ObGyn ListServ is a worldwide social phenomenon that incidentally provides a permanent record of communication between obstetricians.
Archives of its daily cross-talk includes many conversations about the complications of Cesarean surgery, including delayed and downstream of repeat Cesareans.
Obviously these many post-Cesarean complications are widely known and frequently discussed by obstetricians among themselves.
The following excerpt of an email discussion occurred in 2004 btw members of an obstetrical ListServ. This group began in the mid-1990s, and was one of the first to use the internet as an effective social medium that used the on-line abilities of the web to connect hundreds of English-speaking obstetricians and other professional maternity care providers (family practice physicians and midwives).
A decade before MySpace and facebook, a significant percentage of its worldwide membership regularly logged on everyday to exchange ideas “across the Pond” (as the Brits on the list put it) in the comfort and privacy of homes and offices on both sides of the Atlantic.
This “thread” on a post-Cesarean placenta percreta tragedy begins with a distressing account by an obstetrician member describing his largely futile attempts to successfully treat the critical complications from an extremely invasive placenta percreta in a patient who was only 24 wks pregnant.
At this point in the story, her extremely premature baby has already died, and its critically ill mother is still in the ICU. Despite the obstetrician’s best surgical effort, her “prognosis is poor” and he is afraid that she may not make it.
Then the focus of the tread changes to a hotly debated (yea and nay) obligation of the obstetrical profession to tell pregnant women about the many complications associated with Cesarean surgery, particularly the greatly increased danger of after a previous Cesarean of developing the potentially fatal complications caused by abnormal implantation of the placenta in a subsequent pregnancy.
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British obstetrician Steve R******:
In 30 years of Obstetrics I have never encountered a true case of percreta until this weekend.
The patient aged 30 with two previous Lower Segment Caesars presented on Friday at 24 weeks with bleeding, at a district hospital near here. The fetal heart was still present and the uterus tender, with ultrasound evidence of a “haematoma” in the anterior low-lying placenta, and estimated fetal weight about 700 grams.
Initial advice to the resident was to rupture the membranes and deliver – that this was essentially a mid-trimester miscarriage. About five hours later they rang again to say that she had not dilated beyond 3cm and this time it was a new doctor who had seen the patient and informed me that the previous doctor had missed the fact that she had had two caesars, and had given Cytotec.
The bleeding was minimal, but I asked him to transfer her to our hospital as the progress was unsatisfactory. Overnight she made a few more centimetres dilatation progress and the fetal heart disappeared.
On opening the abdomen the placenta was found to have gone right through the lower segment into the bladder and down into the anterior vaginal wall. It was impossible to see the anatomy properly as the bleeding from this area was just horrendous. I had to excise a strip of bladder wall along with the uterus, and then try to get sutures around the top of the vagina which would be haemostatic. The control of bleeding from this area was particularly tenuous.
In the end we packed and came out. She has had six units of cross-matched blood and three of ONEG, and has produced about 50 ml urine all day today! I was very glad I had put on a long apron and gumboots! But I fear that the prolonged hypotension and hypovolaemia indicate a very poor prognosis.
Re: Placenta percreta
From: Anna M*****, MD (firstname.lastname@example.org)
Mon Jun 14 22:17:35 2004
Yes, I realize we had this discussion not too long ago, but just as a reminder, do those of you who offer your pts elective primary c-sections on demand or for very iffy indications warn your patients of their increased risk of this very thing? Just wondering.
Anna M*****, MD
From: R. Daniel B****, (email@example.com)
Tue Jun 15 05:25:25 2004
After the 6th cesarean, it reaches an incidence of 5% according to one study from Dublin.
Re: Placenta percreta
Tue Jun 15 22:20:36 2004
In a message dated 6/14/2004 11:34:09 PM Eastern Standard Time, firstname.lastname@example.org writes:
“Yes, I realize we had this discussion not too long ago, but just as a reminder, do those of you who offer your pts elective primary c-sections on demand or for very iffy indications warn your patients of their increased risk of this very thing?”
I was thinking this exact same thing myself. Most women I know who had c/s were never given informed consent about risks that c/s present for future babies and pregnancies. This is a huge issue, especially for women who plan to have more than one or two children.
Chris A, NP, sneaking out of lurkdom for a moment…
Re: Placenta percreta
Wed Jun 16 07:17:03 2004
Ok again to play devil’s advocate, since you mentioned informed consent, what about informed consent for vaginal delivery?
Robert M****** MD, MBA FACOG
In a message dated 6/16/2004 1:23:03 PM Eastern Daylight Time, email@example.com writes:
> do you list potential genital prolapse and incontinence as potential
> long term complications? I figure if counseling for placenta percreta as
> a complication of cesarean is in order, than counseling for prolapse as
> a complication of vaginal delivery is also in order.
In a message dated 6/16/2004 7:13:26 PM Eastern Standard Time, firstname.lastname@example.org writes:
“That may be the case, but it is apples and oranges if you are talking about lack of informed consent for a relatively “elective” cesarean section, such as: “I think you have a large baby and it may get stuck coming out” and the baby turns out to be a pound smaller than her last baby; vs. the patient with the cord prolapse or abruption who needs a C/S immediately and the only information she needs is that her baby may die if she doesn’t get to the OR right now.
The relative risks of future pregnancy takes a back seat to the immediate problem in most circumstances. It is not a “huge issue” as you state.”
Wed Jun 16 20:29:39 2004
Obviously, when a baby’s life is truly in danger (prolapse, abruption, previa, etc.), the risks are well worth the benefit. I don’t have a problem with informed consent in that situation. But true life-threatening emergencies do not occur in 26.1% of births, which was the c/s rate for last year.
You give an example of a ‘relatively “elective” c/s’- but I don’t really think that is elective when a mom is told by her doctor whom she trusts tha her baby could die or be seriously injured if she attempts a vaginal birth. It’s those women who are not told the risks, yet are made to believe their babies lives are in danger.
We may differ on what true indications are for c/s, but I hear from so many women who are given the most absurd reasons for why their baby MUST be born by c/s. It happens all the time.
And we have already discussed many times how we will opt for the c/s which is a “better safe than sorry choice” even if the indication is unclear- and this is usually to avoid law suits.
What about the women who are counseled to have ERCS [i.e. Elective Repeat Cesareans Sections] instead of have a TOL d/t the very small risk of UR [i.e. uterine rupture]?
Are they told the risks of each additional c/s? Placental complications? Etc? I don’t think so. And I think the problem is much large than you say. Even if it is 25% of c/s births, that to me is HUGE.
Chris A., NP
In a message dated 6/17/2004 8:11:38 AM Eastern Standard Time, email@example.com writes:
“And I doubt that women are told about the potential long term complications of vaginal delivery either.”
Thu Jun 17 15:39:02 2004
I guess this means you agree with me, since you have nothing further to say on the subject.
And .. I don’t believe women are told the risks and potentials long term complications of routine obstetrical management of vaginal births – epidural, episiotomy, lithotomy pushing positions, vacuums/forceps.
Chris A., NP
In a message dated 6/17/2004 8:27:16 PM Eastern Standard Time, firstname.lastname@example.org writes:
“And in your years of experience in the field, what would satisfy you in this pursuit of patient autonomy and choice? Do we need to have loaner library f Williams Obstetrics for our patients to check out at the beginning of pregnancy?
How do we make sure they read or understand the material? Perhaps a final exam at 36 weeks, to make sure they are safe to enter the hallowed halls of L&D, like the exit exams now required of our high school students?
If they don’t pass, they have to repeat the pregnancy 😉 “
Actually, I would steer many women away from an obstetrical textbook, but truly educate them about the realities of birth and the limitations of modern obstetrics.
I also would tell them not rely on their doctor for every piece if info they get about pregnancy and birth (and before everyone jumps on me fo that comment, I think ALL people should educate themselves about medical issues that affect them.
Once again, no one has actually responded to what I said- you have changed the subject and resorted to sarcasm– must be because you know I am right.
Re: Placenta percreta
From: ainsron (email@example.com)
Sat Jun 19 14:26:59 2004
Call it sarcastic if you like, but I would truly like to know what your source of information for the education of patients “about the realities of birth and the limitations of modern obstetrics” is.
If you find that “Holy Grail,” share it with us.
We all need to be educated about many of areas of our lives, so we can avoid being ripped off by the investment advisors, plumbers, mechanics, teachers, politicians and many more.
Unfortunately, we live in an explosion of information. None of us are modern day versions of Ben Franklin or Thomas Jefferson, well rounded and well-versed in all of the events of our day, let alone all the subtleties of our specialty.
We rely on experts in every field we interface with. If we find someone we trust, we tend to believe what they say and expect them to have our best interests at heart until someone better or with new information comes along.
If the women I care for trust me blindly, that is their mistake and not my intent or request. I provide lots of information on every aspect of the care I provide, from one-on-one discussions to ACOG pamphlets and many other sources to reinforce what I say nor do I leave the patients room until I have satisfactorily answered her questions.
Additionally I offer consultations when complex issues arise and patients are confused about their choices. When I talk to patients about the current state of VBAC, I tell them that I feel it is safe for most patients, but because of the realities of care in our current medico-legal environment, I cannot offer it to them – most understand and accept that as the way things are.
Everyone in direct healthcare is a teacher, some are better than others. It is much more rewarding for me to provide care to patients who are appreciative, informed and interact at an adult to adult level. I don’t want to baby-sit patients or make their decisions for them; some days it is hard enough making my own!
Ronald E. A********, MD
Re: Placenta percreta
In a message dated 6/19/2004 7:32:54 PM Eastern Daylight Time, firstname.lastname@example.org writes:
> Women having cesarean delivery are more likely than those delivering vaginally to
> have an antepartum stillbirth in their second pregnancy. The major
> reason is an excess of unexplained stillbirths. Possibly ligating major
> uterine vessels affects uterine blood flow in later pregnancies. Another
> possible explanation is abnormal placentation secondary to
> the uterine
> Anna M*****, MD
In other words we should be more vigilant in women who have had previous cesareans because they probably have a higher incidence of intra-uterine growth restriction.
Robert M****** MD MBA FACOG http://www.novaobgyn.yourmd.com