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Thursday, February 13, 2014

C-Section Moms AsK in the Sectond pregnancy: Wait Until Labor, Induce, or Schedule Repeat Surgery and When to Do These Interventions

Generally we have told women that waiting until full term is best for babies. In pregnancy complicated by a prior c-section the decision is to whether labor, induce, or perform a repeat c-section. And since we are caring for two patients,  we can also look at two studies which may dramatically affect a woman's decision as to when to schedule these obstetrical interventions. Laura Hart, MD, a fellow in the division of maternal fetal medicine at the University of Texas Health Science Center in Houston decided to look at this from Mom's standpoint, and see if waiting until 39 weeks, or one week before the due date, is really the best time for a woman to have her c-section, and in fact she has now been quoted to say: "The optimal time of delivery is 38 weeks for women with 2 previous cesarean deliveries and 37 weeks for those with 3 or more."
Our national c-section rate is about 30%, with 22% of all women birthing having a cesarean procedure for their first delivery. Risk of c-section for first c-section is only 22%, but virtually all moms will have repeat deliveries as  VBACs, or having a of vaginal birth after a cesarean delivery is about 9%.  In the US women discuss having a vaginal birth with their next pregnancy, but in reality most are scheduling a repeat c-section. So for the over 90% of women having that repeat c-section, the timing of that operative procedure is critically important. We want the baby to be fully mature, but we want that baby bed to still be healthy and do what's best for mom. Although rare, problems can occur if we delay delivery so long that some women go into labor, and that was the focus of Dr. Hart's research. For one thing, she was able to determine that over half of all women having a repeat c-section will go into labor before 39 weeks. So by delaying the scheduled c-section we are forcing over half the patients into emergency surgery, even if they have requested an elective planned surgery. Experts across the country are saying that this study is very likely to change practice, although these guidelines have not taken hold yet. Right now there is a push for accurate due dates, and then to discuss the mode of delivery, and the NIH is tracking c-section rates as well. Which course of therapy is best was compared in a new study that evaluated when to induce labor compared with the outcome of expectant management waiting for natural labor. In one such study of over 12,000 women with  pregnancies who were greater than or equal to a week from their due date and no more than one prior cesarean delivery, women undergoing induction at 39 weeks without an acute obstetric medical indication were more likely to deliver vaginally than those in whom their obstetricians awaited natural labor (74 versus 61 percent). But the cost of waiting was grave as the group that waited also experienced a higher rate of uterine rupture (1.4 versus 0.5 percent).  If you have had a c-section, time to go in to see your gyno to discuss what the next step really will be when you plan your next pregnancy.

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