As most of you would know I am a HUGE advocate for VBAC access and VBAC education. I run the very popular facebook group VBAC Australia Support Group and have spent the last 10 years of my life living and breathing all things VBAC.
But what a lot of people wonder is why. Why do I advocate for increased VBAC rates across the country? Coz, what's the big deal about caesareans? They're just a birth!
People often make assumptions about this and see it as me just not liking caesareans or refusing to support women’s choices to have caesareans.
This couldn’t be further from the truth.
When I first wrote this blog post in 2017 there had just been a mass of media coverage in regards to the 2010 death of a Victorian woman from complications arising from placenta accreta. The purpose of this blog post isn’t to add too much to the commentary around that specific case. From the mainstream media reports it certainly sounds like the family had no idea that her risk of placenta accreta was increased with each subsequent caesarean and there has been a lot of commentary (including my own) about whether she was truly “cursed with a small pelvis” (true CPD only affects less than 5% of women, and I know MANY women who have been officially diagnosed with it but gone on to vaginally birth larger babies complication free) or whether she was simply a victim of a maternity care system that does not support physiological birth or VBAC.
Do women actually know the risks?
I run a VBAC support group of almost 5000 women (there's now over 15k!). Being a VBAC group, the vast majority of the women in it have had a caesarean. And many have had more than one. Given that one of the major risk factors for placenta accreta is previous caesarean surgery I thought that it would be interesting to find out how many of the women were informed of this risk as part of the consent process for their caesarean
In the initial group only one woman (out of 47) had been informed of the risk of placenta accreta, and the impact this could have on their future reproductive health, as part of the consent process. Many women mentioned having never heard of it.
So I decided to further narrow the focus to only women who had a planned caesarean. I figured that in an emergency situation (even though most “emergency” caesareans are not emergent) there could be significant logistic and time issues regarding full discussion of risks. I don’t think that this excuses is as you can’t consent if you are not informed, but this is the reality in which we birth.
Out of 43 women who had a planned caesarean only 4 were asked how many children they were planning to have and informed of the risks of placenta accreta in future pregnancies. What is truly scary is that several women reported specifically asking about risks to future health only to be told that there were none. Several women also reported having never heard of the term placenta accreta until this conversation in the VBAC Australia Support Group. Many of these women mentioned being thoroughly and frighteningly informed of the risks associated with physiological birth and / or VBAC, while the risks of caesarean surgery were glossed over or not mentioned at all.
To add my own experience to this: At 41+5 weeks and planning a VBAC I had an OB try to pressure me into a planned caesarean based on a foetal weight guess. Foetal weight estimates via ultrasound are not an evidence based indication for a planned caesarean or a planned induction. The OB did ask me how many children I wanted and I responded with 4. She then told that she understood why I wanted a VBAC as this would be my last chance for a vaginal birth. There was no discussion about me wanting a VBAC in order to keep my risk of placenta accreta low in future pregnancies. Or what the ongoing risks would be of having 3 or 4 caesareans and the risks in those pregnancies.
Why is this a big deal?
Placenta accreta comes with a maternal mortality rate of between 7 – 10%. The standard management of placenta accreta (as per RANZCOG guidelines) is to perform a caesarean hysterectomy. That means that the baby is delivered via caesarean (often planned as early as 35 weeks if there are no additional complications) and then a hysterectomy is performed. There is quite a lengthy list of other possible complications including the need for blood transfusions, pulmonary embolism, surgical injury and requiring additional surgeries. (Referenced from http://vbacfacts.com/2009/08/03/risk-of-serious-complications-increase-with-each-cesarean-surgery/)
Having multiple caesareans also increases the chance of a mum developing placenta praevia. Having placenta praevia AND multiple caesareans increases your chance of having placenta accreta considerably.
So why am I an advocate for VBAC access and VBAC education?
Because caesareans are a big fucking deal and can have huge impacts on a woman’s health and fertility.
And women deserve to know this. Before they agree to one.
Because multiple caesarean surgeries is one of the leading risk factors for placenta accreta and the leading reason for caesareans in Australia is “previous caesarean”. Our overall VBAC rate is around 16% with the majority of women not knowing the risks to their future health of undergoing multiple caesarean surgeries.
I am a VBAC advocate because caesareans are major surgery, yet women are being frightened out of VBAC.
You deserve to be able to make a fully informed and powerful decision.
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