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Thread: Article: Too Many Caesars

  1. #1

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    Default Article: Too Many Caesars

    I wonder if this has something to do with the fact that an Ob was sued in the US for something like 1.3 million recently for performing a caesarean which was unneccesary and 'uninformed consent'... maybe they are deciding it might be a good idea to think differently. Another thing that will change is that private health funds are starting to clue into the fact that vaginal birth costs them alot less than caesareans - my teacher estimates that within the next four years they will be pushing for action - they are getting whiff of it already, some funds allowing midwifery/homebirth cover.

    Experts are calling for a rethink on the readiness of Australian
    women to have caesareans. Kellie Bisset reports

    The Australian
    July 08, 2006

    IN doctors' rooms around the country pregnant women are walking in and asking for their babies to be surgically removed. They're not the majority, but evidence shows their numbers are increasing. Some of them are paralysed by the fear of giving birth, others want to remain in control of where and when they have their baby, and
    still others think caesarean section is a less risky option than leaving delivery up to Mother Nature.

    Add to these the women advised by their obstetricians to have a caesarean section before, or during, labour and you get a national caesarean rate of nearly 29 per cent.

    Midwives have loudly criticised the rapid growth of surgical deliveries over the past decade, and now doctors are joining them.

    More obstetricians are worried that the looming possibility of one in three babies checking in to the world via the spartan surrounds of an operating theatre is too high a number. And important new research published last month in the US journal Obstetrics & Gynecology (2006;107:1226-1232) gives us an idea as to why.

    The study of more than 30,000 women showed the more caesareans they had, the greater the risk of complications including hysterectomy, bowel and bladder injury, admission to intensive care and blood transfusions. Risks for some complications more than doubled between the first and the third caesar.

    Given that more than 80 per cent of Australian mothers who've had one caesar go on to have another, the US results are particularly relevant to us.

    "In the desire to do good we have actually started to do some harm, and this paper illustrates that well," says David Ellwood, professor of obstetrics and gynaecology at the Australian National University.

    Ellwood says we need to think carefully about getting the balance right between what's excessive and a safe level of intervention to avoid harm. "I really think at the moment we have swung too far the other way. We perhaps overestimate the size of the impact on outcomes for babies and underestimate the risks (to the mother)."

    Senior vice-president of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists Dr Chris Tippett agrees. She says too many women are getting biased or selective information on the pros and cons of caesarean section, which is now seen by many doctors and their patients as the preferred option.

    "Caesarean section is a significant intervention . . . there are concerns about whether or not we are leaving a legacy of problems."

    Until now, studies looking at the question of repeat caesarean risk have reported mixed results, but many doctors and midwives have long suspected the caesarean story is not a completely rosy one. Experts say that while this study confirms what they've been thinking, it's significant because of its sheer size and conclusive results, which can now be used to give women a better picture of what they're up against.



    It showed one in 155 women needed a hysterectomy after their first caesar, but that risk rises to nearly one in 40 for those having their fourth figures Ellwood describes as "surprisingly high". Another major complication was placenta accreta, an abnormally firm attachment of the placenta to the wall of the uterus, which hampers control of bleeding after the baby is born. In many cases of placenta accreta, severe bleeding leads to the need for a blood transfusion or hysterectomy.

    According to the study the risk of placenta accreta more than doubled for those women having their third caesar (one in 175) compared with those having their first (one in 413). By the fourth caesar, the risk was one in 46. Tippett says she now sees a case of placenta accreta every three to four weeks, a huge jump from when she started her obstetrics training in the early 80s.

    "This study is good evidence it says to women that caesarean section is generally a safe procedure, but if you are planning on having a family of three to four children, think very carefully before you go down the caesarean section pathway."

    Ellwood thinks we've lost sight of the bigger picture.

    "It is the third caesarean where you start to see this increased risk, and in numerical terms it is going to be a relatively small proportion of the population. But the scale of the morbidity in placenta accreta and hysterectomy is enormous and the only way we are going to address it is by an overall reduction in the caesarean rate."

    Some might argue that most women just have one or two children these days, so the risk of three, four, five and six caesareans isn't something we need concern ourselves with. But Ellwood is seeing a shift.

    He says while government policies to encourage women to start families are having an effect, there's another increasingly frequent story: the impact of the divorce rate.

    He is treating more women entering their second marriage, and while they may have originally intended on one or two children, they often change their mind and plan more when there's a new partner on the scene.

    Ellwood says there needs to be more effort put into encouraging women who have a first caesar to try vaginal delivery next time, particularly if they plan on having more than two children.

    Clinical director of women's services at Melbourne's Royal Women's Hospital Professor Jeremy Oats says his hospital actively supports this policy, but attitudes vary.

    He says a major study published in the New England Journal of Medicine two years ago (2004;351:2581-2589) linking a trial of labour after a prior caesarean to greater risks for mothers and babies had a huge impact, particularly in the US.

    The absolute risks, however, were small: 0.46 in every 1000 births was associated with an adverse outcome such as rupture of the uterus, which in some cases led to birth asphyxia (where the baby does not receive enough oxygen). And problems were more likely if the labour was induced.

    Oats says there shouldn't be any reason for concern provided the labour is carefully monitored. "It comes back to the obstetrician and the maternity team to work with the woman and give her confidence and support in her decision."

    Robin Austin says she could have done with that kind of support when she decided to have her second and third children naturally and at home after having a caesarean when her first labour failed to progress.

    "What I came up against was other people's fear," says Austin, 38. "No one was talking to me about other choices and I found that distressing because I felt I had been butchered."

    She describes the distress of coming home from hospital the first time with an infected wound and unable to pick up her screaming baby because of the impact of major surgery.

    "The whole process was traumatic and we thought it should not be like this. Whatever happened to women just having babies where is that? It is almost like it is a medical condition that needs to be fixed, rather than a process that needs to be gone through."

    Austin, who now has her hands full with Toby, 2, Lucy, 13 months, and one-month-old Isabella, says she felt a sense of loss after the birth of her son. "I missed his birth and so did his father. It is gone and it is something that will never come back."

    Tippett also wonders whether rising caesar rates are denying women an important life experience. She spends up to an hour with every new patient explaining why surgery is not the easy option. "There are many women coming in and requesting elective caesarean section and that did not happen 10 years ago," she says. "We very rarely do a primary elective caesarean it is our policy not to but there are other doctors who rarely do vaginal deliveries."

    So are women or their doctors driving the upward trend in caesareans?

    Senior obstetrician at Sydney's Royal Prince Alfred Hospital Tony Frumar believes it's a little of both. He says there's every chance more women would be talked out of the procedure if medico-legal concerns were not an issue for doctors: "If you steer someone away from a caesarean section and have a problem you leave yourself open to action."

    He says most women can be discouraged from elective caesareans by the end of their pregnancy, but there are those that are so "freaked out" by the pain of childbirth that not to do the procedure could have its own psychological consequences.

    Australian College of Midwives spokesperson Shannon Morris says the convenience factor for obstetricians can't be discounted as a driver of the caesarean rate. She says this was acknowledged privately recently by a senior
    obstetrician.

    "There's a new generation of obstetricians who don't want to put in the hours who say 'This will be safe and I can do it on this day at this time and still be home to pick up my kids from school'."

    Morris also raises concerns about the number of induced labours (where a mother is given hormones to kick-start contractions). She says incorrect due dates are causing supposedly overdue women to be induced before their babies are ready. And induction of labour dramatically increases your chances of needing an emergency caesarean
    section.

    Oats agrees energy needs to be devoted to addressing this. But he also raises the possibility that nature, as well as societal attitudes, might be having an impact on the caesar rate. "There's an argument that with better nutrition babies are getting bigger and there is a genetic gap between that and the increase in maternal pelvis size."

    While Morris says caesars are a fabulous intervention that have saved many lives, they've become as routine as getting your tonsils out.

    Ellwood agrees obstetricians must step up to the challenge.

    "It is quite unreal to think women when making choices about what to do in this pregnancy will think long term about what might be happening 10 years on. It is a responsibility that we as obstetricians have to point that out to them and not be involved in unnecessary caesareans."
    Last edited by BellyBelly; July 10th, 2006 at 03:47 PM.
    Kelly xx

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    Author of Want To Be A Doula? Everything You Need To Know
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  2. #2

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    That was a really interesting article, thanks

  3. #3

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    About time they woke up, and decided that its NOT good the rising csec rate in Oz!!

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    Thats a very interesting article. Thanks for posting that Kelly.

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    Thanks for posting the article Kelly. It was an interesting read.

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    Gee, I am going in for my fourth Caesarean with this little one, as I wasnt told I had an option with the first, and the next 2 wern't either as that is the way my OB insisted it after the first (which I shouldnt have had to have anyways). When I booked in for the last one though, we were told not to worry, as their record at the Lismore Base hospital for Caesarean's was 10!!!!. We are having tubal ligation at the birth of this one, as no matter what the sex this time, our family will be complete and we are happy with that,,,,but 10????? What on earth was the mother thinking?
    Thanks for the article Kelly, I have had no info on the risks with any of mine, and no one has ever told me of such horrid things that can happen, I was just told that this was the only way for me to have them, and that was that.

  7. #7

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    And on the other hand, there was apparently a woman in Canberra about 6 years ago who had her 8th baby at home after 7 caesareans. Wow.
    Kelly xx

    Creator of BellyBelly.com.au, doula, writer and mother of three amazing children
    Author of Want To Be A Doula? Everything You Need To Know
    Follow me in 2015 as I go Around The World + Kids!
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  8. #8

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    wow, a homebirth after 8 c-sections...that rocks!

    Lil_Aussie....I'm so angry on your behalf!! That is so wrong of your health-care-providers to not give you all the information you need to make an informed decision yourself. I wish you all the best with your next baby!!

  9. #9

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    Thanks Liana,
    Kelly, with my last bub, I actually secretly wished to go into a super quick labour at home, just to get out of having the caesarean,,,,no such luck, the doctors like to take my bubs at 37wks 5 days to 38 weeks.

  10. #10

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    Easy - change doctors You do know you can get a second opinion, or change to an environment where they are supportive of your choices. Check out the birthrites website and read through that if you have time, it's great information for those who have had a caesar and those wanting a VBAC. There are some doctors in NSW who are supportive of VBAC, a few BB'ers are seeing NSW doctors for theirs It's your body hon, you have veto over anything
    Last edited by BellyBelly; July 10th, 2006 at 03:42 PM.
    Kelly xx

    Creator of BellyBelly.com.au, doula, writer and mother of three amazing children
    Author of Want To Be A Doula? Everything You Need To Know
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  11. #11

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    Thanks Kelly, I'll definetally give that website a thorough reading

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    You go girl! And don't forget to grab yourself a copy of 'The Thinking Woman's Guide to A Better Birth' by Henci Goer - I recommend it to everyone especially those wanting a VBAC. Some of the women in the VBAC thread have read it Henci also had written another great book Obstetric Myths vs Research Realities which is also a real eye opener. I saw her speak at the homebirth conference, she is such a powerful, intellectual woman and is passionate about birth and birth support.
    Kelly xx

    Creator of BellyBelly.com.au, doula, writer and mother of three amazing children
    Author of Want To Be A Doula? Everything You Need To Know
    Follow me in 2015 as I go Around The World + Kids!
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  13. #13

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    Lil_Aussie...yes, Kelly is 100% right...it's all up to you, not any doctor. Basically, even if you can't get a second opinion (due to travel, or whatever?), you can still TELL your doctor what you will and will not do. I've had a VBAC, and they are (in most cases) much safer than a repeat c-section. Even if you choose to go with c-section, why not go into labour naturally, for instance? You know, get some of the wonderful hormones going and all . Discuss options with people, and decide for yourself what you want. Gosh...I'm just more and more disgusted with the hospital system every day! There is a great book, but it's out of print....called 'Persuing the Birth Machine' by Marsden Wagner. It's a real eye-opener! If you can get your hands on it - perhaps through a uni library, for instance, I can't recommend it enough. It's one of the books I had to read for my doula course, and it's made me that much more passionate! Good luck with everything!

  14. #14

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    There is a story on Today Tonight about this in Melbourne - channel 7. Should be on shortly so flick it on quick!
    Kelly xx

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  15. #15

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    Thanks for posting the article Kelly - good to see the the RWH Melb does support vbac, as I will probably be there if there is a next time. I should print it out in case I get an ob there who is not supportive.

  16. #16

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    Interesting reading...I really hope the tide does start to change and that women, particularly first time mums, can get reassurance and support regarding natural labour and vaginal birth if they are afraid, rather than just having their fears perpetuated by OBs who suggest c/s at the drop of a hat for their own convenience.

  17. #17

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    great article Kelly, thanks for posting it

  18. #18

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    moving to news forum
    Kelly xx

    Creator of BellyBelly.com.au, doula, writer and mother of three amazing children
    Author of Want To Be A Doula? Everything You Need To Know
    Follow me in 2015 as I go Around The World + Kids!
    Forever grateful to my incredible Mod Team and many wonderful members who have been so supportive since 2003.

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