Monday, January 16, 2012

Increased Morbidity After Just One Cesarean

This study is about adverse outcomes in the next pregnancy after just one cesarean.  Women with only one prior cesarean were already at increased risk for anemia, placental abruption (where the placenta pulls away from the uterus before birth, cutting off nutrients and oxygen), uterine rupture, and hysterectomy.

Of course, the actual numerical risk of these complications is generally small, but it does represent an increased risk over women who first birth was vaginal, and that's an important point.

If 1 out of 3 women in the USA is having a baby via cesarean (and in some hospitals, the rate is more like 1 in 2 or more), that's an awful lot of potential risk being put onto women.  And that's after only one cesarean. Most women who have one cesarean will go on to have more with future children because VBAC is not an option in far too many hospitals.

When cesareans save lives, these risks are absolutely worth the trade-off.  When cesareans are used casually or for dubious indications, these trade-offs are much more ominous.

The authors' conclusion is that women who have cesareans need to be counseled about the possible increased risks in future pregnancies. This is true, but the importance of reducing these risks by avoiding that first cesarean whenever possible should also have been mentioned.

Recognizing that cesareans carry risks is an important part of the discussion of the public health implications of a high c-section rate.  

Am J Obstet Gynecol. 2011 Sep 24. [Epub ahead of print] Morbidity following primary cesarean delivery in the Danish National Birth Cohort. Jackson S, et al.   PMID: 22051815
Source: Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, CA. 
OBJECTIVE: Cesarean delivery rates are on the rise in many countries, including the United States. There is mounting evidence that cesarean delivery is associated with adverse reproductive outcomes in subsequent pregnancies. The purpose of this article is to review those outcomes in a well-defined cohort of pregnant women.
STUDY DESIGN: In a cohort of primigravid women from the Danish National Birth Cohort with known baseline exposure characteristics, we stratified women by method of first delivery, vaginal or cesarean, and evaluated for appearance of adverse reproductive events in subsequent pregnancies.
RESULTS: After adjusting for age, body mass index, alcohol, smoking, and socioeconomic status, women who underwent cesarean delivery at first birth were at increased risk in their subsequent pregnancy for anemia (odds ratio [OR], 2.8; 95% confidence interval [CI], 2.3-3.4), placental abruption (OR, 2.3; 95% CI, 1.5-3.6), uterine rupture (OR, 268; 95% CI, 65.6-999), and hysterectomy (OR, 28.8; 95% CI, 3.1-263.8).
CONCLUSION: Women who deliver their first baby with a cesarean are at increased risk of adverse reproductive outcomes in subsequent pregnancies and should be counseled accordingly.

1 comment:

Anna said...

Thanks for posting this. As an LCCE and Labor Doula, I'm reminded about how critical it is before birth to be specific when educating pregnant people about the impact of decisions they make during the labor process - including the follow-up implications of cesarean birth. By the time cesarean is encouraged by the practitioner after a long labor in which many decisions were made that led to that moment, it's often past the point when the laboring woman can chose otherwise. We need more direct conversations that include benefits and risks of all potential decisions in labor.