Placenta Accreta: Brandy's Story

Brandy and her 7th baby postpartum
Notice the large central IV line in her neck and IV line in her arm for quick blood transfusion

As part of Cesarean Awareness Month, we are drawing attention to the high cesarean rate and the public health implications of too many cesareans.

One of the complications of multiple cesareans is that the placenta in a subsequent pregnancy can implant too low in the uterus (placenta previa) or grow into the uterine wall (placenta accreta).

This can cause life-threatening complications, including premature birth, impaired growth, or stillbirth for the baby, and severe hemorrhage, hysterectomy, and even death for the mother. Placental abruption (placenta detaching too early) is another potential risk after a prior cesarean.

We've written about placental complications after cesarean before. As a brief reminder, there are three levels of severity in accretas:

1. Accreta (placenta is abnormally attached to uterus and can't detach easily after birth)
2. Increta (placenta grows into the wall of the uterus and cannot detach after birth)
3. Percreta (placenta grown through the wall of the uterus and into surrounding organs)

Image Source: Reitman 2011, Anesthesiology

[If you are looking for more technical information about placenta accreta, see Part One (what is accreta, how a placenta works), Part Two (risk factors, symptoms, and incidence of accreta), Part Three (risks to mother, baby, and future pregnancies), and Part Four (diagnosis and treatment) of my prior series on placenta accreta.]

This time, rather than writing about what accreta is and how to manage it, we present the first-hand story of one mother's experience with placenta accreta (increta in her case). 

It's important to remember that placenta accreta is real and affects real women and babies. Do enough cesareans, and increasing numbers of women will face this devastating and life-threatening complication. I've known several women now who have been affected by this condition; all suffered severe hemorrhages and several lost their fertility and uteri forever. One lost her baby and very nearly her life too.

That's why it's so important to do cesareans only when medically indicated and to keep VBAC (Vaginal Birth After Cesarean) an option for those who want it.

Brandy's Story

Brandy has had 7 births and 2 miscarriages. 3 of her births were by cesarean.

Yes, high parity is a risk factor for placental complications, but multiple cesareans is a stronger risk factor. Combine the two and the risks multiply.

Her first birth was a c-section after mismanagement by her doctor. She was told she'd never deliver a baby over 8 lbs. and that her babies were "too big" for her to deliver vaginally. She developed a terrible infection and wasn't allowed to hold her baby for 3 days.

Her second birth was a VBAC at 32 weeks. The placenta detached prematurely and baby might have had some lack of oxygen issues. He passed away at 21 months from seizures.

She miscarried her next pregnancy. Her third birth was another VBAC. She had to fight hard for it when her labor stalled for a little while but in the end she had a VBAC.

Her fourth birth was a CBAC (Cesarean Birth After Cesarean). She had a big baby (10 lbs.) and her doctor scared her into a repeat cesarean because of a recent shoulder dystocia in the practice.

Her fifth birth was another CBAC. Her doctor was opposed to a VBA2C. After her water broke and labor did not start for several days, she had the repeat cesarean. The doctor said she had very little scarring and could have more children. The risks of multiple cesareans, including accreta, were never mentioned.

In her next pregnancy, Brandy weighed the potential risks of VBAC after multiple cesareans against the cumulative risks of multiple cesareans and chose VBAC. She stayed at home in order to have a supportive provider. Her sixth baby was a homebirth VBA3C. He was 11 lbs. 4 oz., three lbs. bigger than her first doctor said she could ever birth vaginally.

She had another miscarriage again, then became pregnant a few months later. She planned another VBAC. Unfortunately, this time the fertilized egg implanted low, near the cervix (placenta previa) and the placenta grew into the uterine wall and into the cervix itself (placenta increta).

In the end she lost her uterus and most of her cervix and suffered a severe hemorrhage but was very fortunate to escape with her baby and her life.

This is the story of Brandy's placenta accreta pregnancy and birth.

I was so excited when I found out I was pregnant. I was also very scared since I had just miscarried 8 months prior. At 7 weeks when I started spotting I just knew something was wrong. I had no idea what the real problem was and what I would end up facing.

I decided to go to the ER and get checked. It was a pleasant surprise to see a healthy little heart beat. I did notice on my discharge paper that it was noted that the placenta had attached to the lower uterine segment.

A week went by and I was still spotting. I called my OB and they decided to schedule a ultrasound to check on things. The ultrasound tech noted that I had a short cervical length. I was sent to a perinatologist to see if they wanted to place a stitch. I was very confused. I had already carried 6 other children. I did deliver one of my babies at 32 weeks, but I never had a incompetent cervix.

The perinatologist quickly pointed out that I had a complete posterior placenta previa. I was so upset; I knew that would mean another c-section. I had already had 3 c-sections; I did not want another. I had already begun dreaming of another beautiful HBA3C. I had it in my head how I was gonna make a music list and dance through labor. I was gonna walk around outside in the nice cool October weather. I was looking forward to feeling every contraction and being more relaxed this time since it would be my 2^nd HBA3C. [kmom note: Home Birth After 3 Cesareans]

Time went on and I continued to get ultrasounds monthly. It was always the same thing...the placenta had not moved. I was still spotting everyday; it was there every time I wiped. At one ultrasound appointment my OB made a comment that she saw a lot of placental lakes. I started researching placental lakes and learned that they are seen a whole lot with accreta. I started to worry.

I finally got good news at my 20 week ultrasound. The perinatologist said it looked like the placenta had moved and it was only the tip of it covering my cervix. He did say that there was a blood clot covering the cervix now, but that my body should reabsorb it. I questioned him a little bit about the blood clot. He reminded me that I had been spotting and that is what it was from. I had noticed the spotting had been slowing down so it all made sense. It was good news! The placenta moved some and I had a healthy baby boy. No one had to tell me I was having a boy; he decided to show off for momma.

I left the doctor's office practically skipping. I went and bought a bunch of "It's a Boy" balloons and filled a bag with them to let my other kids tear open. We were all so happy and back to planning our home birth.

At the next ultrasound I was 24 weeks and I just knew they were gonna tell me the placenta had moved more.  The look on the ultrasound tech's face said something was wrong. When she told me she wanted the doctor to see it I felt my stomach go into my throat. 

Two minutes felt like a century as the doctor was looking at the ultrasound. He said, “What I believed was a blood clot last appointment actually looks like a accreta.” He then went on to say that unfortunately with your c-section history and what this looks like, it I am pretty sure we will have to take your womb. 

He went on to show me how vascular one section of the uterus was. He continued to talk about unfortunately this is like the weather, there is nothing you can do about it. He continued to talk and all I heard was some mumble about any OB can do a hysterectomy and I should be able to deliver at my local hospital.

I was numb, how could this be. I waited at the check-out desk trying to breathe, trying not to cry. I got my card for my next appointment as the tears started to fall. I don’t know how I walked to my car. My phone rang and I could not get out hello.

After I had a little while to process things and talk to a few people I decided to go to get a second opinion in Baltimore. The blood clot theory made sense. My spotting stopped at 22 weeks.  I figured that was a good sign. The specialist in Baltimore knew more about accreta and could give me better answers.

Once I got to my appointment in Baltimore, that look the first tech had, I saw it all over again. This look of fear, maybe even confusion, just like the tech before she went to go get the doctor. He showed me that the placenta was supposed to look black on the ultrasound and there was these weird gray areas. He told me that at the least we were dealing with increta, but that he believed it was percreta. 

He went on to say all my care would be transferred there. That with this condition there would be massive blood loss and my local hospital could not handle delivering me. I tried to be strong but I burst into tears. We decided to do a MRI to try to get a better ideal if any of my other organs were involved.

Everything then just became a blur. I spent every Monday in Baltimore seeing doctors and having ultrasounds. The group of specialist were waiting on the MRI results to decide whether to deliver closer to 34 or 36 weeks.

Once the MRI results came back it looked like no other organs were involved but that the placenta was invading the uterine wall. I was so happy to get the news that none of my other organs were involved. That was the first time through all of this I got good news. It is funny looking back now how wonderful that news really was to me.  Since I was doing good and had no bleeds they decided to schedule my c-section at 36 weeks. Some of the doctors were still hopeful that once they got in there the placenta would detach easily.

I had 6 weeks until delivery and I was trying to understand and accept things. I was terrified. I felt like a ticking time bomb. I could not sleep. My husband was working nights so I was alone with 4 little ones, eight and under. I was scared I would have a bleed in the middle of the night and the kids would be terrified. When I did sleep I would have nightmares of having a c- section and my incision opening up and I was standing there holding my insides. 

I would hold my little ones and wonder if  I would be able to see them grow up. I would think, "My 2 year-old will not remember me." I think all these thoughts but had no patience with my kids. Then I would think if I don’t make it all they will remember is me snapping at them. 

One of the hardest things I had to deal with was knowing that the people that got me here by doing 3 unnecessary c-sections on me were the same people I now had to trust to get me out of this.

As the weeks went by I realized that I had no control over the outcome. I had to do the best I could and control what I could and give the rest to God.  I had to believe that even if I did not make it through that God would take care of my kids and it would be OK.

Days before my delivery I had to go do pre-op blood work and meet with anesthesia. I was told with the blood loss they were expecting I may have a lot of swelling and fluid in my lungs. They may have to keep me asleep until Friday until the swelling went down. They wanted my family to be prepared. That broke my heart to think I may not see my baby on the day he was born. They said I would go home with a bladder bag if they had to do the hysterectomy. With the scar tissue from my c-section they were sure that they would rip my bladder when they removed my uterus.

Delivery day came saying good bye to my kids was one of the hardest things I ever had to do. They were so excited to meet their brother the next day. And I had no idea if I would ever meet my baby or see my other kids again. 

I got to the hospital around midnight. They got me situated in my room and then let me sleep for a few hours. I would doze off for a few minutes then wake back up with a knot in my stomach and a lump in my throat. I didn't want to be there. I wanted to run far far away from that place.

At 6 a.m. they came in and started to get me prepped for surgery. We had decided that it was best for me to just be put under general. My surgeon was afraid he would lose time if I began to hemorrhage and they had to put me under then. They did not want the baby to be under general any longer then he had to. 

All the prep was done in my room. Anesthesia came and placed a central line in my neck and a large IV in my wrist; both of those were for blood transfusion. They also placed a monitor in my wrist that would send labs and gives them second-by-second blood pressure reading. By this time I was numb, I had shut down. I just prayed and sang worship songs in my head and took myself away from there.

My surgeon came in and did a quick ultrasound to see where he was gonna cut.  As funny as it sounds I was still hoping that he was gonna find that the placenta had moved.

Once it was time to go to the OR the two main surgeons wheeled me down. My husband got off on another floor to wait in the waiting room. I just wanted to scream, “NO!” I didn't want my husband to go. I wanted him there when I fell asleep. I just gave him a kiss and told him I will see you in little while. He said a quick prayer and slipped off the elevator.

We were outside the O.R. doors and had to wait. The blood bank had not brought down the blood that was to be on stand-by in the O.R. There were doctors everywhere. My neck hurt so bad from the central line. I could barely move. And there was so many people coming up introducing themselves. MY nurse kept saying, “Oh my goodness, everyone is here.” She said, "You have the best of the best!"

All of a sudden here comes two big coolers. I just hear everyone say, “OK, let's go.” My surgeon told me, "I have been resting for 2 days for your surgery." 

I said, “Hey, you have to take good care of me. I have lots of little ones that need me.” He said, “Brandy, we know what you got and we are gonna take good care of you.”

Things got real busy in the O.R., they put the oxygen mask on me, and kept telling me to to take nice slow breaths. The mask made me feel like I could not breathe. I was getting frustrated that I was not asleep yet. I wanted it over. No matter what the outcome was gonna be I was ready to get there. Everyone was rubbing my arms telling me that they were there and they aren't gonna leave, that I was OK. I remember thinking I am never gonna fall asleep.

I heard, "Don’t talk, you still have the breathing tube in." I raised my arm and started to write in the air. The nurse got me a paper and pen. I wrote "b" and dozed off, I wrote "a" and dozed off. The nurse said, "Are you writing 'baby'?" and I shook my head yes! She told me that he was healthy, 7lbs 2.5 oz. He had no problems and went straight to the newborn nursery.

They took the breathing tube out and I said, "Is it Friday?" and the nurse said, "No, it is Thursday, 2 in the afternoon!" I was so so happy my baby was OK and I was still here. It was finally over! The worry, the fear, the unknown!

My surgeon came and held my hand and  told me that they did have to do the hysterectomy, the main vein in the placenta had grew very deep into my cervix. They also had to take most of my cervix. I lost 7 ½ liters of blood. I was given 13 units of blood products. 

[kmom note: 7.5 L is 7500 ml. Normal blood loss in a vaginal birth is 500 ml; 1000 in a cesarean. She had more than 7x the normal blood loss for a cesarean.]

I didn't care at that point. I was alive, my baby was healthy! We made it to the other side. PRAISE GOD we were OK!

I met my little man when he was 8 hours old. He is perfect. I would do it all again to have him. We have both done very well recovering physically. I didn't need a bladder bag after all. I delivered on a Thursday and we came home together on Sunday. 

But emotionally it has not been so easy. I do sit here in disbelief sometimes wondering why me? Other days I get angry. I want to punch something and yell GIVE ME MY UTERUS BACK! I mourn the loss of my fertility, the loss of his birth and the first 8 hours of his life. The loss of my last pregnancy. The loss of some relationships that have been damaged through all this for one reason or another.

I share my story not to scare anyone. I know what it feels like to be scared into something. I would never want to do that to someone else. I just want women to be aware of all possible complications. I want women to be able to give true consent and be aware of all risks. 

If sharing my story saves one women from having a different ending than me then it wasn't all for nothing. Accreta is not talked about, but it is real, very real!

Preventing the First Cesarean: Don't Go to the Hospital Too Early

Dark line with squares is overall cesarean rate,
Light line with triangles is primary cesarean rate,
Line with diamonds that goes up and then plummets is the VBAC rate

As part of Cesarean Awareness Month, we are discussing the long-term implications of a high cesarean rate, as well as how to lower the sky-high cesarean rate in women of size.

One of the important parts of lowering the overall cesarean rate is preventing the first (or "primary") cesarean.

As you can see from the chart, the primary cesarean rate (middle line) has risen over the years pretty much in parallel with the overall cesarean rate, even as the VBAC (Vaginal Birth After Cesarean) rate has drastically declined.

The VBAC rate has declined so strongly because many places have VBAC bans in place. Once a woman has that first cesarean, she usually has repeat cesareans thereafter, unless she is one of the lucky ones who can find a provider that is truly willing to support VBAC.

Thus the first step to lowering the high overall cesarean rate is to prevent the very first cesarean from happening whenever possible.

And one important step in preventing primary cesareans is not going to the hospital too early in labor. 

Research has shown that when women are admitted early in labor ("latent" labor), they have a much greater chance of having a cesarean than if they get to the hospital a bit later, when contractions are consistent and dilation starts to change more quickly ("active" labor).

In fact, a recent consensus statement from the American Congress of Obstetricians and Gynecologists and the Society for Fetal-Maternal Medicine suggests that the definition of "active" labor be changed from 4 cm to 6 cm.

Lamaze International has highlighted this with their related discussions on "Six is the New Four."

This proposed change is based on research that suggests that labor tends to progress more slowly in the early stages of labor than recognized in previous guidelines, and that many "failure to progress" cesareans might be prevented by being just a little bit more patient during labor.

Below is yet another study that confirms the importance of not going into the hospital until labor is well-established and "active."

In this study, more than half the women were admitted during "preactive" labor, and those that were had more than twice the c-section rate of those who were admitted in active labor.

If half of women are regularly being admitted into the hospital during latent labor, this strongly suggests that delaying admission to the hospital until labor is truly in the "active" phase might help lower the primary cesarean rate significantly.

This may be a particularly important consideration for women of size. Some research suggests that "overweight" and "obese" women have longer labors, especially in the stage just before transition. Although no one has actually studied yet whether delaying admission until 6 cm in obese women would lower cesarean rates in that group, it certainly seems like a logical conclusion.

In combination with lowering unnecessary induction rates and being more patient in labor, delaying hospital admission until 6 cm might really help impact the cesarean rate in obese women.

Summary

The take-home message for mothers is that if you plan to birth in the hospital, don't rush to the hospital in early labor.

Obviously, if there is something that is concerning you or doesn't feel right, it's important to be evaluated, and you should not hesitate to go in and ask for evaluation. Certain other medical situations, of course, might also call for early evaluation; your care provider will help you determine the situations to be cautious about.

However, most of the time, there is no need to be in the hospital right away if labor has started. The sooner you go in, the more likely you are to have interventions like oxytocin augmentation and cesareans.

The take-home message for hospitals is to have stricter admissions policies, given that around half of women are being admitted in early labor. The secondary message is to allow more time in labor before moving to a cesarean (barring fetal distress); a "failure to progress" cesarean is too often a "failure to wait" cesarean.

Bottom line: To lower the rate of primary cesareans, wait till labor is well-established before going to the hospital, and practice more patience during labor before moving to a cesarean if all else is well. 


References

J Midwifery Womens Health. 2014 Jan;59(1):28-34. doi: 10.1111/jmwh.12160. Epub 2014 Feb 11. Outcomes of nulliparous women with spontaneous labor onset admitted to hospitals in preactive versus active labor. Neal JL, Lamp JM, Buck JS, Lowe NK, Gillespie SL, Ryan SL. PMID: 24512265

INTRODUCTION: The timing of when a woman is admitted to the hospital for labor care following spontaneous contraction onset may be among the most important decisions that labor attendants make because it can influence care patterns and birth outcomes. The aims of this study were to estimate the percentage of low-risk, nulliparous women at term who are admitted to labor units prior to active labor and to evaluate the effects of the timing of admission (ie, preactive vs active labor) on labor interventions and mode of birth. METHODS: Data from low-risk, nulliparous women with spontaneous labor onset at term gestation were merged from 2 prospective studies conducted at 3 large Midwestern hospitals...RESULTS: Of the sample of 216 low-risk nulliparous women, 114 (52.8%) were admitted in preactive labor and 102 (47.2%) were admitted in active labor. Women who were admitted in preactive labor were more likely to undergo oxytocin augmentation (84.2% and 45.1%, respectively; odds ratio [OR], 6.5; 95% confidence interval [CI], 3.43-12.27) but not amniotomy (55.3% and 61.8%, respectively; OR, 0.8; 95% CI, 0.44-1.32) when compared to women admitted in active labor. The likelihood of cesarean birth was higher for women admitted before active labor onset (15.8% and 6.9%, respectively; OR, 2.6; 95% CI, 1.02-6.37). DISCUSSION: Many low-risk nulliparous women with regular, spontaneous uterine contractions are admitted to labor units before active labor onset, which increases their likelihood of receiving oxytocin and giving birth via cesarean. An evidence-based, standardized approach for labor admission decision making is recommended to decrease inadvertent admissions of women in preactive labor. When active labor cannot be diagnosed with relative certainty, observation before admission to the birthing unit is warranted.

Previous Research on Early Admission in Labor

Midwifery. 2013 Dec;29(12):1297-302. doi: 10.1016/j.midw.2013.05.014. Epub 2013 Jul 24.
Influence of timing of admission in labour and management of labour on method of birth: results from a randomised controlled trial of caseload midwifery (COSMOS trial). Davey MA1, McLachlan HL, Forster D, Flood M. PMID: 23890679

OBJECTIVE: to explore the relationship between the degree to which labour is established on admission to hospital and method of birth...SETTING: a large tertiary-level maternity service in Melbourne, Australia. PARTICIPANTS: English-speaking women with no previous caesarean section at low risk of complications in pregnancy were recruited to a randomised controlled trial. Trial participants whose management did not include a planned caesarean and who were admitted to hospital in spontaneous labour were included in this secondary analysis of trial data (n=1532)... RESULTS: ...Pooling the two randomised groups of nulliparous women, and after adjusting for randomised group, maternal age and maternal body mass index, early admission to hospital was strongly associated with caesarean section. Admission before the cervix was 5 cm dilated increased the odds 2.4-fold (95%CI 1.4, 4.0; p=0.001). Augmentation of labour and use of epidural analgesia were each strongly associated with caesarean section (adjusted odds ratios 3.10 (95%CI 2.1, 4.5) and 5.77 (95%CI 4.0, 8.4) respectively. CONCLUSION: these findings that women allocated to caseload care were admitted to hospital later in labour, and that earlier admission was strongly associated with birth by caesarean section, suggest that remaining at home somewhat longer in labour may be one of the mechanisms by which caseload care was effective in reducing caesarean section in the COSMOS trial.

J Obstet Gynecol Neonatal Nurs. 2003 Mar-Apr;32(2):147-57; discussion 158-60.
Impact of collaborative management and early admission in labor on method of delivery.
Jackson DJ1, Lang JM, Ecker J, Swartz WH, Heeren T. PMID: 12685666

OBJECTIVE: This study compared the effects of early admission in labor and perinatal care provider on delivery method. Higher spontaneous vaginal delivery rates for certified nurse midwives as compared with physicians have been reported in observational studies and randomized clinical trials. Certified nurse midwives, with their more expectant approach to labor management, would be expected to admit women later in labor than obstetricians. METHODS: Prospective cohort study of 2,196 low-risk pregnancies, with singleton, vertex infants admitted in spontaneous labor. Independent and joint effects of perinatal care provider and cervical dilation at admission on delivery method were evaluated... RESULTS: Fewer (23.4%) women in collaborative care were admitted in early labor (< 4 cm cervical dilation) than women managed by obstetricians (95% CI = -27.6 to -19.2). Obstetrician care had 9% to 30% fewer spontaneous vaginal deliveries. Women admitted early in labor also had 6% to 34% fewer spontaneous vaginal deliveries. Evaluation of joint effects suggested that interaction between obstetrician provider and earlier admission increased the risk of operative delivery. CONCLUSION:
Later admission in labor (at 4 cm or greater cervical dilation) and management of perinatal care by certified nurse midwives in collaboration with obstetricians increased the rate of spontaneous vaginal delivery in low-risk women.

Long-Term Implications of a High Cesarean Rate in Obese Women

April is Cesarean Awareness Month.

This is an annual observance sponsored by the International Cesarean Awareness Network (ICAN) to raise awareness of the implications of a high cesarean rate and lack of access to VBAC (Vaginal Birth After Cesarean).

It's always important to remind readers that this observance is not meant to make anyone feel bad about having had a cesarean, or to imply that having a cesarean makes you "less of a mother" or "less of a woman." Nonsense.

Cesareans can be life-saving and wonderful when used appropriately, but they are not risk-free. When over-utilized, they can have dramatic negative consequences too, especially long-term.

Cesarean Awareness Month is not about any one person's experience at all, but rather about the widespread public health implications of a high cesarean rate and lack of access to VBAC. And this certainly is an under-appreciated public health care issue.

Long-Term Risks of Too Many Cesareans

As we posted about extensively last year, one of the overlooked long-term consequences of a high cesarean rate is an increase in the risk for placental disorders.

Specifically, there is a substantial increase in the risk for:

• placenta previa (a low-lying placenta which is near or which covers the cervix)
• placental abruption (where the placenta pulls away from the uterus prematurely)
• placenta accreta (an abnormally-attached placenta that does not detach after birth). 

Here is yet another study that confirms cesarean section as a strong risk factor for placental disorders.

Although this meta-analysis does not evaluate the risk by number of prior cesareans, merely by the presence of prior cesarean, a number of other studies have shown that the risk increases strongly with multiple prior cesareans in a dose-dependent manner.

This is why it is important not to have cesarean after cesarean unless it is medically necessary, and why the ban on VBACs in many hospitals is so frustrating.

The ban on VBAC (Vaginal Birth After Cesarean) in some places means that thousands of women have been and are continuing to be subjected to unnecessary cesareans. This in turn is raising the incidence of placental disorders like previa, abruption, and accreta, as well as maternal morbidity from the surgeries and the very serious complication of cesarean scar pregnancy.

Although with good care, many of these complications can be handled, they do often result in life-threatening hemorrhages, bladder or renal damage, uterine ruptures, hysterectomies, prematurity, stillbirth, and even maternal deaths at times.

Although these complications are overall rare, they are happening to real women, with real results, sometimes devastating ones.

This is why it is SO important to do cesareans only when truly indicated, to avoid automatic repeat cesareans, and to keep VBACs available as an option everywhere.

Implications for Women of Size

Long-term complications of cesareans is a particularly pertinent issue for women of size.

If a 32.8% overall national c-section rate is too high, then the rate in "obese" women is an even GREATER reason for concern because in most studies it starts at 30% and goes as high as 40%, 50%, 60%, and even 70% in some places and groups.

And many of the cesareans done in obese women are done without any labor at all. Many care providers have a de-facto policy of automatic "elective" cesareans for very obese women, despite the fact that this does not improve outcomes.

This disproportionately exposes the larger mother to the risks of cesareans (hemorrhage, infection, blood clots, bladder injury, and anesthesia problems) and subsequent placental disorders. This is insane. Yet few in the obstetric community even question the high cesarean rate in obese women.

This is why observing Cesarean Awareness Month is so important. It's not about putting down anyone who had a c-section, but to raise awareness of the health implications of a too-high cesarean rate.

In addition, it's time for care providers to focus on the implications of the sky-high cesarean rate in women of size and what can be done to lower that rate.

This is why I always observe Cesarean Awareness Month here and why I urge others to do so too.


References

Cesareans and Subsequent Placental Disorders

J Perinat Med. 2014 Feb 24. pii: /j/jpme-ahead-of-print/jpm-2013-0199/jpm-2013-0199.xml. doi: 10.1515/jpm-2013-0199. [Epub ahead of print] Cesarean section and placental disorders in subsequent pregnancies - a meta-analysis. Klar M, Michels KB. PMID: 24566357

...OBJECTIVE: To examine the association between CS and three major types of placental disorders (placental abruption, placenta previa, and placenta accreta with its variants increta/percreta) in subsequent pregnancies. SEARCH STRATEGY: ...observational studies published between January 1990 and July 2011 for examining the association between CS and placental disorders in subsequent pregnancies, without focusing on the effect of increasing number of CSs... DATA COLLECTION AND ANALYSIS: Five cohort and 11 case-control studies met the inclusion criteria for this meta-analysis...MAIN RESULTS: The calculated summary odds ratio was 1.47 (95% confidence interval, CI: 1.44-1.51) for placenta previa, 1.96 (95% CI: 1.41-2.74) for placenta accreta, and 1.38 (95% CI: 1.35-1.41) for placental abruption. CONCLUSION: In this meta-analysis, cesarean delivery appeared as a consistently reported risk factor for all three major forms of placental disorders in subsequent pregnancies.

Obstet Gynecol Clin North Am. 2013 Mar;40(1):137-54. doi: 10.1016/j.ogc.2012.12.002. Placenta accreta, increta, and percreta. Wortman AC, Alexander JM. PMID: 23466142

Placenta accreta is an abnormal adherence of the placenta to the uterine wall that can lead to significant maternal morbidity and mortality. The incidence of placenta accreta has increased 13-fold since the early 1900s and directly correlates with the increasing cesarean delivery rate...

Placenta. 2012 Apr;33(4):244-51. doi: 10.1016/j.placenta.2011.11.010. Epub 2012 Jan 28. Placenta accreta: pathogenesis of a 20th century iatrogenic uterine disease. Jauniaux E, Jurkovic D. PMID: 22284667

...Overall these data support the concept that abnormal decidualization and trophoblastic changes of the placental bed in placenta accreta are secondary to the uterine scar and thus entirely iatrogenic.

Am J Obstet Gynecol. 2011 Dec;205(6 Suppl):S2-10. doi: 10.1016/j.ajog.2011.09.028. Epub 2011 Oct 6. Long-term maternal morbidity associated with repeat cesarean delivery. Clark EA, Silver RM. PMID: 22114995

Concern regarding the association between cesarean delivery and long-term maternal morbidity is growing as the rate of cesarean delivery continues to increase. Observational evidence suggests that the risk of morbidity increases with increasing number of cesarean deliveries. The dominant maternal risk in subsequent pregnancies is placenta accreta spectrum disorder and its associated complications. A history of multiple cesarean deliveries is the major risk factor for this condition. Pregnancies following cesarean delivery also have increased risk for other types of abnormal placentation, reduced fetal growth, preterm birth, and possibly stillbirth. Chronic maternal morbidities associated with cesarean delivery include pelvic pain and adhesions. Adverse reproductive effects may include decreased fertility and increased risk of spontaneous abortion and ectopic pregnancy. Clinicians and patients need to be aware of the long-term risks associated with cesarean delivery so that they can be considered when determining the method of delivery for first and subsequent births.

J Matern Fetal Neonatal Med. 2011 Nov;24(11):1341-6. doi: 10.3109/14767058.2011.553695. Epub 2011 Mar 7. The effect of cesarean delivery rates on the future incidence of placenta previa, placenta accreta, and maternal mortality. Solheim KN1, Esakoff TF, Little SE, Cheng YW, Sparks TN, Caughey AB. PMID: 21381881

OBJECTIVE: The overall annual incidence rate of caesarean delivery in the United States 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.

Obesity and Over-Utilization of Cesareans

Am J Obstet Gynecol. 2012 May;206(5):417.e1-6. doi: 10.1016/j.ajog.2012.02.037. Epub 2012 Mar 7. Maternal superobesity and perinatal outcomes. Marshall NE1, Guild C, Cheng YW, Caughey AB, Halloran DR. PMID: 22542116

OBJECTIVE: The purpose of this study was to determine the effect of maternal superobesity (body mass index [BMI], ≥ 50 kg/m(2)) compared with morbid obesity (BMI, 40-49.9 kg/m(2)) or obesity (BMI, 30-39.9 kg/m(2)) on perinatal outcomes. STUDY DESIGN: We conducted a retrospective cohort study of birth records that were linked to hospital discharge data for all liveborn singleton term infants who were born to obese Missouri residents from 2000-2006. We excluded major congenital anomalies and women with diabetes mellitus or chronic hypertension. RESULTS: There were 64,272 births that met the study criteria, which included 1185 superobese mothers (1.8%)...Almost one-half of all superobese women (49.1%) delivered by cesarean section, and 33.8% of superobese nulliparous women underwent scheduled primary cesarean delivery. 

BJOG. 2011 Mar;118(4):480-7. doi: 10.1111/j.1471-0528.2010.02832.x. Epub 2011 Jan 18.
Planned vaginal delivery or planned caesarean delivery in women with extreme obesity.
Homer CS1, Kurinczuk JJ, Spark P, Brocklehurst P, Knight M. PMID: 21244616

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...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.