Study urges avoiding 2 cesareans
Hospitals vary widely in practice
NEW HAVEN — Women whose first child was born by cesarean delivery are getting mixed messages about whether their second child can be delivered vaginally or whether they must have another surgery.
According to a new study published online in the American Journal of Obstetrics and Gynecology, hospitals vary widely in the number of women who have delivered vaginally after previously having a cesarean.
There has been a dramatic increase in the number of cesarean births in the United States, more than 600 percent between 1970, when the rate was 5 percent, and 2016, when it reached 31.9 percent, according to the American College of Obstetricians and Gynecologists.
According to Dr. Jessica Illuzzi, medical director of obstetrics at Yale New Haven Hospital’s Vidone Birth Center on the St. Raphael campus, the risks of vaginal delivery after a cesarean are low, and the risks of undergoing multiple cesareans rise with each birth, so that most women should be encouraged to deliver their babies vaginally even after they have had their first child by cesarean delivery.
But she worries that mothers-tobe aren’t always getting the right information, and the obstetric college, in a November 2017 Practice Bulletin, reported that a decrease in cesareans to 20 percent in 1996 resulted in a related rise in uterine ruptures and other complications in some women trying to deliver vaginally after having had a cesarean. Some doctors and hospitals, who also feared lawsuits, began counseling women to have a second cesarean, resulting in a total cesarean delivery rate of 31.1 percent in 2006.
The paper, in which Illuzzi is senior author, states that in 2016 87.6 percent of American women who delivered via cesarean had a repeat cesarean delivery
Some hospitals, including at least one in Connecticut, according to Illuzzi, do not allow women who have had cesareans to attempt labor and vaginal delivery.
“I think that most women in this generation know that it’s OK” to deliver vaginally after having had a cesarean, Illuzzi said. “I think there’s a lot of variability that occurs in the conversations that happen in the physicians’ offices regarding the risk and benefits” of vaginal birth after cesarean.
The Practice Bulletin, while recognizing exceptions based on a woman’s health and previous experience, recommended that “most women with one previous cesarean delivery with a low-transverse incision are candidates for and should be counseled about and offered TOLAC,” or trial of labor after cesarean delivery, its medical name. It also said a second vaginal birth after cesarean would be reasonable and that labor could be induced in such women.
Illuzzi said she’s concerned that women are not getting the best advice because, while a second cesarean is not especially risky, having a third or fourth can result in serious problems.
“I think that most physicians do have the conversation but, like with any procedure or any choice that patient has regarding pregnancy, how you talk about the risks and how you talk about the benefits can easily sway a decision, and physicians may be more concerned about risks that are rare than about the benefits that can occur in a future pregnancy,” she said.
“The decision often depends on whether she’s intending to have a third or fourth child, because the risks increase for her with each child she has” by cesarean, Illuzzi said.
The major risk with repeated cesareans has to do with “increasing scar tissue on all of the layers going down to the uterus,” she said. The placenta may attach itself to the scar tissue, a condition known as placenta accreta. Because the scar does not have a good blood supply, the placen- ta “keeps digging deeper, trying to find a blood supply,” Illuzzi said. “It may even invade into the bladder,” forcing early delivery and possibly a hysterectomy.
She said the condition can cause excessive blood loss and can be fatal. The condition is “extremely unusual,” and “the second cesarean is not as risky as the third, fourth or fifth cesarean.”
Illuzzi said there are slight risks to vaginal delivery as well, and a woman attempting it after a cesarean may only succeed in avoiding surgery 60 to 80 percent of the time. But since the cesarean rate overall is 30 percent, the chance a second cesarean will be necessary is worth the odds, she said.
The main risk of labor after a cesarean is that the scar will open, requiring an emergency cesarean, but that happens only 0.5 to 0.9 percent of the time, Illuzzi said. When it does occur, usually the cesarean “is done without complication and mother and baby usually come out of this safely,” she said.
On rare occasions, about one in 1,000 cases, there is massive blood loss or the baby’s oxygen level decreases during a uterine rupture.
“There’s a large effort right now across the United States and here to decrease primary cesarean deliveries,” Illuzzi said. “But I think we also have to be concerned over the second cesarean and making sure women are offered and educated about … vaginal birth after cesarean.”
Daisy Rainho of Monroe changed her obstetrician because she wanted to deliver vaginally after having given birth to her and her husband Justin Rainho’s daughter, Gabriella. Gabriella, who was born by cesarean because she was in a breech position, is now 5. But, when their son Noah was due 20 months ago, “I switched OBs at 40 weeks to Yale’s midwives because I just felt like I wasn’t getting the support needed from the OB that Iwas with,” Daisy Rainho said.
She was scheduled to deliver at Bridgeport Hospital, which is part of the Yale New Haven Health System, and was told that if she hadn’t delivered by 42 weeks she would undergo a cesarean. “They didn’t want to really perform any medical intervention to induce my labor,” Rainho said. “Pitocin wasn’t an option.” Pitocin is a synthetic version of oxytocin, which induces labor.
“I felt like I had every ability to be able to labor,” Rainho said. She was referred to Yale New Haven by HypnoBirthing of Connecticut, based in Westport. At the St. Raphael campus, “They knew nothing about me and my experience in the delivery was more than I could ask for. They were just very, very supportive and welcoming me into the practice to have a delivery that I wanted.”
Rainho was given a small dose of Pitocin at Yale New Haven. “I labored for 15 hours, I pushed for 45 minutes, the pain got very intense,” she said. “Richard Jennings — he was my midwife and he was phenomenal. Susan Schimler was my nurse and she was amazing.”
Her third child, Ethan, was born on Thanksgiving after undergoing labor and a vagina delivery. Born at 3:19 a.m., he weighed 7 pounds, 8 ounces, and is 191⁄ inches long. Her midwife was Erin Morelli.
Rainho said Friday in a text she went into “active labor just after 2:30 and ... after one good push he made his debut. All natural and unmedicated birth. It all happened so quick, I couldn’t believe it,” compared to the “intense lower back pain” she felt when she gave birth to Noah.