Dr. Friedman on "The peril of multiple c-sections"

Dr. Alex Friedman from the Hospital of the University of Pennsylvania published an article in yesterday’s Philadelphia Inquirer detailing his own experience with the serious risks of multiple cesareans:

The worst surgical case of my residency came when we delivered my patient’s baby by cesarean – her ninth cesarean birth.

The baby came out fine, but for the mother we suspected one of most feared complications in obstetrics – that her placenta had burrowed deep into the muscle of the uterus.

To get oxygen and nutrients to the fetus, the placenta needs to attach just a few millimeters deep into the uterus. We worried that hers had gone much farther and might eat through the entire thickness of the uterus, keeping it from shrinking back to its normal size after delivery and causing a massive hemorrhage.

We gave a gentle tug on the umbilical cord. Usually the placenta peels off with such gentle pulling, but hers remained stuck – an ominous sign.

Importantly, Friedman notes:

The case points out a fundamental truth about surgical delivery: a first cesarean for most women leads to a cesarean with every pregnancy. And while a first section is quick, easy to perform, and rarely complicated, each repeat surgery carries greater risk.

Why the greater risk? Friedman explains:

Repeat C-sections pose more risk than a first section for many reasons. One factor concerns anatomy. When a doctor performs a first cesarean, the layers of tissue look and feel very different from each other. These visual cues and textures guide the surgeon, indicating exactly where to cut…

The surgeon loses the advantage of good anatomy after the first section. The tissue undergoes scarring, toughens, and blends together as it heals. The variations in color and texture disappear. The intestines and bowel sometimes stick to the healing wound, putting them in harm’s way the next time surgery is performed.

These changes in anatomy due to previous cesarean surgery can lead to serious complications.

A study from 2006 published in the journal Obstetrics and Gynecology compared C-section complications in more than 30,000 patients. Risks of requiring a large blood transfusion, incurring a bladder injury, needing to be on a ventilator, and ending up in intensive care all increased significantly with the number of sections after the first.

The study also showed greater risk for my patient’s complication. Scarring on the inside of the uterus after a cesarean causes the placenta to attach abnormally in future pregnancies. During a first section, the risk of this complication was less than 1 in 400. After a sixth section, the risk ballooned to more than 1 in 15.

Ultimately, Dr. Friedman’s patient survived, but only after a risky hysterectomy that left the OR awash in blood and the mother in the ICU for several days.

My patient lost three times the entire blood volume of a normal person, sixteen liters in all. Only a massive transfusion kept her alive. Anesthesiologists pumped in 51 units of red blood cells and seven six-packs of platelets.

Sadly, Friedman notes what so many of us cesarean moms know:

More and more women are finding themselves on the C-section path. Almost one in three babies was delivered by cesarean in 2007, the most recent year for which data are available, an increase of more than 50 percent from a decade earlier.

At the same time, it’s becoming harder for mothers to avoid repeat surgery. The number of vaginal births after a C-section fell by two-thirds, to fewer than 10 percent, over the same time period. This year, the National Institutes of Health estimated that since 1996, one-third of hospitals and one-half of doctors who offered vaginal births after a C-section no longer do so.

As Friedman’s experience demonstrates, the stakes in this quandary are incredibly high:

With a first cesarean, the up-front costs – a few more days in the hospital, a longer recovery – may seem reasonable. Only in retrospect can the true costs become apparent.