In regard to Dr. Robert L. Barbieri’s September editorial, “Repeat cesarean again and again and again,” it is not just surgical technique on the 4th cesarean that is important. We also need to be very honest with patients and discuss the increased risk cesarean births pose for future pregnancies. I am aware of 2 tragedies related to this issue. Both occurred in rural hospitals. The first was on a Navajo reservation in a blizzard, when extra personnel and blood products were unable to reach the patient before she died. The second patient spontaneously aborted at 20 weeks and bled out within minutes of reaching her small local hospital. Presumably both women had previas with accreta. Please discuss the option of sterilization with the patient and her partner before doing her third cesarean.
Remember: Your patient may not stay in an urban area with access to tertiary care. She may not make it to a planned 4th cesarean under controlled circumstances. Many of my patients have been willing to settle for 3 and are grateful for the family they have, including an intact mother.
Dr. Barbieri responds:
I agree, whole-heartedly, with Dr. Kerr. As noted in my editorial, at the time of a high-order repeat cesarean section, consideration of a permanent or reversible contraceptive is critical to the reproductive health of the woman and her family. Additional research on the safety of a fourth pregnancy after 3 cesareans for women who live in rural areas would be of special importance.
Nancy Kerr, MD