Nursing Birth

One Labor & Delivery Nurse’s View From the Inside

More Risks for Baby With Repeat C-Sections May 24, 2009

A new study entitled Neonatal Outcomes After Elective Cesarean Delivery published in the June issue of Obstetrics & Gynecology (aka “The Green Journal” published by American College of Obstetrics & Gynecology (ACOG)) concluded that:

 

“In comparison with vaginal birth after cesarean, neonates born after elective repeat cesarean delivery have significantly higher rates of respiratory morbidity and NICU-admission and longer length of hospital stay.”

 

The journal article begins with the following introduction:

 

“In 2006, the United States cesarean delivery rate of 31.1% was at an all-time high, making cesarean delivery the most common surgical procedure performed in American women.  This high rate of cesarean delivery is attributed to the rise in primary cesarean delivery rates from 14.6% in 1996 to 20.3% in 2005, an increase of 60%.   With the rates of vaginal births after cesarean delivery (VBAC) at an all-time low of 7.9% in 2005, women who have a primary cesarean delivery have a greater than 90% chance of having a repeat cesarean delivery, only serving to increase the overall cesarean delivery rate.   Almost one half of cesarean deliveries, a rate of 15%, are done electively, before the onset of labor.”

 

This study found that neonates born by intended cesarean delivery were more prone to NICU admission for:

 

1)      hypoglycemia (low blood sugar),

2)      needing higher rates of oxygen supplementation,

3)      needing intubation/ventilator support

 

This study’s findings were consistent with the multiple studies previously done that documented respiratory morbidity in neonates born after elective repeat cesarean delivery, particularly with an increase in:

 

1)      respiratory distress syndrome,

2)      transient tachypnea of the newborn,

3)      persistent pulmonary hypertension,

4)      need for supplemental oxygen

5)      respiratory morbidity related to failure to clear fetal lung fluid related to birth without benefit of labor

 

The authors write:

 

“While the common perception is that conditions such as transient tachypnea of the newborn are benign, self-limiting illnesses, several studies indicate that neonates with such conditions can progress to severe respiratory failure, leading to the need for extracorporeal membrane oxygenation or death.”

 

This study really hits home for me since I had to scrub three, count them, THREE primary elective cesarean sections the other week, all attended by the same physician, for the most outrageous and bogus reasons EVER!  Stay tuned….More on elective primary cesarean section to come!

 

To read the full text of this study click here.

 

To read the Health Day newspaper article on this study check out Yahoo! News.

To learn more about Vaginal Birth After Cesarean (VBAC) and the risks of Repeat Cesarean Section, please visit ICAN’s website.

 

Special THANKS to The Feminist Breeder for alerting me to this study!

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16 Responses to “More Risks for Baby With Repeat C-Sections”

  1. The positive is that those three women had you there as a nurse to make sure they had as nice a birth experience as you can have with a c-section, right?

    Do you do anything special (for lack of a better word) during c-sections? Keep meaningless staff chatter at bay, keep lights a bit lower, keep parents informed along the way, etc. Is there anything you can do?

    • nursingbirth Says:

      Jill-Unnecesarean…depends on the doctor. I do my best to make a cesarean section as nice of an experience as major abdominal surgery can be. After my assessment I wrap the baby up and give her/him to dad/partner who will sit by mom’s head and either hold the baby or help prop the baby up on mom’s chest so she can hold the baby. I try to get the baby to breast within 15 minutes of being in the recovery room (after i make sure here vitals/bleeding is stable) and I encourage unlimited breastfeeding and/or skin to skin the entire time in the recovery room. Because of a big stink I made at my hospital we now allow dad and a doula if the couple has one in to the OR. As far as dim lights…that’s still up the the OB. I do as best as I can. THat being said, C/S no matter how much dim lighting, doulas, or breastfeeding we promote are STILL major abdominal surgery and I hope that they more “humanized” cesarean birth movement isnt going to backfire on us so that families feel like its no big deal to have a cesearan so we skyrocket our c/s rate even more. I can see it now…OBs saying…”Why go through the *pain* and *uncertainty* of a VBAC when you can just have an “as human and nice as possible cesarean birth” scheduled for whenever you want! OH BROTHER!! I can see it now!! AHHH!!

  2. Lydia Says:

    I’m curious about the decline in VBAC rates. I keep hearing about hospitals and/or doctors who no longer allow VBACs. Who is making these decisions? Hospital administrators, or doctors? Insurance companies? Why do you think they’re more afraid of VBACs than of elective repeat C-sections?

    • nursingbirth Says:

      Lydia, I really should write a post on your comment because it is a GREAT one! Please if you can read the book “Born in the USA” by Marsden Wagner. Here’s a brief synopsis…. It goes into detail about how new ACOG guidelines in 2004 (i believe its 2004) published a new position statement saying that all hospitals need to have 24/7 on call in house anesthesia, attending OB, and OR staff in order to do VBACs. This “requirement” could not be met by many smaller community hospitals. This coupled with some insurance companies requiring higher malpractice insurance premiums for OBs who attend “the risky VBAC” (sarcasm noted, as if repeat cesareans have no risk…a NON TRUTH) many OBs stopped doing them because of that. After all, repeat cesareans are way more convenient for the OB anyhow. And repeat C/S are something only OBs can do, not family practice docs or midwives. Talk about job security. If you get a chance go to the library/book store and check out that book…it really blew my mind.

  3. Jackie Says:

    That is why I have to travel 3.5 hrs to deliver my next baby because I refuse to do an elective repeat C-Section. I had such a horrible experience with my c-section that I could never do a repeat unless medically necessary. I had 3 vag deliveries and then c-section due to footling breech. My local hospital refuses to do VBAC’s and so do all of the Doctors. I have heard because of insurance reasons.

    • nursingbirth Says:

      Jackie, you are an awesome woman and an awesome mom for traveling 3.5 hours to get the birth experience you want and deserve!! For goodness sake you had three vaginal deliveries before your cesarean! I’d like to march up to those hospital admins, ACOG, and all the OBs that wont “do” VBACs and say “Okay why dont YOU take care of my 4 KIDS while I recover from my repeat cesarean section!” All I can say is YOU GO GIRL! I hate that you have to go through all this but I applaud you for it!

  4. MM Says:

    I wonder if these “elective” cesareans were really elected by the women or if their OB’s were all about “well, honey, you don’t have anything going on down there, your due date is tomorrow, let’s just go ahead and have this baby”.

    I know that many women seem fine while they are in the hospital recovering, but I worry about them 3-6-9 months down the line. After they start getting some real sleep, when they’ve found their groove. That’s usually when I get a phone call that they are struggling and they found my ICAN chapter’s contact info online. It is something I hear over and over (and OVER) again.

    What’s the informed consent process like at your facility? I know at our local hospitals it is a joke because if it were true informed consent, they would not have a 50% c/s rate.

    • nursingbirth Says:

      MM….you write “I wonder if these “elective” cesareans were really elected by the women or if their OB’s were all about “well, honey, you don’t have anything going on down there, your due date is tomorrow, let’s just go ahead and have this baby”.”

      You nailed it sister. STay tuned for a post on elective primary c/s at my hospital!!!

  5. Kim Says:

    Hey I was looking for an email or something, but I guess the best way to talk to you is through comments. So sorry, but this is unrelated.

    I was wondering if you have thought about having a Q&A section to your blog. I know you’re a busy person so I understand if that’s too much! It’d be awesome to get your take on some things though.

    Anyone else chime in too since I know we have a lot of experience hanging around here.

    I was wondering about birthing positions. The (very few) births I’ve seen have been all natural. However one thing I wonder about is this….regardless of the mom’s previous desire, all of those moms have ended up pushing in a semi-sit or reclined position usually with lots of leg support. Some of them wanted to squat and some of them wanted to do hands and knees. By the time we got there though, when I asked if they still were interested, they didn’t really seem to be anymore, or they were so into it that it didn’t feel right to try to get them to move…especially being the only person there interested in doing so.

    I guess it bothers me because I feel like I’m not giving them something they wanted and are too tired or too zoned out to ask for themselves. I know birth plans change and you have to stay in the moment, but I wonder if they’re really okay to do that of if they just go for it because it’s easier for everyone including the midwife. Also, if I want to do a different position in my own birth, will I just give up and not have the strength?

    Also physically speaking, what are the pros/cons about reclining? I would imagine it would push the tailbone in. Wouldn’t it?

  6. I second the request for a Q & A section!

  7. doctorjen Says:

    I haven’t commented before, although I’ve been reading a while! Wanted to actually address another commenter – not so much your post, although that study saddens me. I’m no longer allowed to attend VBACs on purpose (I had an accidental one a few mos ago!) I’m a family doc that attends births, but our hospital changed it’s policy at the urging of the perinatologists in our referral hospital (we are a small community hospital with a Level II nursery, so we have to have a signed perinatal agreement with a tertiary care center with a Level III) Our new policy is that VBACs can only happen if the OB, an anesthesiologist, and the surgery team are waiting in house for the entire labor. The OBs don’t want to sit in house for their own clients, let alone mine, so I can’t attend VBAC moms any longer. Prior to the change, I had an over 90% success rate for VBAC, so it really sucks to not be able to even offer them anymore.

    On positions for birth: this is something I worked and worked on in my own practice. If you want to attend upright births (which all evidence suggests is preferable for most women) you have to have a culture shift in how you act. When I first started practicing, after training in a hospital that featured standard modern medical obstetrics, I really wanted to let my clients choose thier own positions. However, it seemed like every client “didn’t care” in the end, and ended up in the standard stranded beetle position. It took some work to make changes. First, I encouraged my clients to practice upright positions in late pregnancy, and during labor, I’d suggest an upright position any time a client looked uncomfortable, or was asking for help. Once clients got comfortable trying out hands and knees or squatting, they were quicker to try it themselves. If they’d tried upright positions in labor, they were more likely to naturally try them during pushing, too. I worked with the nurses getting comfortable with a lot of differnet positions. We try hard to not get people all tied up to stuff – and if they are hooked up because they have an epidural, or IV, and the monitor, we try to keep all cords on one side of the bed so it’s easier to grab them and move. When it’s obvious women are hitting transition, I try not to do things that direct people to the bed on their back – so I don’t start setting up pads on the bed, or encourage women to lie down. If a mama says “Can I get up?” we say yes! and the work to make it happen. I tell my nurses again and again there is nothing special about the bed that makes it a safer place to have the baby – it isn’t safer than the rocking chair, or the floor, or the toilet, or whatever – we can monitor as we need to wherever we are (we have dopplers if appropriate, or telemetry monitors if needed.) Also, the birth attendant has to get comfortable. Right after training, I felt like I needed to be doing something while women were pushing. In upright positions, it’s much harder to be messing with the perineum (which is a GOOD thing as far as I’m concerned, but hard to get used to if you’ve been trained to think you have to be stretching things or something.) You have to trust that women’s bodies know how to push a baby out even if you don’t have full view of the perineum. You have to be comfortable sitting on the floor, or leaning and reaching to catch – instead of having everything set up perfectly for your comfort.

    Once I started truly encouraging upright positions, it turns out women really do prefer them! It’s rare now for me to attend a birth in the semi-sitting position (although it happens occasionally, as some women do truly prefer it.) As a doula or nurse, I think would be harder, but you can still encourage women to practice ahead of time, and to advocate for themselves, and encourage them to avoid just pushing cause they’re 10 or whatever, but to stay mobile and upright until they just can’t not push (which delays a provider getting their hands in there while they are pushing.)

  8. Krista Says:

    Lydia, speaking only from personal experience, I’ve found that most of the “bans” I’ve seen aren’t really official bans, just that no doctor affiliated with that hospital will attend a VBAC. There are some hospitals who do have bans and that decision was probably made by the hospital administration. Sometimes its made because the doctors would have to pay a higher insurance premium (to cover malpractice) if they attend VBACs….I personally switched from an OB for my 1st VBAC (who really did believe in VBACs) because the other OBs who covered for him did not attend them and I was told I would have to be induced early to make sure he was on call (which of course I did not agree to and switched to another OB). So, I think there are a variety of reasons why there are so many “VBAC bans”.

    Kim, about positions, I think if you have good communication with your clients (sounds like you’re a doula, right?) and you support what they want to do, you are doing your job well. For my 1st VBAC, I was semi-reclined….very traditional. I didn’t really know any different and I had a very long and hard labor and was just tired. I was definitely not open to any additional positions at that time. However, with my 2nd VBAC, I did not want to be in bed at all. I stood my entire labor and only got in bed when I needed to be checked. My midwives were open to me birthing in whatever position I wanted. I did have my son standing up. I remember being a little worried wondering how it was all going to work and if my midwives hadn’t been so supportive of me standing, I probably would have gotten into bed to birth. Out of curiosity, are your clients disappointed afterward that they were in bed? If they’re not bothered, I wouldn’t worry about it, but if they wish they had gone a different route and tried something, then maybe with future clients you can talk about that and come up with a plan. I know that the things I talked about with my doula before hand were easier to handle when they came up during my actual labor.

  9. I want to tag on to Dr. Jen’s comment. In the state where I work the perinatal center agreements include that VBACS can only be performed in hospitals that have in -house anesthesia and OB coverage. This is so a C-Section can happen within 30 minutes from the time of incision to decision. Many hospitals do not have the capability to have in-house anesthesia and OB coverage so they will deny VBACS. It is a shame. Other hospitals simply deny them due to liability reasons. One anecdotal story, I was just in a VBAC delivery, with undiagnosed twins! It was fabulous. For those not aware, twins are a contraindication to a VBAC delivery.

  10. Diana J. Says:

    Dear NursingBirth,

    I’m a huge fan of your blog! Please keep the awesome entries coming! I am learning so much. I am just a novice birth-junkie rather than a birth professional and so am anxious to eat up all the great information you’re giving out here.

    And I second the Q&A idea!

    This is actually a question for you, but I understand if you haven’t the time to address it – based on the number of comments I see here, people are keeping you quite busy!

    Anyhow…. Our state treasurer’s wife (that’s here in Arizona) died today in childbirth, and their baby is said to be in grave condition. They’re not giving causes or reasons. Here’s the link:

    http://www.azcentral.com/news/articles/2009/05/26/20090526treasurers-wife0526-ON.html

    Can you think of occurrences in hospital-birth that would end up with a dead mother and a baby in really bad condition? I’d love to hear from someone who knows her stuff. The things that came to mind for me were amniotic fluid embolism, severe uterine rupture, and cesarean gone really wrong.

    Keep up the amazing work!!!
    Diana

  11. Kayce Says:

    I actually just posted about repeat cesareans the other day on my blog. I had a cesarean with my daughter, and I will do whatever it takes to have a VBAC with my next.

    This is a really great article here. I am excited my sister in law found your blog and sent it to me. I love reading new things, especially about pregnancy and birth!

    • nursingbirth Says:

      Kayce, WELCOME!! I am a total birth junkie too! (and you would think I get enough of a fix at work…..but I don’t!!) Haha! I am so glad you have joined our community!


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