Large study reports 2.9% prevalence of severe anal sphincter tears with spontaneous VD

A Norwegian study that set out to analyze the circumstances relating to severe anal sphincter tears during spontaneous vaginal delivery at five hospitals has uncovered some interesting findings.

Firstly, Annelill Valboslash et al's study analyzed midwife-conducted non-operative vaginal deliveries only during a 12-month period..., so arguably, a best practice scenario (according to many natural birth advocates) of birth care.

Secondly, it found that 357 women sustained third and fourth grade anal sphincter tears; that's 2.9% of the 12,438 births analyzed. Remember, this number does not include women who endured less severe anal sphincter tears, which would make the overall risk of anal damage much higher.

Thirdly, the study does not include any anal tears or damage that occurred during instrumental vaginal deliveries. Other studies have documented greater prevalence of anal risk in assisted births, so again, if the outcomes of ALL planned vaginal deliveries were included, the occurrence would have been greater than 2.9%.

What made sphincter damage more/less likely to occur?
The study found that "sphincter tear incidence varied significantly between the five hospitals, from 1.3 to 4.7%", and that the "use of oxytocin in the second phase of labor and of epidural analgesia was significantly more often applied in the hospital with the lowest rate of sphincter tears." So medical intervention in this particular study was associated with better outcomes.

On the other hand, the "midwives' perception of having applied perineal support was not significantly different between the two hospitals with the highest and the lowest incidence of sphincter tear."

The authors conclude that: "The observed difference in incidence of sphincter tear between the hospitals remains unexplained, but could be due to different perineal protection handling techniques."

Planning a cesarean
What is probably of most interest to women planning an elective cesarean delivery is the fact that their risk of ANY anal sphincter damage is considerably less than if they were planning a vaginal delivery. This is surely a reasonable factor to take into consideration during an individual risk-benefit analysis of different birth types.

Study finds SUI is twice as common with PVD

This new study from Brazil is the latest in a long line of studies to show that stress urinary incontinence is more common following a vaginal delivery than it is following a cesarean delivery.

This particular study by Herrman et al assessed women's health three years after they gave birth, and found that: "Women that were asymptomatic during pregnancy and had vaginal delivery developed SUI 2.4 times more frequently than after c-section (19.2% and 8.0%, respectively)."

Difference may be greater if comparing PVD with PCD alone
I have listed other studies on my website that demonstrate a greater prevalence following emergency cesarean delivery when compared with planned cesarean delivery, so although this Brazilian study reported an 8% prevalence with cesarean delivery, it is worth remembering that the study did not separate the two types of surgery. Therefore, the difference between vaginal delivery SUI prevalence and planned cesarean delivery SUI prevalence was likely more than 2.4 times in this group of 120 women.

Natural childbirth movement 'denies women choice'

This is the title of an article in today's Independent newspaper in the UK, which quotes Maureen Treadwell, co-founder of the Birth Trauma Association (BTA):

"Childbirth has become a political football where women are often discouraged from having the sort of birth that they want in order to fulfil someone's idea of a 'normal' birth. Women don't want to have to go into childbirth and have to fight for pain relief... There is a hidden agenda here, one that will result in women being made to feel failures just for asking for pain relief or other forms of medical intervention."

Tomorrow, Monday 24th November, the BTA and other support groups are meeting with Kevin Barron MP, chair of the Commons Health Select Committee, in order to "call for urgent action to ensure women are given a real choice of treatment. The campaigners accuse the Government of having allowed childbirth to be dominated by policies which suit some groups of women to the detriment of others, and are calling on ministers to create an inclusive maternity policy."

I will be there in spirit and would have loved to be there in person as invited, but unfortunately it was not practical. I will keep readers posted on the outcome of this meeting, and invite you to demonstrate your support for autonomy in childbirth - including cesarean delivery - by signing my online petition. Signatures and comments to date are listed here.

Premature delivery rather than cesarean surgery itself increases respiratory illness risk

Unfortunately, I haven't been able to view an abstract or full text of the latest study by Borgwardt et al on respiratory illness in babies born by cesarean, but given the Danish study's title, 'Elective caesarean section increases the risk of respiratory morbidity of the newborn', the conclusion drawn is perhaps evident.

It will be interesting to find out what the gestational age of the babies involved in the above study were, but just in case there is any similarity with that of the well-publicized Anne Kirkeby Hansen et al study, I would like to re-emphasize what I said then.

Planned cesarean delivery with no medical indication is only advisable at 39 weeks confirmed gestation
This is in order to ensure that the baby's lungs are fully matured, since numerous studies have found that the lowest prevalence of respiratory morbidity occurs at 39 weeks gestation or more (some studies actually state that 38 weeks is acceptable, but the NIH and ACOG advise 39).

With the 2007 publication of Anne Kirkeby Hansen et al's study in the British Medical Journal, a number of responses followed, of which mine was one: 'Further evidence of reduced infant morbidity with cesarean delivery on maternal request at 39 weeks EGA.' This response explains in more detail why early gestational age, rather than surgery itself, increases the risk of respiratory illness in newborn infants.

New study finds no allergy risk for cesarean born babies

A Norwegian study involving more than 500 children has found no increased prevalence of childhood allergies in babies born via cesarean delivery. Bente Kvenshagen et al begin by stating the theory that is most often expressed by researchers who believe there is such a link: That cesarean born babies "do not get the same contact with their mother's gut flora as babies delivered vaginally. Theoretically, lack of exposure to maternal vaginal and perineal bacteria might change the gut flora, with secondary changes in the immune system."

However, of 512 children at the age of two (171 delivered by cesarean and 341 born vaginally), those reported to have symptoms consistent with possible food allergy were examined at the outpatient clinic, and there "was no over representation of children born by caesarean section."

The impact of planned cesarean delivery on mother and newborn

A research paper from the Department of Obstetrics and Gynecology at Weill Cornell Medical College, New York has advised that "the most concerning risks related to maternal request cesarean delivery are neonatal respiratory morbidity and those that may affect the mother's future reproductive health, including life-threatening conditions, such as placenta accreta", and advises that pregnant women should be counseled on these.

Risks for the mother are lower with PCD than with PVD
Authors YM Lee and ME D'Alton write: "The literature suggests that overall risks of maternal complications with cesarean delivery on maternal request are slightly lower than a trial of vaginal delivery and are primarily driven by the avoidance of unplanned or emergent cesarean deliveries and their associated increased rate of complications."

This is something I have been highlighting (along with many others) for many years. The risks associated with planned vaginal delivery include ALL potential outcomes of a trial of labor and should be recorded as such. Comparisons between PCD and spontaneous VD alone are ineffective and misleading.

Other issues to consider
The authors do acknowledge that cesarean delivery on maternal request is not a simple decision to make. For instance, "there are many areas on which studies are lacking", and in addition, "numerous factors can alter the risks and benefits - such as culture, maternal obesity, and provider background". This echoes the advice given by the NIH in 2006 that maternal request is only ethical following individualized consultation.

Swedish women choosing cesarean delivery

A new study from the Karolinska Institutet in Sweden set out to examine public attitudes to the act of choosing a cesarean delivery in preference to vaginal delivery. Out of the 1,066 women who responded, "two-thirds stated that a cesarean should be decided on for medical reasons and by a doctor. One-third considered that a woman, without persuasion, should decide herself about mode of delivery and should be free to choose a cesarean."

"These respondents used arguments such as women's rights, bodily integrity and childbirth fear. The results were associated with low trust in health care, women being young or middle aged, urban living and having no children. Low trust in health care was associated with experiences of insecurity, vulnerability and perceived maltreatment."

What does this mean for Sweden's future maternity care?
The study authors (Ulf Houmlgberg, Niels Lynoumle and Marianne Wulff) predict that antenatal care will encounter "more parents asking for a cesarean [in the future], and demanding that health professionals provide an ethically appropriate informed consent process."

They conclude: "Considering the risk of violating young women's trust if not respecting her wish, it seems reasonable that making decisions whether or not to perform a cesarean is part of shared decision making."