Leslie - I
wonder if this has something to do with what you mentioned at Choices last
night (the Ob was sued in the US for something like 1.3 million for performing
a caesarean which was 'uninformed consent') Maybe they are deciding it might be
a good idea to think differently and thought they better say something quick
smart?
From: [EMAIL PROTECTED] [mailto:[EMAIL PROTECTED]]
Sent: Saturday, 8 July 2006 1:46
PM
To: [EMAIL PROTECTED]
Subject: [ozbirthing] Too many
caesars
Too many caesars
Experts are calling for a rethink on the readiness of Australian
women to have caesareans. Kellie Bisset reports
The Australian
July 08, 2006
IN doctors' rooms around the country pregnant women are walking in
and asking for their babies to be surgically removed. They're not the
majority, but evidence shows their numbers are increasing.
Some of them are paralysed by the fear of giving birth, others want
to remain in control of where and when they have their baby, and
still others think caesarean section is a less risky option than
leaving delivery up to Mother Nature.
Add to these the women advised by their obstetricians to have a
caesarean section before, or during, labour and you get a national
caesarean rate of nearly 29 per cent.
Midwives have loudly criticised the rapid growth of surgical
deliveries over the past decade, and now doctors are joining them.
More obstetricians are worried that the looming possibility of one in
three babies checking in to the world via the spartan surrounds of an
operating theatre is too high a number. And important new research
published last month in the US
journal Obstetrics & Gynecology
(2006;107:1226-1232) gives us an idea as to why.
The study of more than 30,000 women showed the more caesareans they
had, the greater the risk of complications including hysterectomy,
bowel and bladder injury, admission to intensive care and blood
transfusions. Risks for some complications more than doubled between
the first and the third caesar.
Given that more than 80 per cent of Australian mothers who've had one
caesar go on to have another, the US results are particularly
relevant to us.
"In the desire to do good we have actually started to do some harm,
and this paper illustrates that well," says David Ellwood, professor
of obstetrics and gynaecology at the Australian
National University.
Ellwood says we need to think carefully about getting the balance
right between what's excessive and a safe level of intervention to
avoid harm. "I really think at the moment we have swung too far the
other way. We perhaps overestimate the size of the impact on outcomes
for babies and underestimate the risks (to the mother)."
Senior vice-president of the Royal Australian and New Zealand College
of Obstetricians and Gynaecologists Dr Chris Tippett agrees.
She says too many women are getting biased or selective information
on the pros and cons of caesarean section, which is now seen by many
doctors and their patients as the preferred option.
"Caesarean section is a significant intervention . . . there are
concerns about whether or not we are leaving a legacy of problems."
Until now, studies looking at the question of repeat caesarean risk
have reported mixed results, but many doctors and midwives have long
suspected the caesarean story is not a completely rosy one.
Experts say that while this study confirms what they've been
thinking, it's significant because of its sheer size and conclusive
results, which can now be used to give women a better picture of what
they're up against.
It showed one in 155 women needed a hysterectomy after their first
caesar, but that risk rises to nearly one in 40 for those having
their fourth – figures Ellwood describes as "surprisingly
high".
Another major complication was placenta accreta, an abnormally firm
attachment of the placenta to the wall of the uterus, which hampers
control of bleeding after the baby is born. In many cases of placenta
accreta, severe bleeding leads to the need for a blood transfusion or
hysterectomy.
According to the study the risk of placenta accreta more than doubled
for those women having their third caesar (one in 175) compared with
those having their first (one in 413).
By the fourth caesar, the risk was one in 46.
Tippett says she now sees a case of placenta accreta every three to
four weeks, a huge jump from when she started her obstetrics training
in the early 80s.
"This study is good evidence – it says to women that caesarean
section is generally a safe procedure, but if you are planning on
having a family of three to four children, think very carefully
before you go down the caesarean section pathway."
Ellwood thinks we've lost sight of the bigger picture.
"It is the third caesarean where you start to see this increased
risk, and in numerical terms it is going to be a relatively small
proportion of the population. But the scale of the morbidity in
placenta accreta and hysterectomy is enormous and the only way we are
going to address it is by an overall reduction in the caesarean rate."
Some might argue that most women just have one or two children these
days, so the risk of three, four, five and six caesareans isn't
something we need concern ourselves with. But Ellwood is seeing a
shift.
He says while government policies to encourage women to start
families are having an effect, there's another increasingly frequent
story: the impact of the divorce rate.
He is treating more women entering their second marriage, and while
they may have originally intended on one or two children, they often
change their mind and plan more when there's a new partner on the
scene.
Ellwood says there needs to be more effort put into encouraging women
who have a first caesar to try vaginal delivery next time,
particularly if they plan on having more than two children.
Clinical director of women's services at Melbourne's
Royal Women's
Hospital Professor Jeremy Oats says his hospital actively supports
this policy, but attitudes vary.
He says a major study published in the New England Journal
of
Medicine two years ago (2004;351:2581-2589) linking a trial of labour
after a prior caesarean to greater risks for mothers and babies had a
huge impact, particularly in the US.
The absolute risks, however, were small: 0.46 in every 1000 births
was associated with an adverse outcome such as rupture of the uterus,
which in some cases led to birth asphyxia (where the baby does not
receive enough oxygen). And problems were more likely if the labour
was induced.
Oats says there shouldn't be any reason for concern provided the
labour is carefully monitored. "It comes back to the obstetrician and
the maternity team to work with the woman and give her confidence and
support in her decision."
Robin Austin says she could have done with that kind of support when
she decided to have her second and third children naturally and at
home after having a caesarean when her first labour failed to
progress.
"What I came up against was other people's fear," says Austin,
38. "No one was talking to me about other choices and I found that
distressing because I felt I had been butchered."
She describes the distress of coming home from hospital the first
time with an infected wound and unable to pick up her screaming baby
because of the impact of major surgery.
"The whole process was traumatic and we thought it should not be like
this. Whatever happened to women just having babies – where is that?
It is almost like it is a medical condition that needs to be fixed,
rather than a process that needs to be gone through."
Austin, who now has her hands full with Toby, 2, Lucy, 13 months, and
one-month-old Isabella, says she felt a sense of loss after the birth
of her son. "I missed his birth and so did his father. It is gone and
it is something that will never come back."
Tippett also wonders whether rising caesar rates are denying women an
important life experience. She spends up to an hour with every new
patient explaining why surgery is not the easy option.
"There are many women coming in and requesting elective caesarean
section and that did not happen 10 years ago," she says. "We very
rarely do a primary elective caesarean – it is our policy not to –
but there are other doctors who rarely do vaginal deliveries."
So are women or their doctors driving the upward trend in caesareans?
Senior obstetrician at Sydney's
Royal Prince Alfred Hospital Tony
Frumar believes it's a little of both.
He says there's every chance more women would be talked out of the
procedure if medico-legal concerns were not an issue for doctors: "If
you steer someone away from a caesarean section and have a problem
you leave yourself open to action."
He says most women can be discouraged from elective caesareans by the
end of their pregnancy, but there are those that are so "freaked out"
by the pain of childbirth that not to do the procedure could have its
own psychological consequences.
Australian College of Midwives spokesperson Shannon
Morris says the
convenience factor for obstetricians can't be discounted as a driver
of the caesarean rate.
She says this was acknowledged privately recently by a senior
obstetrician.
"There's a new generation of obstetricians who don't want to put in
the hours who say 'This will be safe and I can do it on this day at
this time and still be home to pick up my kids from school'."
Morris also raises concerns about the number of induced labours
(where a mother is given hormones to kick-start contractions). She
says incorrect due dates are causing supposedly overdue women to be
induced before their babies are ready. And induction of labour
dramatically increases your chances of needing an emergency caesarean
section.
Oats agrees energy needs to be devoted to addressing this. But he
also raises the possibility that nature, as well as societal
attitudes, might be having an impact on the caesar rate.
"There's an argument that with better nutrition babies are getting
bigger and there is a genetic gap between that and the increase in
maternal pelvis size."
While Morris says caesars are a fabulous intervention that have saved
many lives, they've become as routine as getting your tonsils out.
Ellwood agrees obstetricians must step up to the challenge.
"It is quite unreal to think women when making choices about what to
do in this pregnancy will think long term about what might be
happening 10 years on. It is a responsibility that we as
obstetricians have to point that out to them and not be involved in
unnecessary caesareans."
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