[ozmidwifery] warning on caesareans. The Age Monday 28 March 2004, page 3

[Denise Hynd]

Reporter Amanda Dunn
http://www.theage.com.au/articles/2004/03/28/1080412235095.html
An alarming rise in the number of emergency hysterectomies performed on
Victorian women after childbirth has prompted an obstetrics expert to warn
doctors against performing elective caesareans without medical cause.
The warning follows a report commissioned by the Department of Human
Services to investigate claims of an increase in hysterectomies to stem
severe bleeding in new mothers. The report found that, although still rare,
the incidence had risen from 20 post-partum hysterectomies in the state in
1999 to 48 in 2002. Over the same period, caesarean rates rose from 22.8 per
cent of births to 27.4 per cent. The report's author, obstetric
epidemiologist James King, said it was likely there was a causal link
between the two.
Obstetricians and midwives are also concerned about the number of women
opting to have their babies surgically without medical reason. The elective
caesarean rate has jumped from 11.5 per cent of births in 1999 to 14.1 per
cent in 2002.
Professor King told The Age the increase in post-partum hysterectomies was
of concern. "If that's going up too - they're never done for trivial reasons
- that means there is an increase in severe post-partum hemorrhage," he
said.
Professor King, who chairs the committee that gathers data on childbirth in
Victoria, said he believed that caesarean section should be advised against
where there was no medical reason for the surgery. "The cautious
practitioner would not want to approach it willy-nilly," he said.
Post-partum hemorrhage occurs in about one in 10 women, with varying degrees
of severity. Professor King said that women who had had a previous caesarean
had an increased risk of a condition called placenta praevia accreta. This
is when the placenta attaches to the scar tissue left by the previous
caesarean, depriving its blood supply. The placenta then burrows into the
muscle of the uterus to try to compensate and get more blood.
"When that happens, when it's time for the placenta to separate, it doesn't
separate completely," he said. This can lead to hemorrhage and, in severe
cases, hysterectomy as a last-resort measure to stop blood loss.
Obstetrician Julie Quinlivan, head of the Royal Women's Hospital's maternity
care program, said the consensus among obstetricians was that the elective
caesarean rate was too high, but the difficulty was in convincing women who
did not need caesareans to try natural birth.
Fewer women who had had a caesarean were opting to try a vaginal birth
subsequently, she said.
Euan Wallace, an obstetrician at Monash Medical Centre, said it was to be
expected that rising caesarean section rates would be associated with
increasing post-partum hemorrhage. But he said placenta accreta was an
uncommon complication, occurring in about one in 200 to 250 births.
Kate Duncan, a private practice obstetrician and vice-president of the
Australian Medical Association's Victorian branch, said there should be a
concerted effort to bring caesarean rates down to no higher than 20 per
cent. She said some were requested for social reasons, or because women were
worried about the pain of childbirth, or about urinary or bowel incontinence
from vaginal delivery.
Joy Johnston, a midwife in private practice, believed the medicalisation of
birth - including caesareans and induced labour - had made birth less safe
for women. She said convenience and money for obstetricians were driving
factors in the elective caesarean rate.
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ps from Joy
I have sent the following letter to the editor.
I do not like attacking obstetricians, and in this article it appears that I
am.  I understand that a reporter is restricted in what can be included in
an article, and my comments were only partially reported.  I believe that
midwives and women, as well as obstetricians, need to take responsibility
for reducing unnecessary medical interference in birth, and making birth as
safe as it can be.  It’s a shared responsibility.  I believe that the safest
care in pregnancy and birth is when a woman accepts and works with the
natural process, and agrees to intervention only when medically indicated.
Optimal maternity care is achieved when each woman is working in partnership
with a known midwife who is primary carer, and who can collaborate with
obstetric and other specialist medical and nursing experts when and if the
need arises.  INCLUDEPICTURE
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HYPERLINK "http://www.theage.com.au/articles/2004/03/28/1080412235095.html";
\l "top#top" Top
Joy Johnston
RN Midwife FACM IBCLC
25 Eley Rd
Blackburn South Vic 3130
03 9808 9614

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