Consortium for the Evidence-based practice of Obstetrics -- 
C.E.O. is dedicated to bringing science-based 
maternity care to all childbearing women

 Quotes and Excerpts from and 
 other respected sources  of professional information
on safety, complications & practice trends for obstetricians  

Bibliography, Recommended Reading and Scientific Citation from obstetrical sources for the:
Post-Cesarean Pregnancy ~ Placental Complications 

Cesarean Rate Portends Rise in Placenta Accreta, Maternal mortality 7% Ob.Gyn.News Mar 1, 2001 

 Last 50 Years Show 10-fold Rise in Plactenta Accreta – Behind 50% of emergency hysterectomices, Ob.Gyn.News Dec 5, 2002, Vol 37, No 24;

 Placenta Previa, C-section History Ups Accreta Risk; Ob.Gyn.News Sept 15, 2001, Vol 36, No 18;

 Case Reports Suggest Placental Invasion is on the Increase –Hike in C-Section may be responsible, Ob.Gyn.News Jan 15, 2003, Vol 38, No 2;

 Diagnosis and Management of Placental Percreta
 ~ Continuing Medical Education Review Article; Vol 53,No 8 1998

 Experts Say Cesarean Section Rates are Headed ‘Sky-High”; Ob.Gyn.News, April 1, 2002, Vol 37  

October 7th, 2002 article in Los Angeles Times, Giving Birth Their Way 
Pregnant women who've had a previous C-section have a tough time persuading doctors to let them deliver vaginally

 ACOG Press Release October 31, 2003 ~ New AGOC Opinion Addresses Elective Cesarean Controversy

 Elective Caesareans Judged Ethical – Doctors Group Issues Statement on Poplar Procedure; Washington Post Staff Writer Rob Stein / October 31, 2003  

Cesarean Rate Portends Rise in Placenta Accreta, Maternal mortality 7% Ob.Gyn.News Mar 1 01, Vol 36;   

“The rise in cesarean rate over the last several years may portend an increase in the incidence of placenta accreta… The maternal mortality rate with placenta accreta is 7%.  

Even when physicians are prepared and well equipped, the condition can be extremely dangerous.   the patient ended up going into cardiac arrest during the procedure and had postoperative complication that kept her in the hospital for 20 days.”     

Last 50 Years Show 10-fold Rise in Plactenta Accreta Behind 50% of emergency hysterectomices,
Ob.Gyn.News Dec 5, 2002, Vol 37, No 24;  

Placenta accreta is a growing cause of postpartum hemorrhage and an increasing cause of emergency hysterectomy, according to Dr. Gary Dildy III. professor of ob.gyn. at Louisiana State University, New Orleans.

“The incidence of placenta accreta is increasing, and it's thought this may have to do with the increasing rate of cesarean sections since the 1960s,” he said at the annual meeting of District V of the American College of Obstetricians and Gynecologists. 

Research has shown that the incidence of placenta previa and accreta correlates highly with the number of prior cesarean sections that a woman has had. In addition, while placenta accreta accounted for only about 10% of emergency hysterectomies in the 1950s, it accounted for 50% of these procedures in the mid-1980s. 

Currently, the incidence of placenta accreta is about 1 per 2,500 pregnancies and has increased 10-fold in the past 50 years, said Dr. Dildy.  Although placenta accreta remains one of the rarer causes of postpartum hemorrhage, Dr. Dildy urged physicians to be aware of it. Occasionally, the condition can be diagnosed prenatally, which can be highly advantageous. 

Women who have had at least two cesarean deliveries with anterior or central placenta previa have nearly a 40% risk of developing placenta accreta in the future

The ACOG Committee Opinion No. 266, issued in January 2002, recommends that when placenta accreta is suspected prenatally, appropriate measures need to be taken to acquire blood for transfusion, arrange for Cell Saver technology when available, arrange a preoperative anesthesia consultation, and recruit the appropriate backup expertise.  “If you have vascular involvement, you may need a vascular surgeon; if you have urologic involvement, you may need a urologist or a gynecologic oncologist,” he explained. 

The ACOG committee opinion states that
profuse hemorrhage can occur when attempting to separate the placenta. If the clinician is extremely confident in the diagnosis, it may be prudent to complete the delivery of the infant and proceed with hysterectomy while the placenta remains attached.” 

 Placenta Previa, C-section History Ups Accreta Risk; Ob.Gyn.News Sept 15, 2001, Vol 36, No 18;  

Maintain a high index of suspicion for placenta accreta in patients with placenta previa, particularly if a patient has had a prior cesarean section, Dr James E. Ferguson II said at the annual Southern Obstetric and Gynecologic Seminar. 

.....the rate of placenta accreta in patients with placenta previa was 5% if no prior C-section, 25% with one prior C-section and 50% with two or more prior C-sections    

...if ultrasound finding reveal placenta accreta, the patient has an 80% likelihood of undergoing a hysterectomy following delivery. Plan ahead Dr. Ferguson said

Because of the extensive blood loss the patient is likely to experience, consider autologous blood transfusion. Make sure the blood bank is prepared, make sure the anesthesiologist is prepare d for substantial hemorrhage and make sure the proper help is on hand. That may include a urologist if suspicion that the placenta has eroded into the bladder), a vascular surgeon, a radiologist, a neonatologist … and plenty of nurses. 

 Don’t hesitate to perform a hysterectomy. Prepare for a 4-hour surgery with an average 4-liter blood loss, You may need to use up to 20 unites of packed red blood cells and ...prepare for ureteral injuries which occur in 2%-3% of patients. Many patient require resection of at least part of the bladder, Dr Ferguson noted.  This is one of these areas were we really earn our money." he said.  

Case Reports Suggest Placental Invasion is on the IncreaseHike in C-Section may be responsible,
Ob.Gyn.News Jan 15, 2003, Vol 38, No 2;  

Placental invasion is not the most common cause of postpartum hemorrhage, but it is occurring more frequently and it has the highest association with maternal complications resulting from postpartum hemorrhage, according to Dr. Gary A. Dildy III, who is professor of obstetrics and gynecology at Louisiana State University in New Orleans. 

Case reports published over the past two decades suggest the
incidence of these placental abnormalities is on the rise, most likely as a result of the increased cesarean section rates during that time period. At one institution the incidence nearly doubled from just over 0.02% between 1975 and 1978 to 0.04% between 1985 and 1984, Dr.
Dildy said at a perinatal symposium sponsored by Symposia Medicus. 

Studies also show that prior C-sections are associated with an increased incidence of placental abnormalities. Placenta previa occurs in less than 1% of women with no prior C-sections. The risk increases substantially as the number of prior C-sections increases. In those with placenta previa and a prior C-section, the incidence of abnormal invasion of the placenta is nearly 50%. 

Placenta percreta ...  was shown in a 1996 study to be associated with a 7% mortality rateeven with prenatal diagnosis and, presumably, with preoperative preparation for excessive bleeding, he noted. 

The American College of Obstetricians and Gynecologists, for example, published a Committee Opinion on placenta accreta in January 2002, stating that patients with suspected or diagnosed placenta accreta should be
counseled about the likelihood of hysterectomy and blood transfusion, and that blood products and clotting factor, as well as adequate surgical personnel and equipment, should be on hand for these patients.  “Even in this day and age, this is not a minor concern,” Dr. Dildy said. 

Diagnosis and Management of Placental Percreta  ~ Continuing Medical Education Review Article; Vol 53,No 8 1998  

Clinical and surgical methods of placenta previa with a high risk of percreta are all based on prevention of uncontrolled hemorrhage.

Placenta precreta can be a very challenging situation for the obstetrician and this complication of pregnancy is being diagnosed prenatally with increasing frequency. The higher incidence of cesarean delivery today is strongly associated with the greater frequency of placenta previa, which has increased from one in a thousand (1 in 1000) pregnancies in 1950 to 101 in a thousand in 1985  (1). Given the known association between placenta previa and placenta accreta/percreta, it is not unreasonable to suggest that the increased cesarean delivery rate has directly contributed to the rising incidence of placenta accreta/percreta. 

The risk of placenta previa is linked to the number of prior cesarean deliveries, with a risk of 0.65 percent after one [cesarean], 1.8 percent after two, 3 percent after three and 10 percent after four cesarean deliveries. We know that 75 percent of placenta percreta are associated with placenta previa. 

Approximately 25 percent of women with placenta previa and one previous cesarean have an accreta/percreta, whereas almost 50 percent with placenta previa and two prior cesareans have placenta accreta/percreta  (2). When one considers the patient demographics faced by the modern obstetrician, it is expected that we will have to del with this clinical situation more frequently.

Maternal mortality and morbidity are significantly increased by placenta percreta. Mortality, secondary to hemorrhage and its complications, can be as high as 10 percent  (3,4). Significant intraoperative blood loss may necessitate massive blood transfusion with the attendant complications of disseminated intravascular coagulation (DIC), transfusion reactions, allo-immunization, fluid overload, and less commonly, infection.

Surgical morbidity includes: hysterectomy, bowel injury, urological injuries including  a 2 to 3 percent risk of ureteral trauma and bladdder laceration that may require partial vesical resection. The patient is also at increased risk for thrombotic events. Despite prophylactic antibiotic theraphy, ther is a high incidence of sepsis and infectionus morbidity. Also secondary acute respiratorydistress syndrome (ARDA) is not common in there patients. Postoperative bleeding necessitates reexploration in up to7peercent of patients with accreta/percreta (3,5).

ACOG NEWS RELEASE October 31, 2003 ~ New Opinion Addresses Elective Cesarean Controversy  

Contact: ACOG Office of Communications //

Washington, DC -- A new committee opinion from The American College of Obstetricians and Gynecologists (ACOG) addresses the controversy of elective cesarean delivery, using it as an example of how doctors can ethically help patients make decisions about surgical treatment when there is a lack of firm evidence for or against such surgery.

In "Surgery and Patient Choice: The Ethics of Decision Making," ACOG notes that while the right of patients to refuse unwanted surgery is well known, less clear is the right of patients to have a surgical procedure when the scientific evidence supporting it is incomplete, of poor quality, or totally lacking -- a frequent scenario in medicine.

Where medical evidence is still limited, ACOG says there is no one answer on the right ethical response by a physician considering a patient request for surgery. Thus the decision on whether to perform an elective cesarean delivery (also known as "patient choice cesarean" or "cesarean on demand") will come down to a number of ethical factors including the patient's concerns and the physician's understanding of the procedure's risks and benefits

An increasing number of women are requesting elective cesarean instead of vaginal delivery in the belief that the surgery will prevent future pelvic support or sexual dysfunction problems, or for other reasons. A number of physicians believe that such surgery should not be selected over a natural process without immediate and compelling medical need.

ACOG cautions that "both sides to this debate" must recognize that evidence to support the benefit of elective cesarean is still incomplete and that there are
not yet extensive morbidity and mortality data to compare elective cesarean delivery with vaginal birth in healthy women. With better data, there may be a shift in clinical practice.

# # # The American College of Obstetricians and Gynecologists is the national medical organization representing over 45,000 members who provide health care for women.

Excerpts from an October 7th, 2002 article in Los Angeles Times, Giving Birth Their Way ~ Pregnant women who've had a previous C-section have a tough time persuading doctors to let them deliver vaginally

"Women who have had a caesarean section often want to deliver their next child vaginally--and many are physically capable of doing so. But across the nation, they're increasingly denied that option." 

"Only 16.5% of U.S. women with prior caesarean sections had a vaginal birth last year, according to the National Center for Health Statistics, a 20% drop from the previous year. California's rate, at 14.5%, is among the lowest in the nation and some local hospitals report current rates of less than 5%."

"Statistics show that VBACs are successful in 80% of women who are considered good candidates for the procedure."

".... a 24-year-old Simi Valley woman, sought a vaginal birth earlier this year because of a difficult recovery after the caesarean birth of her first child. Although doctors said she was a good candidate for a vaginal delivery, she had to change physicians twice before finding one who supported her request."

"Women's health experts agree that VBAC can be a reasonably safe--even preferable--option. The American Academy of Obstetricians and Gynecologists concluded in a 2000 report that the
benefits of a vaginal birth after a caesarean outweigh the risks for many women. And the federal government has set a goal of 37% VBAC deliveries as part of its Healthy People 2010 objectives, up from the 28% rate reported in 1998."
"But safety, cost, convenience and malpractice concerns have
sent the rates plunging, not increasing. The decline started in 1999 when the American College of Obstetricians and Gynecologists recommended that a doctor and an anesthesiologist be "immediately available" when a VBAC patient is in labor. Before 1999, a doctor and surgical team were advised to be "readily available," widely interpreted to mean that they be within 30 minutes of the hospital." 
"There has been absolutely no change in the underlying scientific background on VBAC," says Dr. John Aiken, an obstetrician at Northridge Hospital Medical Center. "But because of this ... requirement, the physician has to be on site. A lot of physicians don't come in to the hospital until their patient is fully dilated [ready to give birth]. So they can't meet the criteria.

Both hospital administrators and doctors say it's too costly and inconvenient for a doctor to sit with a patient in labor (which may last many hours). "There really isn't any incentive for the physician to do VBACs," said Dr. Roger K. Freeman, an obstetrician at Long Beach Memorial Medical Center and chairman of the obstetricians task force on VBAC. "It's more time-consuming, more worry. And they don't get paid any more for it.".. [the patient's doctors] were blunt in denying her VBAC attempt. "One doctors said he wouldn't be willing to wait during my labor. 

"Some women, patient advocates and doctors are upset that non medical issues may lead to unnecessary surgery that has attendant risks of its own. The risk of infant death due to a uterine rupture during a VBAC is about 1 in 1,000, twice the rate among other laboring women, according to studies. Uterine rupture can cause permanent injuries in babies and lead to hysterectomies."

"But women who have successful VBACs avoid the much longer recovery time and risks associated with C-sections. For the mother, those risks include infection, hemorrhage, blood clots, injuries to other organs and exposure to major anesthesia. The risks to the baby from C-sections are higher rates of respiratory disorders, fetal trauma and fetal death."

"San Pedro woman who is expecting her second child, was surprised when her obstetrician balked at her request to try a vaginal birth.
"He came right out and said it was for liability reasons," says Gang, who has hired a doula to help advocate for her during her labor. "Part of me was a little offended at his honesty.... I want my doctor to do what is in my best interest."
"To reduce possible complications, the American College of Obstetricians and Gynecologists recently admonished doctors to avoid using drugs that start or speed up labor in VBAC deliveries. Use of labor-inducing drugs, called prostaglandins, have doubled in the last decade (from 9.3% of all deliveries in 1990 to almost 20% in 2000). But the drugs dramatically increase the risk of a uterine rupture during VBAC, according to a study published last year in the New England Journal of Medicine."

Elective Caesareans Judged Ethical – Doctors Group Issues Statement on Poplar Procedure;
Washington Post Staff Writer Rob Stein / October 31, 2003