Bigger Dose of Antibiotics Needed For Women of Size?

It's time to finish our focus this Cesarean Awareness Month on the over-utilization of cesareans in women of size and the burdens this high rate imposes on this group.

Consider a new study just out that suggests that women of size might benefit from a bigger dose of antibiotics if they undergo a cesarean. 

This further supports the idea of the importance of weight-based dosing of certain types of antibiotics when people of size undergo other surgeries as well. 

Wound infection is a very significant risk of cesarean sections in women of size, especially "morbidly obese" women.  Part of the reason for this is that adipose tissue tends to be poorly vascularized and oxygenated, which makes it harder for that area to heal as effectively.

However, another reason for a higher infection risk may be that "obese" women are being under-dosed with antibiotics when standardized dosing (the same for all weights) is used instead of weight-based dosing. 

In this new study, the same standardized antibiotic regime was given to all women (regardless of size) undergoing a planned cesarean delivery.  Women were categorized by BMI, and then tested to see how well the dosage was working at different times during the delivery (incision time, closure time). 

The antibiotic dosage was fine for everyone for gram-positive bacteria, but the story was considerably different for gram-negative bacteria.

One-third of the "extremely obese" women (BMI greater than 40 in this study) did not achieve minimal inhibitory concentrations at skin incision, and 44% did not achieve minimal inhibitory concentrations at closure. 

So by the end of the surgery, nearly HALF of the women with BMI greater than 40 did not have enough concentration of antibiotics in their tissue to effectively ward off a gram-negative infection. 

Reflections on the Study

For years, doctors have blamed all kinds of factors for the higher rate of wound infection in fat women. And to be fair, many of these factors are relevant.

However, this study shows it's likely that fat women also have higher rates of wound infections because their doctors are inadvertently underdosing them with antibiotics.

We in the fat acceptance community have been telling them this for years, but on the whole doctors have been very slow to listen and heed our feedback. Why has it taken the medical community so long to listen?  Will this study finally change the standard of care? 

Only time will tell...but I'm not holding my breath.  In the meantime, in light of just how high the cesarean rate (both planned and unplanned) is among women of size in the USA....consider the implications of such an excessive cesarean rate for infectious burden, healthcare costs, and disruptions to the mother's life just as she is trying to bond with her newborn.

The lessons from this study are twofold. 

First, for when a "morbidly obese" mother truly needs a cesarean, doctors should explore weight-based dosing with certain types of antibiotics, and then study this practice to see if this lessens the risk of infection. 

Second, because the risk for infection/wound complications is increased in "morbidly obese" women, doctors should stop doing things that increase the cesarean rate in this group.  For example, doctors need to stop scheduling this group for routine "elective" cesareans, and stop practices (like induction for suspected "big baby") that increase the risk for cesarean during labor. 

The medical, financial, and personal burdens that result from infections and wound complications after cesarean are clear. 

Stop placing fat women at increased risk of these burdensome complications by over-utilizing cesareans and inductions in this group.



Study Abstract

Pevzner L, Swank M, Krepel C, Wing DA, Chan K, Edmiston CE Jr. Effects of maternal obesity on tissue concentrations of prophylactic cefazolin during cesarean delivery.  Obstet Gynecol. 2011 Apr;117(4):877-82.

From the Department of Obstetrics and Gynecology, University of California, Irvine, Orange, California; Surgical Microbiology Research Laboratory, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin; and the Department of Obstetrics and Gynecology, Long Beach Memorial Medical Center, Long Beach, California.

Abstract

OBJECTIVE:  To estimate the adequacy of antimicrobial activity of preoperative antibiotics at the time of cesarean delivery as a function of maternal obesity.

METHODS:  Twenty-nine patients scheduled for cesarean delivery were stratified according to body mass index (BMI) category, with 10 study participants classified as lean (BMI less than 30), 10 as obese (BMI 30-39.9), and nine as extremely obese (BMI 40 or higher). All patients were given a dose of 2 g cefazolin 30-60 minutes before skin incision. Antibiotic concentrations from adipose samples, collected after skin incision and before skin closure, along with myometrial and serum samples, were analyzed with microbiological agar diffusion assay.

RESULTS:  Cefazolin concentrations within adipose tissue obtained at skin incision were inversely proportional to maternal BMI (r=-0.67, P less than .001). The mean adipose concentration was 9.4 plus or minus 2.7 micrograms/g in the lean group of women compared with 6.4 plus or minus 2.3 micrograms/g in the obese group (P=.009) and 4.4 plus or minus 1.2 micrograms/g in the extremely obese group (P less than .001).

Although all specimens demonstrated therapeutic cefazolin levels for gram-positive cocci (greater than 1 microgram/g), a considerable portion of obese and extremely obese did not achieve minimal inhibitory concentrations of greater than 4 micrograms/g for Gram-negative rods in adipose samples at skin incision (20% and 33.3%, respectively) or closure (20.0% and 44.4%, respectively).

No significant difference in cefazolin concentration was observed in mean closure adipose, myometrial, or serum specimens across the BMI categories.

CONCLUSION:  Pharmacokinetic analysis suggests that present antibiotic prophylaxis dosing may fail to provide adequate antimicrobial coverage in obese patients during cesarean delivery.

PMID: 21422859

Anesthesia and Wound Complications in Cesareans in "Morbidly Obese" Women

This month is Cesarean Awareness Month.  We are continuing our month-long focus on the overutilization of cesareans in the USA as a whole, and in particular in the subgroup of "obese" and "morbidly obese" women. 

In the United States and many other countries, many care providers are unfortunately moving towards a policy that a planned "elective" cesarean is the delivery method of choice for "morbidly obese" women.  As we recently discussed, they assume that very fat women are unlikely to birth vaginally anyhow, that vaginal birth in very fat women is unsafe for the baby, that an emergent cesarean would take too long to save the baby, and that just doing a planned cesarean ahead of time as a matter of routine care will result in better outcomes among these women.

However,  as we pointed out, a recent study from the U.K. shows that in fact, routine planned cesareans do not improve outcomes at all (and there was a trend towards poorer outcomes in the planned cesarean group).  Furthermore, the study found that 70% of the women with "extreme obesity" (defined as BMI of 50 or more) were able to give birth vaginally when they were given the chance to. 

Now, two other studies confirm that the policy of routine planned cesareans in "morbidly obese" women carries significant risks for these women. In the first study, high rates of anesthesia complications were found in planned cesareans for "morbidly obese" women.  In the second study, even higher rates of wound complications were found as well. 

Increased Anesthesia Complications

It is well-known that people of size are at higher risk for anesthesia complications. General anesthesia is far more risky in "obese" people, and difficult intubations account for some rare but very serious complications that are sometimes seen in general anesthesia in "obese" people. 

This is why regional anesthesia (epidural or spinal) is the anesthesia of choice for cesareans in women of size.  However, even with regional anesthesia in women of size, there is a higher rate of difficult placements, inadequate anesthesia, anesthesia that wears off too soon, or low blood pressure during the surgery.

In the first study (Vricella 2010), about 1 in 12 "morbidly obese" women who underwent a planned cesarean with regional anesthesia experienced a significant anesthesia complication.

No, the complications were not because they were trying to do a difficult epidural or spinal placement on an "obese" woman during labor.  These were planned cesareans.....not emergency cesareans, but cesareans planned ahead of time, with regional anesthesia. 

And still, 1 in 12 had anesthesia complications.

High Rate of Wound Complications

In another study from around the same time (Alanis 2010), researchers looked at the complications associated with cesareans in women with "massive obesity" (BMI of 50 or more). 

They found a much higher rate of wound complications than they expected.....30%, or about 1 in 3. 

Now the reasons for this higher rate of wound complications are many (and there's another blog post on this coming soon), but even so, about 1 in 3 is a really high rate. 

Their focus?  Changing the management that increases the risk for wound complications, such as subcutaneous wound drains and vertical incisions.  And these are very valid points....again something we'll be blogging about soon.....but the bottom line should have been making every effort to reduce the number of cesareans being done in this group at all.

Summary

These new studies present yet more compelling reasons to avoid unnecessary cesareans in women with "morbid obesity." 

Yet currently, many providers in the USA automatically schedule "morbidly obese" women for planned cesareans as a routine procedure, claiming it to be safer for the mother and baby, despite research showing that this is not true.

This practice has to change.

Most very fat women CAN give birth vaginally if just given an adequate chance to.  Automatically scheduling them for planned cesareans instead exposes the entire group to high rates of anesthesia complications, wound infections, blood clots, and hemorrhage, not to mention increased complications in future pregnancies. 

It is indefensible to place an entire group so at risk like this, across the board.

It is time for doctors to recognize that they are causing MORE harm than good through the practice of routine planned cesareans in "morbidly obese" women. 



References

Vricella LK, Louis JM, Mercer BM, Bolden N.  Anesthesia complications during scheduled cesarean delivery for morbidly obese women.  Am J Obstet Gynecol. 2010 Sep;203(3):276.e1-5. Epub 2010 Jul 31. PMID: 20673866

OBJECTIVE: We sought to estimate the morbidity associated with regional anesthesia in morbidly obese women undergoing scheduled cesarean delivery. STUDY DESIGN: This was a retrospective cohort study of women undergoing elective scheduled cesarean delivery from September 2004 through December 2008. RESULTS: A total of 142 morbidly obese, 251 overweight and obese, and 185 normal-weight women met inclusion criteria. Differences between groups were identified regarding: complicated placement (5.6%, 2.8%, and 0%, respectively; P = .007), failure to establish (2%, 0%, and 0%, respectively; P = .047), and insufficient duration (4%, 0%, and 0%, respectively; P = .02) of regional anesthesia. The groups differed in the frequency of general anesthesia (6%, 0%, and 0%, respectively; P = .003), intraoperative hypotension (3%, 0%, and 0%, respectively; P = .01), and overall anesthetic complications (8.4%, 0%, and 0%, respectively; P less than .0001). Prepregnancy body mass index greater than or = 40 kg/m(2) (receiver operating characteristic area under the curve, 0.856; positive likelihood ratio, 4.0) and delivery body mass index greater than or = 45 kg/m(2) (receiver operating characteristic area under the curve, 0.877; positive likelihood ratio, 4.1) were predictive of anesthetic complications. CONCLUSION: Morbidly obese women have significant risk for anesthesia complications during cesarean delivery.

*My snarky reply to their conclusion: So stop doing so many cesareans already!

Alanis MC, Villers MS, Law TL, Steadman EM, Robinson CJ. Complications of cesarean delivery in the massively obese parturient.  Am J Obstet Gynecol. 2010 Jul 31. PMID: 20678746

OBJECTIVE: The objective of the study was to determine predictors of cesarean delivery morbidity associated with massive obesity. STUDY DESIGN: This was an institutional review board-approved retrospective study of massively obese women (body mass index, greater than/=50 kg/m(2)) undergoing cesarean delivery. Bivariable and multivariable analyses were used to assess the strength of association between wound complication and various predictors. RESULTS: Fifty-eight of 194 patients (30%) had a wound complication. Most (90%) were wound disruptions, and 86% were diagnosed after hospital discharge (median postoperative day, 8.5; interquartile range, 6-12). Subcutaneous drains and smoking, but not labor or ruptured membranes, were independently associated with wound complication after controlling for various confounders. Vertical abdominal incisions were associated with increased operative time, blood loss, and vertical hysterotomy. CONCLUSION: Women with a BMI 50 kg/m(2) or greater have a much greater risk for cesarean wound complications than previously reported. Avoidance of subcutaneous drains and increased use of transverse abdominal wall incisions should be considered in massively obese parturients to reduce operative morbidity.

*Illustration credit: Amy Swagman of The Mandala Journey.  Used with permission. Isn't it amazing?

Routine Cesareans Not Better for "Extreme Obesity"

If you are a "supersized" woman, many doctors won't even give you a chance anymore for a vaginal birth. 

They often argue that a cesarean delivery is better and safer in women with "extreme obesity."  They argue that it is unlikely that a woman that fat will be able to deliver vaginally, and even if they did, the baby is likely to be harmed via hypoxia or birth injuries. They also argue that if a cesarean during labor were needed emergently, doing one on someone of that size would lead to poorer outcomes because of the delay that could be encountered in getting to the baby. So many doctors contend that it's just better to plan an "elective" cesarean with women of that size.

However, little research exists to support this idea. Instead, doctors are relying on their biases and their fears when making the decision about planned vaginal vs. planned cesarean births in this group.  The bottom line is that most don't believe that "extremely obese" women CAN birth vaginally, that vaginal birth in fat women is extremely dangerous when it does happen........so a planned cesarean is assumed to be safer for this group.

A new study finally questions this assumption and actually collects data on this issue. 

It showed that a policy of routine cesarean delivery in supersized women does NOT improve outcomes, and that most women with "extreme obesity" can birth vaginally.  It concludes that decisions about planned cesareans in very fat women should be made on an individual circumstances, just as it is with other women. 

Study Details

This is a very strong study, done nationwide in the UK as part of their National Health Service (NHS).  You need that kind of nationwide study because there usually aren't all that many women with BMI greater than 50 (the definition of "extreme obesity" in this study) in any one hospital or even any one region.  In order to have robust findings, you need data from a large group of hospitals, with a large sample of women who fit the study's parameters. Even in a nationwide study like this, the study group size was only 591, but that's as robust a study group as you are likely to get in research on this population.

Of the 591 women with BMI greater than 50, 174 had a planned cesarean, compared to 417 who were in the planned vaginal delivery group.  The study then tracked the outcomes of each group.

[It's damning with faint praise to have to say this, frankly, but lukewarm kudos to the NHS for planning a vaginal delivery for most (70%) of these "extremely obese" women ─ this wouldn't happen in many areas of the USA.  The trend here is simply to automatically schedule most supersized women for a cesarean.]

Considerably warmer kudos to the NHS for the fact that of those supersized women who planned a vaginal delivery, 70% actually achieved a vaginal delivery. 

Yes, you read that correctly.  70%, or nearly 3 in 4 of women with a BMI greater than 50, actually had a vaginal birth when given the chance to labor.

This is extremely different than what most doctors believe about a "morbidly obese" woman's ability to give birth vaginally. And I'd bet good money that the UK's vaginal birth rate in this group could be even better if they induced less.

Even so, that's far better than the US rates. Compare the NHS's 30% c-section rate in women with BMI over 50 to US studies. For example, Weiss (2004) and Dietz (2005), both very large, multi-hospital studies in the USA, found a nearly 50% c-section rate in women  with BMI greater than 35 ─ in first-time mothers!

Do you really think that the uteri of British women are that much more efficient?  A ~20% lower c-section rate, despite a BMI starting more than 15 points higher? 

Doctors like to assume that cesarean rates in morbidly obese women are due solely to maternal factors, like "poor contractility" or "soft tissue dystocia" (a.k.a. fat vaginas). 

But obviously, physician management has much more to do with cesarean rates in very fat women, or the cesarean rate in high-BMI women would be consistent between countries and over time. 

Nitpicks About The Study

Overall, it's a pretty decent study, but I would nitpick a few things.

First of all, their multivariate model of risk factors for cesarean in labor did not even address induction (!), which is probably one of the biggest drivers of a high c-section rate in women, let alone women of size.  Study after study shows an extremely high rate of inductions in women of size, yet rarely do studies control for this factor.  Connect the dots, people!  (More on this below.)

The study could also have used a lot more information on how the labors of "extremely obese" women were managed, especially in comparison with the labors of non-obese women.  Furthermore, it might have been quite illuminating to compare the labors and physician management of those high-BMI women who ended up with a cesarean after labor to those who ended up with a vaginal birth.  Why aren't we evaluating and discussing how to improve vaginal birth rates in high-BMI women instead of just clutching our pearls and lamenting cesarean rates in this group?

Don't get me wrong; the study was ground-breaking and pretty amazing for the generally fat-phobic world of obstetrics.  But I wish they would go beyond the simplistic and get into more substantial evaluation of the deeper questions these studies bring up.

The main negative finding in the study was the fact that the "extremely obese" women in the vaginal birth group had a shoulder dystocia rate of 3.1%, which is higher than the rate reported in an unselected population (0.6%).  Fear of shoulder dystocia and related birth injuries causes many doctors to promote planned cesareans for women of size, but it's important to note that NONE of the babies involved experienced permanent injury so the finding is of questionable importance.  Also, some studies that control for fetal size and diabetic status have found that once these are accounted for, obesity is not associated with shoulder dystocia. So it's ridiculous to mandate a cesarean for supersized women simply out of fear of shoulder dystocia and birth injuries.

Furthermore, if they wanted to reduce the shoulder dystocia rate in this group, I bet they could do so by "allowing" them more mobility during labor, encouraging alternative positioning instead of the "stranded beetle" position, inducing less often, discouraging early epidural placement, and avoiding forceps/vacuum extraction more often.

The answer to shoulder dystocia concerns is not more cesareans, but rather exploring preventive management during labor and improving SD management if it does occur.

Another negative finding in the study is that almost no supersized women tried for for a VBAC, and of the few who did, the success rate was very low (9 of 26, or 35%).  The study notes that the VBAC rate in some studies is low in women of size, implying that there is little reason to allow a trial of labor in this group. However, they fail to note that these studies have extremely high rates of induction, which is known to lower the VBAC success rate substantially, nor did they note how many of the women in this study were induced in their attemtped VBAC. We have yet to have a really good-quality study of VBAC in "morbidly obese" women, one in which these women were given a reasonable chance at VBAC with a spontaneous trial of labor.  It is FAR too soon to be making sweeping judgments about who should and should not be "allowed" a trial of labor.

The lack of recognition of the negative role that induction plays in the birth outcomes of high-BMI women is tremendously frustrating to me and remains one of my pet peeves in this type of research. Even this study ignores it.  Sigh.

On a happier note, one positive finding was that the study did not find any statistically significant differences in anesthetic, maternal or neonatal complications between the planned vaginal and planned cesarean groups, except the occurrence of shoulder dystocia (again, none of whom experienced permanent injury).  This belies the common perception that outcomes are poorer when vaginal delivery is "allowed" in supersized women. 

It's important to note that the rate of composite major maternal morbidity was higher in the planned cesarean group (6.3% vs. 4.3%), but alas, the difference did not rise to statistical significance.  With a larger study, chances are it would have.

Cesareans are an important risk factor for hemorrhage, blood clots, infection, wound comlications, and admission to Intensive Care, especially in this group.  Therefore, it's indefensible to automatically expose supersized women to these complications across the board, based on their weight alone.

Conclusions

Finally, the commentary by S Quenby that accompanied this study was interesting. 

A consequence of this data [about complications among obese women] is the frequently voiced opinion at midwifery, obstetric and anaesthetic conferences that the safest way to deliver a women with a body mass index (BMI) over 50 kg/m2 may be by elective CS. This elective option has been proposed as a way of avoiding the known risks of vaginal delivery and emergency CS in this population.

[This study] challenge[s] the assumption that elective CS is safer than planned vaginal delivery in these morbidly obese women. A large proportion, 70% of women with BMI [greater than] 50 kg/m2, who had a planned vaginal delivery did indeed deliver vaginally without the expected increase in neonatal and postnatal complication rates compared with those with planned elective CS.

These data strongly indicate that elective CS in morbidly obese women cannot be justified, except for the usual obstetric indications. Only in very unusual circumstances should elective caesarean be performed if the requisite obstetric indications are not present.

Doctors need to STOP automatically scheduling cesareans for supersized women on the basis of their weight alone. 

Planned cesareans do NOT improve outcomes in this group, and there was a trend towards poorer outcomes with planned cesareans. 

Furthermore, contrary to what many doctors believe, this study shows that very fat women CAN give birth vaginally if given an adequate chance to do so.  It's about time we let them.

*Image above of obese cesarean from BMJ 2006 study on "Obesity and Reproduction," courtesy of Pubmed.


Study abstract

Homer CS, Kurinczuk JJ, Spark P, Brocklehurst P, Knight M.   Planned vaginal delivery or planned caesarean delivery in women with extreme obesity.  BJOG. 2011 Mar;118(4):480-7. doi: 10.1111/j.1471-0528.2010.02832.x. Epub 2011 Jan 18

National Perinatal Epidemiology Unit, University of Oxford, UK.

Abstract

OBJECTIVE: To compare the outcomes of planned vaginal versus planned caesarean delivery in a cohort of extremely obese women (body mass index ≥ 50 kg/m(2)).

DESIGN: A national cohort study using the UK Obstetric Surveillance System (UKOSS).

SETTING: All hospitals with consultant-led maternity units in the UK.

POPULATION: Five hundred and ninety-one extremely obese women delivering in the UK between September 2007 and August 2008.

METHODS: Prospective cohort identification through UKOSS routine monthly mailings.

MAIN OUTCOME MEASURES: Anaesthetic, postnatal and neonatal complication rates.

RESULTS: After adjustment, there were no significant differences in anaesthetic, postnatal or neonatal complications between women with planned vaginal delivery and planned caesarean delivery, with the exception of shoulder dystocia (3% versus 0%, P = 0.019). There were no significant differences in any outcomes in the subgroup of women who had no identified medical or antenatal complications.

CONCLUSIONS: This study does not provide evidence to support a routine policy of caesarean delivery for extremely obese women on the basis of concern about higher rates of delivery complications, but does support a policy of individualised decision-making on the mode of delivery based on a thorough assessment of potential risk factors for poor delivery outcomes.

PMID: 21244616

A Peek Into The Future?

Here's an interesting little study with possibly big implications for the future. I haven't seen the full text yet, just the abstract, but I hope the study will generate some dialogue in the birth community during this Cesarean Awareness Month.

For years, birth activists have been decrying the increasing cesarean rate, while some doctors shrugged off the increase as unimportant. "A healthy baby is all that matters, and it doesn't matter how it gets here," is the refrain.

Yes, a healthy baby is always everyone's priority, but a healthy mama should be important too.  And generally speaking, a mama recovering from surgery is less healthy than a mama recovering from vaginal birth. And it's not just about the actual surgical recovery but also about the long-term complications that may ensue. As a result, more and more research is finding that a high cesarean rate has major public health implications.

This study uses computer modeling to predict just how high our cesarean rate may go in the future and what the implications will be for women's health. It predicts that the U.S. cesarean rate could top 55% by the year 2020 (which is not that far away!).

Now, I saw that and thought.....55% by 2020?  Really? The national rate is nearly 33% as of 2009, and they expect an increase of 20% more in just 11 years?  Seems like the prediction is a little excessive to me.  On the other hand, some hospitals in some areas of the country are already there.  If enough of them develop these outrageously excessive rates, who knows?

Currently, the cesarean rate is at or near 40% in some states. In the Miami area, the rate is around 50% already.  Twenty-four hospitals in California have rates between 40-50%, and five hospitals in California have rates already over 50%. At Kendall Regional Medical Center in Miami and in Corona Regional Medical Center in California, the cesarean rate is more than 70%.  What are the long-term implications for women in these areas?

It's very clear from research that cesareans increase the risk for placental complications in future pregnancies.  Conditions like placenta previa (a low-lying placenta, which can cause severe bleeding, prematurity, and death) and placenta accreta (where the placenta grows into the muscle of the uterus and sometimes even into the bladder or other structures near the uterus, which can cause catastrophic bleeding, hysterectomy, and death) will only increase as the cesarean rate goes up. 

We are already seeing increases in the rates of placenta previa and accreta due in large part to the rise in the cesarean rates. And rates seem to have a dose-response relationship ─ the more cesareans, the higher the risk for previa or accreta. 

For example, Clark (1985) found  that the risk of previa "increased almost linearly with the number of prior cesarean sections." They tracked the rates of previa by number of prior cesareans and found:

• 0.26% rate in an unscarred uterus
• 0.65% after one prior cesarean
• 1.8% after two prior cesareans
• 3.0% after three prior cesareans
• 10.0% after four, five, or six prior cesareans

Silver 2006 tracked the rates of accreta by number of prior cesareans and found:

• Placenta Accreta with second cesarean - 0.31%
• Placenta Accreta with third cesarean -     0.57%
• Placenta Accreta with fourth cesarean -   2.13%
• Placenta Accreta with fifth cesarean -      2.33%
• Placenta Accreta with sixth or more cs-   6.74%

The only reason we do not already have an epidemic of these complications is because most women have smaller family sizes now. The more cesareans a woman has, the more likely things like previa become. So the smaller family sizes of today has been somewhat protective...but is not enough.

Women who are having "only" their second or third cesarean are not safe from complications. Even just one cesarean increases your risk for placenta previa or abruption (tearing away of the placenta, which can kill the baby) next time.  Getahun (2006) found that the risk for previa in a second pregnancy after a first-pregnancy vaginal birth was 0.38%, but the risk was 0.63% if the first birth was by cesarean.  A similar increase in the risk for placental abruption was seen; there was a risk of 0.74% after a vaginal first birth, which increased to a risk of 0.95% after a cesarean first birth.

Although rarer in low-order cesareans, major complications can occur even after only 1 or 2 cesareans.  Fleisch 2007 is a case report of a 30-year-old woman, pregnant with her second child after one cesarean 2 years previously.  At only 20 weeks of pregnancy, she experienced a uterine rupture because of placenta percreta (an accreta that's grown into surrounding structures).  She lost her baby and her uterus.  She was lucky not to lose her life.  And there are other case reports similar to that one, too.

And although maternal death is a very rare outcome of cesareans, if you do enough cesareans, more women are going to die, as the study suggests.  Cesareans increase the rate of blood clots, which can be deadly, and hemorrhaging, which can be life-threatening if they can't stop it.  Anesthesia accidents, although very rare, do happen.  Do enough anesthesia, and even the less-risky regional anesthesia (epidural/spinal) cesareans will eventually cause some deaths.

And these are only the most serious of complications.  How many women will suffer the less lethal yet still serious complications?  Hysterectomy rates also increase significantly with each cesarean.  Infection is always a potential issue after any surgery, and especially so for women of size.  Internal scar tissue is extremely common after abdominal surgery, and it can cause great pain for some women, and even bowel and bladder complications years later.  Small bits of uterine lining can inadvertently be deposited outside the uterus and cause aggravating and painful endometriosis. The rate of tubal pregnancies and pregnancies in the scar goes up.  Fertility after a cesarean may decrease too. 

Of course, it's important not to panic. On an individual basis, the increase in cesarean rate is not that earth-shaking. Let me reassure you that if you personally have a cesarean, the odds are quite good that you will survive it and that you will recover just fine.  Although surgery is not the ideal way to start out your life as a parent, it obviously can be done, and many of us have indeed done it.  You'd get through it if you had to. A cesarean is not the end of the world, and it certainly doesn't mean you are any less of a mother or a woman if you have one.

But if you look at it from a public health point of view, the increase in cesareans has serious implications.  On a population-wide basis, a high cesarean rate means more women and babies will die, and even more will have other complications. The only thing that's kept it in relative check up till now is the smaller family size of most women these days.  But although the more serious complications tend to happen in those with multiple repeat cesareans, even women with only one or two cesareans are still at risk. Clearly, cesareans should only be done when the benefits outweigh the risks.

Even if you don't have children, never plan to have children, or don't care about whether people have cesareans or not, your health insurance costs will go up, just to pay for the complications that accompany a high cesarean rate. 

As a matter of public health, a high cesarean rate does matter, and we all need to care about it. 



Study Abstract

Solheim KN, Esakoff TF, Little SE, Cheng YW, Sparks TN, Caughey AB.  The effect of cesarean delivery rates on the future incidence of placenta previa, placenta accreta, and maternal mortality.  J Matern Fetal Neonatal Med. 2011 Mar 7. [Epub ahead of print]

Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, CA, USA.

Objective. The overall annual incidence rate of caesarean delivery in the United Sates has been steadily rising since 1996, reaching 32.9% in 2009. Primary cesareans often lead to repeat cesareans, which may lead to placenta previa and placenta accreta. This study's goal was to forecast the effect of rising primary and secondary cesarean rates on annual incidence of placenta previa, placenta accreta, and maternal mortality.

Methods. A decision-analytic model was built using TreeAge Pro software to estimate the future annual incidence of placenta previa, placenta accreta, and maternal mortality using data on national birthing order trends and cesarean and vaginal birth after cesarean rates. Baseline assumptions were derived from the literature, including the likelihood of previa and accreta among women with multiple previous cesarean deliveries.

Results. If primary and secondary cesarean rates continue to rise as they have in recent years, by 2020 the cesarean delivery rate will be 56.2%, and there will be an additional 6236 placenta previas, 4504 placenta accretas, and 130 maternal deaths annually. The rise in these complications will lag behind the rise in cesareans by approximately 6 years.

Conclusions. If cesarean rates continue to increase, the annual incidence of placenta previa, placenta accreta, and maternal death will also rise substantially.

PMID: 21381881

New Facebook Resource for Big Moms

Good news!  Some friends of mine from the birth and Fat-Acceptance worlds just created a Facebook page for moms of size.   It can be found at:

http://www.facebook.com/pages/The-Ample-Mother/196081560418122

The idea behind the Facebook page is to create a complementary site where women of size can post their pregnancy photos, belly photos, birth photos, breastfeeding photos, etc.  There are also discussion threads available.

Here is an excerpt their blurb:

The Ample Mother was started by two friends, both Ample Mommies! We wanted to create a safe, supportive community where other Ample Mommies could ask questions and share pictures and stories....
While we would like to promote exercise and good nutrition, we do so with the understanding that health is not synonymous with thin, and good health happens at all sizes! We will not focus on weight loss here.

We would like to encourage and enlighten women of size. Casting off the misconceptions based on bias and judgement in order to achieve the best pregnancy, birth and journey into motherhood that one can have....

ICAN Conference Next Week

Next week, the International Cesarean Awareness Network will hold their bi-annual conference.  It will be held in St. Louis, April 8-10. 

Leaders in the childbirth field such Dr. Geoge Macones, Henci Goer, Pam England, Dr. Poppy Daniels, Gail Tully, Geraldine Simkins, Dr. Emmanuel "Mike" Vlastos, and others will be speaking at the conference.  An agenda for the conference can be found here.

Here is a quote from an article about the conference:

"I think we've seen the bottom of the pendulum with the VBAC rate, and it will swing the other way," said Dr. George Macones, an expert in the safety of a vaginal birth after Caesarean.

Color me a little dubious since nothing has changed much in my area......but from his mouth to God's ears!  Since about a third of hospitals and about half of physicans currently do not offer VBACs, it's about time for the pendulum to swing back.

If you have not heard of ICAN before, here is some more information about the organization:

The International Cesarean Awareness Network, Inc. (ICAN) is a nonprofit organization that was founded by Esther Booth Zorn in 1982.

ICAN’s Mission Statement

To improve maternal-child health by preventing unnecessary cesareans through education, providing support for cesarean recovery, and promoting Vaginal Birth After Cesarean (VBAC).

ICAN’s Vision Statement

A healthy reduction of the cesarean rate driven by women making evidence-based, risk appropriate childbirth decisions.

ICAN’s Statement of Beliefs

We, the International Cesarean Awareness Network, Inc., believe that:

1. The inappropriate over use of cesarean surgery is jeopardizing the lives of mothers and babies.
2. When a cesarean is necessary, it can be a lifesaving technique for both mother and baby, and worth the risks involved.
3. Birth is a normal physiological process. Research shows that with emotional support, education, and an honest opportunity, the vast majority of women can have a healthy vaginal birth.
4. A healthy birth incorporates emotional, physical, and spiritual well-being.
5. Research shows that VBAC is reasonable and safe for both mother and baby. A repeat cesarean should never be considered routine– it is major abdominal surgery with many risks.
6. It is unethical and unenforceable for hospitals to institute VBAC bans. Women have the right to refuse any procedure, including a cesarean.
7. Women have the right to true informed consent and refusal, which entails full knowledge of the risks and benefits of all tests, drugs, and procedures.
8. It is incumbent upon every care provider and institution to facilitate the informed consent process.
9. Women must be allowed to express all their birth related feelings in a safe and supportive environment. The emotions of a pregnant and birthing woman have profound effects on the birth outcome and recovery.
10. It is unethical for a physician to recommend and/or perform non-medically indicated cesareans (elective). Women are not being fully informed of the risks of this option in childbirth, and therefore make decisions based on cultural myth and fear surrounding childbirth.
11. The trend of “elective cesareans” is being significantly overstated through distortion of research and data.
12. We as women must now assume more responsibility for our own births.
13. It is critical that women’s choice of care provider and location of birth is respected.

Hope to see you at the conference!