One More Reason to Support VBAC: Fewer Maternal Deaths

24 Aug

Cesarean section is major abdominal surgery can put mothers and babies at risk for several complications.  Pulmonary embolism, a blockage in a lung artery,  is one of the leading causes of maternal mortality.  It is caused by a blood clot in the leg (deep vein thrombosis) that breaks free and travels through the blood stream to the lungs. Cesarean section is an independent risk  factor for deep vein thrombosis.

If given the option to labor for a VBAC, about 75 percent of women would give birth normally and avoid exposure to the risks of a surgical delivery.

On August 22nd ACOG issued this press release to raise awareness about the risk of pulmonary embolism related to cesarean section and published Practice Bulletin #123 “Thromboembolism in Pregnancy” in the September 2011 issue of Obstetrics & Gynecology.

New Recommendations to Prevent Blood Clots
During Cesarean Deliveries Issued

Washington, DC — In an effort to reduce maternal mortality due to blood clots—a leading cause of maternal death in the US—The American College of Obstetricians and Gynecologists (The College) now recommends that all women having a cesarean delivery receive preventive intervention at the time of delivery. The new recommendation was released today along with updated guidance for the prevention, management, and treatment of blood clots during pregnancy.

Thromboembolism—blood clots which can potentially block blood flow and damage the organs—is a leading cause of maternal morbidity and mortality in the US. The majority of blood clots in pregnant women are venous thromboembolism (VTE), usually occurring within the deep veins of the left leg. “Cesarean delivery is an independent risk factor for thromboembolic events—it nearly doubles a woman’s risk,” said Andra H. James, MD, who helped develop the guidelines. Most women who develop clots in the lower extremities will have pain or swelling in the leg. Sometimes, clots travel to the lungs causing a life-threatening condition known as pulmonary embolism. Symptoms include sudden shortness of breath, chest pain, and coughing.

“Fitting inflatable compression devices on a woman’s legs before cesarean delivery is a safe, potentially cost-effective preventive intervention,” said Dr. James. “Inflatable compression sleeves should be left in place until a woman is able to walk after delivery or—in women who had been on blood thinners during pregnancy—until anticoagulation medication is resumed.” The College notes, however, that an emergency cesarean delivery should not be delayed for the placement of compression devices.

Pregnancy is associated with a four-fold increase in the risk of thromboembolism. Clotting problems are more common among pregnant women because of the physiological changes that accompany pregnancy, such as blood that clots more easily, slower blood flow, compression of pelvic and other veins, and decreased mobility. Other risk factors include a personal history of VTE, an increased tendency for excessive clotting (thrombophilia), and medical factors such as obesity, hypertension, and smoking.

“VTE is a major contributor to maternal mortality in this country. The risk of VTE is increased during pregnancy and the consequences can be severe,” said Dr. James. The recommendations explain how to monitor women for these events, address certain risk factors, and treat suspected or acute cases of VTE. “It’s important for ob-gyns to adopt these recommendations to help reduce maternal deaths.”

The College recommends preventive treatment with anticoagulant medication for women who have had an acute VTE during pregnancy, a history of thrombosis, or those at significant risk for VTE during pregnancy and postpartum, such as women with high-risk acquired or inherited thrombophilias. Women with a history of thrombosis should be evaluated for underlying causes to determine whether anticoagulation medication is appropriate during pregnancy. Most women who take anticoagulation medications before pregnancy will need to continue during pregnancy and postpartum.

“Because half of VTE-related maternal deaths occur during pregnancy and the rest during the postpartum period, ongoing patient assessment is imperative,” Dr. James noted. “While warning signs in some women may be evident early in pregnancy, others will develop symptoms that manifest later in pregnancy or after the baby is born.”

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According to a World Health Organization report on maternal mortality, in 2010 the United States ranked 50th among 59 developed countries.

In the September issue of Obstetrics & Gynecology, Howard Blanchette, MD of New York Medical College wrote an article entitled, The Rising Cesarean Delivery Rate in America, What Are the Consequences?

He writes, “In 1998 when the cesarean delivery rate was 21.2% in the United States, the maternal mortality rate was 10 per 100,000. In 2004, with a cesarean delivery rate of 29.1%, the maternal mortality rate increased to 14 per 100,000…To reverse the trend of the rising cesarean delivery rate in America, we as obstetricians must reduce the primary cesarean delivery rate, and avoid the performance of a uterine incision unless absolutely necessary for fetal or maternal indications. For women with one previous low transverse cesarean delivery we must promote a trial of labor after previous cesarean delivery…We must constantly remind ourselves, Primum non nocerum (First do no harm).

2 Responses to “One More Reason to Support VBAC: Fewer Maternal Deaths”

  1. hamileningunlugu November 12, 2011 at 4:23 am #

    Great site..

  2. Athena September 30, 2011 at 2:00 am #

    Recently, a doctor in my area refused to treat me any further because I told him I was not open to the idea of a second cesarean. I have been told this kind of blatant and sudden termination of patient care is not only illegal but unethical. I am currently 40 weeks and 5 days pregnant and terrified to go to any hospital in the area – they are all owned by the same corporation this doctor worked for and they all state they have “VBAC Bans” in place, despite the idea of banning vaginal birth after cesarean is illegal (with regards to my internationally and federally protected rights to informed consent and refusal of medical treatment.)
    Who do I contact about my doctor abandoning me as a patient? Who do I contact about the “health system” corporation in my area violating patient rights? Lawyers in the area will not help me because for them, they only take a malpractice case after someone has been hurt or died. I’m not looking for an ambulance chaser, but someone to help me ensure no other woman is frightened or forced into unnecessary major uterine surgery because she doesn’t know her rights.
    I’m supposed to be able to trust my OB/GYN and have no been able to find help anywhere. After reviewing your highly respected articles I feel like my doctor doesn’t have my best interest at heart and is not concerned with the health of my baby. This man didn’t even take the time to review my past medical history before assuming my second child was “too big” to fit through my birth canal (something incredibly rare and over-used in today’s doctor’s offices.) This man should not be allowed to treat women and tell them lies – I can think of no other reason for him to be doing this other than to charge insurance companies more money and make more of it because a cesarean is more “efficient” for the doctor’s time. He is a danger to the health of our community and so is the company he is working for.
    Please, help me. Let me know who I can go to. I’m at a loss here, I’ve been searching for two months for help and every place I turn I’m told “the hospital has a ban on VBAC” or “Florida statue doesn’t allow me to treat you in a birthing center.”

    Thank you for your time and understanding,
    Athena

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