't white wash the statistics, it doesn't hide the TRUTH:  Caesarean sections cause more Caesarean sections!!!  And every medical intervention in labour and delivery causes an increased risk of "having to have" a C/Section. 

While the Society of Obstetricians and Gynecologists of Canadais finally realizing that the soaring rates of medical interventions- such as inductions, epidurals, and C/Sections- are having a detrimental effect of the health of our women and children, they have yet to address the worst problem:

The Doctors and the Hospitals themselves.

 The Society of Obstetricians and Gynecologists of Canada has made comments that the C/Section rate is too high, that inductions shouldn't be done so often, that Vaginal  breech births are healthier than C/section deliveries, and that VBAC births should be encouraged.... but that's all just whistling in the wind if the doctors and hospitals are adamantly turning their backs with their fingers in their ears singing "Lalalalalalala..."

It's all very wonderful that they are making these recommendations and statements, but that's not helping the mothers who are out there searching for a birthing attendant who will allow them to have a VBAC or to deliver their breech baby naturally/vaginally. 

And don't just blame the doctors- finding a supportive midwife can be equally difficult.  When I was pregnant with my second child back in 2002, I had three different Toronto midwifery groups turn me down point blank because I had had a previous Caesarean section.  The fact that it happened 10 years previously didn't matter even slightly.  When I was pregnant with my 4th child- having had 2 C/S's and one natural  HBAC (homebirth after C/S)- I had to search for MONTHS and had to beg and cajole to find a midwife to support my wishes to have another HBAC birth.  ...and my 5th child? after THREE Caesarean sections?!?  I was SHOCKED to hell and back when one lone midwifery group in a 100 km radius actually accepted me as a client.  But even then, while they took me on, they did so with a lot of trepidation and scepticism.

If I hadn't been so damn stubborn, (and knowledgable), I probably would of given up on trying to have a vaginal birth years ago and would now be sporting 5 uterine scars.

NOT a Healthy situation.

So yet again, as with just about everything worth having in life, we need to fight to achieve and support our Rights.  If women do not demand that hospitals/doctors/midwives accept their wishes to have a VBAC birth, then change will not happen, no matter how many "recommendations" the Society of Obstetricians and Gynecologists of Canada wants to make.

Worries surround Canada's rising C-section rate

 

 

By Sharon Kirkey, Canwest News Service

 

Dr. Jan Christilaw was in the operating room the day a routine incision was made into a young mother's abdomen to deliver her baby.
What happened next, Christilaw says, "is something we never want to see."
Normally, the placenta separates from the wall of the uterus after birth. It's lacy almost, and not like solid tissue. "You can take your hands and sort of scoop it up, it's like breaking cobwebs as you go," says Christilaw, an obstetrician and president of B.C. Women's Hospital and Health Centre in Vancouver.
But the placenta had eroded through the wall of the uterus, a condition known as placenta accreta. As soon as they stretched the opening of the uterus to deliver the baby, "the placenta started bleeding everywhere," Christilaw says.
They couldn't get the bleeding to stop. The woman was losing two cups of blood every 30 seconds.
"You get into this place where you think, OK, this is what I'm trained to do, I know exactly how to do this," Christilaw, who was a senior resident at the time, says. "You don't panic, but you're calling in everybody you can possibly get into the room." People had to squeeze the bags of blood, because the pump could not put it in fast enough.
The only way to stop the bleeding was an emergency hysterectomy. The woman was in the operating room for eight hours, and lost 15 litres of blood.
It used to be that obstetricians might only ever see one or two cases of placenta accreta in their practice lifetime. Although still rare, obstetricians across Canada say one of the most feared complications of pregnancy is increasing as a direct consequence of the nation's rising caesarean-section rate.
Virtually all placenta accretas occur in women who have had a previous C-section, and the risk increases with each additional surgical delivery. The placenta attaches to the old C-section scar. Scars don't have a proper blood supply to feed a placenta, so the it keeps burrowing into the uterus until it finds one, sometimes pushing through the uterus completely and into the bladder or other organs.
The condition can be detected by ultrasound, but not always. "You almost never see it in a woman who has not had a C-section," Christilaw says.
Today, about 28 per cent of babies born in Canada are delivered by caesarean. In 1969, Canada's rate was five per cent.
More than 78,000 caesarean sections were performed in Canada last year, making it the single most frequently performed surgery on Canadian women.
Ellen Hodnett wonders how so many C-sections could be justified.
"Women have stopped being able to give birth vaginally, in such numbers?" says the professor and Heather M. Reisman Chair in perinatal nursing research at the University of Toronto's Bloomberg Faculty of Nursing.
The World Health Organization says no more than 15 per cent of deliveries should be done by C-section.
"We don't know what the ideal rate is," says Dr. Mark Walker, a high-risk obstetrician at the Ottawa Hospital and senior scientist with the Ottawa Hospital Research Institute. "I think it's fair to assume it's lower than where we are now."
Walker says changing demographics — older first-time mothers, more multiple births from fertility treatments, more mothers with hypertension, diabetes, obesity and other health problems — are not enough to explain an almost doubling in the C-section rate since the early 1990s.
Neither is there evidence to support the idea that women are seeking C-sections on demand. Studies from Ontario suggest less than one per cent of caesareans are for "maternal request."
The Society of Obstetricians and Gynaecologists of Canada says the vast majority of caesareans are done for medically valid reasons. But there are concerns that too many are being ordered because labour isn't progressing quickly enough, and that thousands of "routine" interventions are now being done that increase the odds of a woman needing a surgical birth.
What's more, the number of women who give birth vaginally after a previous C-section is dropping dramatically, meaning more and more women are having repeat C-sections.
"The percentage of caesareans we're doing for repeats because we didn't do a trial of labour, those are the ones we need to be asking ourselves about," Walker says.
Dr. Michael Klein calls it the industrialization of childbirth, where, in today's risk-averse society, women in labour are being treated "as an accident waiting to happen" and where doing something is always better than doing nothing.
"Physicians and society have helped women basically believe that childbirth is no longer a natural phenomenon, but an opportunity for things to go wrong," says Klein, emeritus professor in the departments of family practice and pediatrics at the University of British Columbia.
"But the fundamental issue is, we aren't improving outcomes by doing more C-sections. For the first time in Canada, we are seeing the key indicators for mothers and babies going in the wrong direction."
Risks to babies range from accidental lacerations when the surgeon cuts into the uterus, to neonatal respiratory distress. Research suggests two times as many babies born via C-section will end up in an incubator with water on their lungs, or with serious respiratory problems compared to babies delivered vaginally, because a C-section interferes with the normal hormonal and physiological changes associated with labour that prepare a baby to take its first breath.
Risks to women include higher risks of hemorrhage requiring a hysterectomy, major infections including blood infections, wound infections and bladder infections, and blood clots in the lungs — and every C-section increases the risk for another.
"If you have a caesarean section for the first birth, the probability of having one the second time around is huge, because of the difficulty women have in getting a doctor to look after them once they have a uterine scar," Klein says.
The worry is that the scar will pull apart during labour, causing a uterine rupture.
"If you have a catastrophic rupture, you can get into big trouble," Christilaw says. "You can have a negative outcome for mom or baby. In severe situations, the baby can die or become damaged — but that's a very rare outcome."
Her hospital is encouraging more VBACs — vaginal births after caesarean — in carefully selected women. "In those women who attempt a VBAC, our success rate is well over 80 per cent."
But less than one in five women in Canada with a previous C-section delivered vaginally in 2007-08. Eighty-two per cent had a subsequent C-section.
Christilaw says the only thing preventing Canada from seeing "horrific" complication rates from C-sections is the fact women are not having as many babies as they once did.
"A C-section can be a life-saving manoeuvre for a mother or baby. Nobody is saying differently," she says. "What we're trying to say to people is, a C-section is not a benign thing. If you need one, that's different. But you should not be doing this unless you absolutely have to."
C-sections are frequently the end result of a cascade of interventions that often starts with inductions.
Tens of thousands of women in Canada have their labours artificially induced every year, often via intravenous infusion of artificial oxytocin. Oxytocin is naturally produced by the human body. It's what creates contractions in labour. Today in Canada, one in five women who gives birth in hospital is induced.
What doctors fear are stillbirths. But alarmed by the rising rates of inductions, the Society of Obstetricians and Gynecologists of Canada recently urged doctors not to consider an induction until a woman is at least one week past her due date.
Claudia Villeneuve says that women are getting induced "if they're two, three, four days overdue."
"Inductions are rampant," says Villeneuve, president of the International Cesarean Awareness Network of Canada. "You have a perfectly normal mom who comes in with a perfectly normal baby, and now you put these powerful drugs into her system to force labour to start."
The "humane" thing is to offer an epidural, she says. With an epidural, a woman can't feel pain in the lower half of her body. But epidurals slow labour, sometimes so much that labour stops. "Now you have to get this baby out," Villeneuve says. Two-thirds of first-time C-sections are done for "failure to progress."
Klein says epidurals are too often given before active labour is established.
"The majority of women today get their epidurals in the parking lot."
So the cascade continues: epidurals increase the use of electronic fetal monitoring, where electrodes are strapped to the woman's belly to monitor her baby's heart rate.
"It's hard to change positions when you have a fetal monitor on, and an epidural with its little things taped to your back, and an IV in your arm," Hodnett says. "Why would labour progress normally, if you're stuck in a labour bed with all this machinery on you?"
What's more, EFM is an imperfect technology. It detects subtle changes that can't be picked up by just listening to the baby's heartbeat after contractions, "and those subtle changes are often false positives," Klein says. "In other words, the fetus is OK, you just think it isn't OK."
Kayla Soares had been in mild labour at home for 24 hours when her contractions suddenly stopped. Doctors told the Edmonton mother she would have to be induced. She was three centimetres dilated when they started the oxytocin drip.
"It was the worst pain I've ever felt in the world," she remembers. "I wasn't having contractions at all and then they put me on the oxytocin and every half-hour they would boost it up, so the contractions were coming every minute, pretty much. It was like going from nothing to being in crazy, absolute labour, and in so much pain." Eleven hours later, she was still just three centimetres dilated. "That's when they said it was enough, and they were doing a C-section.
"I didn't want to do it. I was asking, could we just have more time?"
Three weeks later, she still couldn't get out of bed without help. Her incision had become infected. "It felt like I was ripping apart every time I moved. It was a pretty brutal recovery."
Soares had her second baby in June. "I was dead set on having a VBAC," a vaginal delivery after caesarean. "It was a fight, an uphill battle the whole time with doctors." One obstetrician asked her her shoe size. "She said that because I was a size five and smaller framed that I definitely was going to have another caesarean and that a VBAC wouldn't happen. She said that because I was a 'failure to progress' the first time I'll be a 'failure to progress again.'"
Two weeks before her daughter was born, Soares started going in and out of labour. "They had me convinced it was causing stress to the baby even though the tests said everything was fine. They had me convinced it was enough, because I was overdue and they said my incision was going to rupture," she says.
"They just kind of scared me into having another C-section."
skirkey@canwest.com

HERE to read the original article
 

Vaginal birth OK after several C-sections- Reuters

The word is spreading, even making the main stream media now: Women CAN birth vaginally after 2, 3 or more Caesarean Sections!!!! Now if we can just get the Obstetricians and Hospital policy makers to actually read the study and then change how they think about VBAC births. VBAC's are not a liability. Women wanting to have a VBAC birth are NOT a liability: they are women who are trying to give birth to their babies the way that nature intended. The medical machine needs to realize that they have caused countless years of pain and suffering - both physical and emotional - to women by denying then the right to birth their babies as they want. Birth trauma is very real. Women who've been abused by the hospital system need to heal, and the first step for many of them is being allowed to face their fears and be given the support they need to birth naturally- Vaginally. This I can attest to!!!

Just 11 days ago I gave birth to my youngest son Kael in a historical VBA3C - the first of it's kind at Cambridge Memorial Hospital, and the first for the Cambridge Midwives Group. You can read my story here: http://iinformedparenting.blogspot.com/2010/02/victory-my-vba3c.html

We VBAC moms and dads and families and friends need to make the public and the hospitals aware that there ARE options for those women who've had multiple C/Sections. We need to continue to fight for our rights and stand up to the policy makers and make them realize that they do NOT have the RIGHT to tell us how to birth.

We Are NOT Broken.

Vaginal birth OK after several C-sections

Study reconsiders risks and could change guidelines

updated 2:09 p.m. ET, Thurs., Feb. 18, 2010

Women who attempt vaginal childbirth after having several babies by cesarean section may not have a greater risk of complications than women who've had only one prior C-section, a new study suggests.

At one time, doctors believed that once a woman had a C-section, she would have to have one for all subsequent pregnancies — mainly out of concern that the scar on the uterus could rupture during vaginal childbirth.

That thinking has changed, and vaginal delivery is now considered a safe option for many women who have had a past C-section. Because C-sections also carry risks and downsides — such as blood loss or infection from the procedure, and a longer hospital stay and recovery time — many women may prefer a try at labor.

Still, the American College of Obstetrics and Gynecology (ACOG) does not currently recommend vaginal delivery for women who have had three or more C-sections, as their risk of uterine rupture has generally been thought to be higher.

In the new study, however, researchers found that women with at least three prior C-sections showed no increased risk of uterine rupture during vaginal delivery.

In fact, none of the 89 women who opted to try vaginal childbirth had the complication, according to findings published in the British obstetrics journal BJOG.

Based on past research, the expected rate of uterine rupture among women with one prior C-section would be less than 1 percent; a large 2004 study of U.S. women, for example, found a rate of 0.7 percent.

These latest findings suggest it would be "reasonable to reconsider" the current ACOG recommendations for women with three or more prior C-sections, according to lead researcher Dr. Alison G. Cahill of Washington University School of Medicine in St. Louis.

In an interview, she noted that next month, the National Institutes of Health is holding a consensus conference on the overall issue of vaginal birth after cesarean. According to the NIH, the conference will look at the scientific evidence on a number of questions -- including the short- and long-term risks and benefits of vaginal delivery versus repeat C-section; an independent panel will then develop a consensus statement on those issues.

For now, Cahill said, it is important for women with a history of three or more C-sections to be aware of the current ACOG recommendation. But, she added, they can also talk with their doctors about the possibility of vaginal birth as an option, as "recommendations can change as new science emerges."

For their study, Cahill and her colleagues reviewed the records of 25,000 women at 17 U.S. hospitals who gave birth after having at least one prior C-section. The group included 860 women with at least three prior C-sections, 89 of whom attempted a vaginal delivery; the remaining 771 elected to have a repeat C-section.

There were no cases of uterine rupture in either group, the researchers found.

The 89 women who chose to try labor also had no instances of bladder or bowel injury, or lacerations of the uterine artery — the other main complications the researchers assessed. That compared with just over 2 percent of the women who had a repeat C-section — though that difference, the researchers say, is not significant in statistical terms.

When it came to successful delivery — meaning the doctor did not have to switch to a C-section during labor — the chances were similar regardless of the number of prior C-sections.

Just over 13,600 women with one or two prior C-sections elected to try vaginal delivery, with a success rate of about 75 percent. That rate was 80 percent among women with a history of three or more C-sections.

Cahill pointed out that all of the women in the study had had C-sections done with what is called a low transverse incision — a horizontal cut across the lowest part of the uterus. These types of incisions have a lower risk of rupture compared with the "classical" high vertical incision, an up-and-down incision made higher on the uterus.

Another factor to consider in the decision to try vaginal delivery after cesarean, according to Cahill, is whether a woman has ever had a previous vaginal birth. Previous vaginal deliveries increase the chances of success with a post-cesarean attempt at vaginal birth.

HERE to read the original article on MSNBC

Vindication!!! New VBAC study!!!!

I woke up this morning to be greeted with happy happy news. The kind of news to make a woman 39 and a half weeks pregnant, who's spent months fighting for her right to have a VBA3C, get up and dance around the kitchen....albeit awkwardly and vaguely penguin-like, lol.

New research to be published in BJOG: An International Journal of Obstetrics and Gynaecology , has found that women with 3 previous Caesarean Sections have similar outcome rates of success as women with only one previous Caesarean section in a study of 25000 women attempting a vaginal birth after a Ceasarean section. The study shows that not only did the women with 3 previous C/Section uterine scars have a very similar rates of success in having a VBAC birth, but that the rates of morbidity were also very similar between the women that had a VBA3C and those that chose to be delivered by elective repeat caesarean.

This is the first study that has analysed this large a group of women- over 25000 women with at least one previous Ceasarea section over a period of 3 years. I am currently waiting to receive the full abstract of the study and will post it here for those women, like my self, that are searching for the hard proof to back up their decisions to have a VBAC Birth.

Not only am I going to be giving a copy of this article to my midwives this morning, but I think I will attach a copy to my birth plan that I will be handing out at the hospital to the Obstetrical staff.

....Pardon me while I go dance a gig in my kitchen again.



Do We Need To Revisit VBAC Guidelines For Women With Three Or More Prior Caesareans?
Main Category: Pregnancy / Obstetrics
Article Date: 04 Feb 2010 - 1:00 PST

New research to be published in BJOG: An International Journal of Obstetrics and Gynaecology has found that women with three or more prior caesareans who attempt vaginal birth have similar rates of success and risk for maternal morbidity as those with one prior caesarean, and similar overall morbidity (adding vaginal births and emergency caesareans together) as those delivered by elective repeat caesarean.

Planned vaginal birth after caesarean (VBAC) refers to any woman who has experienced a prior caesarean birth who intends to try for a vaginal birth rather than to deliver by elective repeat caesarean. Although relatively low complication rates, including uterine rupture, have been demonstrated among women with two prior low-transverse caesareans who attempt vaginal birth, there are very limited data available on outcomes among women with more than two prior caesareans. Neither the American College of Obstetricians and Gynaecologists (ACOG) nor the Royal College of Obstetricians and Gynaecologists (RCOG) currently recommend planned VBAC attempt in women with three or more prior caesarean deliveries1.

In this study, the researchers sought to estimate the rate of success and risk of maternal morbidity in women with three or more prior caesareans who attempt VBAC. The study reviewed multi-centre data from 17 tertiary and community delivery centres in the Northeastern United States from 1996 to 2000. A total of 25,005 women who had a least one prior caesarean delivery were included.

The findings indicate that women with three or more prior caesarean deliveries did not experience a difference in morbidity based on whether they attempted VBAC or elected for a repeat caesarean. The 89 women with three or more prior caesareans who attempted VBAC were as likely to be successful as women with one or two prior caesareans, 79.8% compared to 75.5% and 74.6% respectively. In addition, none of them experienced significant maternal morbidity such as uterine rupture, uterine artery laceration, and bladder or bowel injury.

The authors suggest that, given the findings, precluding VBAC for all women with three or more prior caesareans may not be evidence based. Although there is a measurable maternal morbidity associated with delivery for a woman with a history of three or more prior caesareans, it does not differ significantly by mode of delivery. Risks associated with multiple caesareans are several, including surgical morbidity and abnormal placentation in future pregnancies.

Lead author, Dr. Alison Cahill, from the Department of Obstetrics and Gynaecology at Washington University in St. Louis School of Medicine, said "These data suggest that women with three or more prior caesareans who attempt VBAC have similar rates of success and risk for maternal morbidity as those with one or two prior caesareans, and along with other publications, suggest that perhaps it is time to revisit the current recommendations for VBAC attempts for women with more than one prior caesarean".

"Many have proposed a 'conservative' approach to VBAC attempts, which we agree is prudent. But our evidence does not suggest that a conservative approach, which we interpret as one that aims to reduce morbidity - and specifically the risk of uterine rupture - is necessarily achieved by allowing VBAC attempts only in women with one prior caesarean. Given appropriate patient selection, VBAC following two or even three previous caesareans in certain cases may be reasonably safe."

Prof. Philip Steer, BJOG editor-in-chief, said "Although confidence in the findings of the study is limited by the relatively small sample size of women who have had three previous caesareans, these findings provide additional information for women, and contribute to the available evidence on VBAC success and safety in women with more than one prior caesarean.

"As childbirth does not always 'follow the plan', the results may also serve as a useful reference for clinicians when a women with three or more prior caesareans presents in spontaneous labour."

Notes

BJOG: An International Journal of Obstetrics and Gynaecology is owned by the Royal College of Obstetricians and Gynaecologists (RCOG) but is editorially independent and published monthly by Wiley-Blackwell. The journal features original, peer-reviewed, high-quality medical research in all areas of obstetrics and gynaecology worldwide. Please quote 'BJOG' or 'BJOG: An International Journal of Obstetrics and Gynaecology' when referring to the journal and include the website: http://www.bjog.org as a hidden link online.

Reference

"Vaginal birth after caesarean for women with three or more prior caesareans: assessing safety and success."
Cahill A. Tuuli M, Odibo A, Stamilio D, Macones G.
BJOG 2010; DOI: 10.1111/j.1471-0528.2010.02498.x.

1. American College of Obstetricians and Gynecologists (ACOG). Practice Bulletin #54: Vaginal birth after previous cesarean. Obstet Gynecol 2004;104:203-12; Royal College of Obstetricians and Gynaecologists (RCOG) Green-top Guideline No.45, Birth After Previous Caesarean Birth (February 2007) available online here.

Source
American College of Obstetricians and Gynecologists

HERE to go directly to the original Article

HERE to read the original abstract of the study

FURTHER information about VBA2/3/4C

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