Friday, January 8, 2010

Hospital readmissions after cesarean delivery - are they really higher than after vaginal delivery?

I've just posted a comment at the bottom of yesterday's Modern Medicine article 'Readmissions After Cesarean Higher Than Vaginal Delivery' because I think that the conclusions drawn - both in the media report and in the medical study itself - are not particularly helpful for women who are deciding which birth 'PLAN' to choose.

The article reports on a new U.S. study by researchers Michael Belfort et al: 'Hospital readmission after delivery: evidence for an increased incidence of nonurogenital infection in the immediate postpartum period', and here are my concerns:

The conclusion reported here (that readmission rates are higher following cesarean delivery than vaginal delivery) is a typical example of the flaws apparent in comparative medical studies – particularly in the U.S. Why? Because the research combines all cesarean outcomes (emergency and elective) together - rather than attributing health outcomes of an emergency cesarean to the planned vaginal delivery it originated as.

Actually, vaginal delivery is a risk factor for readmission
In fact, if you read this study in full, Belfort et al explain: “Potential explanations as to the reason that a primary cesarean section delivery represents a greater risk for readmission than a repeat cesarean delivery may include such factors as increased risk of infection from prolonged labor (repeated vaginal examinations, chorioamnionitis), increased blood loss with emergency surgery, and higher use of general anesthesia.”

So in effect, issues related to the trial of labor and subsequent emergency surgery are risk factors for postpartum readmission to hospital – and the risk of readmission with planned cesareans (even repeat surgeries) is lower.

My concern is that studies like this are used to deter women who request a primary elective cesarean at 39 weeks, when evidently the research has very little to do with their chosen birth plan. Rather, if the data was separated (with readmissions following emergency cesarean attributed to planned vaginal deliveries), it is likely that the reality of these readmissions in relation to the delivery method planned is different to that concluded here.

Balance of risks
In addition to the above, I think it's worth remembering that an emergency cesarean is often carried out in a life or death situation (whether it's the mother's life, the baby's life, or both, that is at risk), and while subsequent hospital readmissions are unpleasant and undesirable, they are certainly preferable to the alternative - mortality or severe morbidity if an emergency cesarean is not carried out.

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