The story I hate to tell: the dark history of obstetrics ~ the data (part 7)

by faithgibson on March 10, 2016

in Historical Childbirth Politics 1820-1980, OB Interventions: Dubious or Detrimental

Link back to part 6

Continued part 7 ~ Source material – ObGynNews – on the dramatic increased in placental abnormalities and its association with our sky-rocketing Cesarean section rate:  

The following quotes are from the professional trade paper ObGynNews. This publication is the obstetrical equivalent of the Reader’s Digest, in that it is a digest of the latest research in which it reports on journal articles and papers presented at national and regional conferences and information about official policy statements and technical guideline published by ACOG.

This information is what obstetricians are telling one another and documents what practicing obstetricians could reasonably be expected to know. In malpractice litigation, medical doctors are held to a standard defined as “What a doctor knows, or should have known”. This is the information that obstetricians “should have known” and if they didn’t, it was because they had insulated themselves from the realities of their risky practices.

At the end of the material from ObGynNews, I have included the first half of the Swedish study on the historical MM from 1751 to early 1900s.

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1. 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.

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.

2. 
Ob.Gyn.News , Sept 15, 2001, Vol 36, No 18

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.

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 prepared 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.  

“Cesarean Rate Portends Rise in Placenta Accreta, Maternal mortality 7%ObGynNews; Mar 01, 2001, Vol 36

The author went on to say:  “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.”

3. 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;  

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%.

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.  

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

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.  

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 re-exploration in up to7peercent of patients with accreta/percreta (3,5).

5. ACOG NEWS RELEASE October 31, 2003 ~ ACOG Office of Communications

New Opinion Addresses Elective Cesarean Controversy  


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

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Continued part 8  — The Decline in Maternal Mortality in Sweden: The role of Community Midwifery

 

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