UAB Medicine News
Cesarean Awareness Month, observed in April each year, aims to raise awareness and educate people about cesarean delivery and reduce the number of these procedures performed. This year’s observation is a perfect time to highlight the success of a new UAB Medicine team created to manage certain medical and surgical complications that may arise from cesarean deliveries.
A cesarean section, or C-section, is a surgery performed to deliver a baby through the mother's lower abdomen, usually when unexpected problems develop during delivery. These problems include how the baby is positioned in the womb (uterus) and signs of distress in the baby, such as an abnormal heart rate. The surgery requires an incision across the belly that also cuts into the womb and the amniotic sac that surrounds the baby. The baby is delivered through this incision.
C-Sections on the Rise
The number of C-sections, whether elective or medically necessary, has greatly increased in recent decades. For that reason, research concerning methods, postoperative care, and how to safely reduce the number of C-sections has led to important health care initiatives. UAB Medicine’s new placenta accreta team is one such initiative.
Placenta accreta is a medical condition in which the placenta – an organ that develops in the uterus during pregnancy to provide oxygen and nutrients to the baby and remove waste products from the baby's blood – grows too deeply into the wall of the uterus. Although the placenta still functions normally, it may not detach on its own after the baby is born. This is dangerous to the mother, because trying to detach the placenta after birth can cause heavy bleeding and damage other organs.
Akila Subramaniam, MD, MPH, an assistant professor in the UAB Division of Maternal-Fetal Medicine, heads the placenta accreta team from the obstetric side. She has directly witnessed the increase in medical complications related to C-sections.
“The cesarean procedure is the single most commonly performed surgery in the U.S. and globally,” Dr. Subramaniam says. “We’ve seen the rate increase annually since the early 1990s, and although it has been stable over the past few years, we are still at a little above 30% nationwide. But with that we have seen a fivefold to tenfold increase in complications arising from cesarean deliveries.”
A woman who delivers her first baby via C-section is much more likely to have C-sections with any babies she delivers later, and the risk of complications increases with each cesarean delivery, Dr. Subramaniam says.
“Multiple caesareans can put a mother’s life at risk,” she says. “Knowing that one procedure leads to subsequent ones, we want to reduce the rate of first-time cesarean deliveries.”
Common Risks
The risks include excessive bleeding (even beyond the 20% blood volume loss associated with C-section surgery), wound infection, infection of the uterus, cardiovascular complications, and scar tissue formation. The chances of infection increase with the length of the surgery, and subsequent C-sections can take longer and longer. Treatment with antibiotics at the time of delivery decreases infection risk by about 50%, but on average, C-section deliveries have a 12% infection rate. UAB Medicine’s placenta accreta team addresses these specific issues and more.
The American College of Obstetricians and Gynecologists (ACOG) recommends that a patient with placenta accreta should deliver her baby in a tertiary care center, meaning that the facility offers highly specialized equipment and expertise. According to ACOG, this should include equipment for high-volume blood transfusion; interventional radiology specialists; specialized obstetric, anesthetic, and intensive care; and consultations with urologists and gynecologic oncology (cancer) specialists and surgeons.
“We developed our team in late 2018, and our decision was a direct response to the current cesarean rate,” Subramaniam says. “What we are seeing is that women who’ve had multiple cesarean deliveries are experiencing greater risk of the placenta adhering to cervical structures. The rate of this event used to be one in 1,000, but now we see this for about one in 272 patients. In turn, that is linked to high morbidity for both the mother and the baby.”
Team of Specialists
The placenta accreta team includes Dr. Subramaniam, who leads the team on the maternal-fetal medicine side, as well as gynecologic physicians (led by Kerri Bevis, MD) who are trained in Ob/Gyn care and in cancer surgery. It also includes an obstetric anesthesiologist, along with a group of specialized nurses who manage the delivery process and schedule the patient for pre-operative evaluation and lab work. The team has a blood bank capable of supplying enough blood for a massive transfusion, which often is needed in severe cases. Critical care expertise, found in UAB Medicine’s multiple intensive care units, rounds out the team.
Dr. Subramaniam says she’s proud of the wide range of expertise and services that this team offers, even in its infancy.
“We are doing real-time placental scanning and 3-D imaging to look for and identify markers of placental invasion,” Dr. Subramaniam says. “Those images also help the surgeons plan specific aspects of their work. We coordinate delivery planning. Dr. Bevis and her team are there for preoperative, intraoperative, and postoperative management for very complex cases. The placenta accreta team is early in its development, but we are seeing very good outcomes. It’s an effort we hope to develop into a center of excellence in coming years.”
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