"At last an article that uses an 'intention to treat' type of analysis to show that primary caesarean section on maternal request is not only ethically legitimate but also has some scientific credibility. This article has demonstrated that, for healthy primiparous women, planned caesarean delivery decreases maternal morbidity whilst, not surprisingly, emergency caesarean section increases maternal risks compared with both vaginal delivery and primary elective caesarean section."
Maternal Outcomes Associated with Planned Vaginal Versus Planned Primary Cesarean Delivery. F1000: "Changes Clinical Practice"
Geller EJ, Wu JM, Jannelli ML, Nguyen TV, Visco AG. Am J Perinatol 2010 Mar 16
Commentary from Faculty Member John Svigos
26 April 2010, Faculty of 1000 Medicine
Changes Clinical Practice: There is insufficient evidence to refuse a woman her legitimate right both ethically and now scientifically to request an elective primary caesarean section at 39 weeks gestation.
At last an article that uses an 'intention to treat' type of analysis to show that primary caesarean section on maternal request is not only ethically legitimate but also has some scientific credibility. This article has demonstrated that, for healthy primiparous women, planned caesarean delivery decreases maternal morbidity whilst, not surprisingly, emergency caesarean section increases maternal risks compared with both vaginal delivery and primary elective caesarean section.
The National Institutes of Health (NIH) statement re caesarean delivery on maternal request in 2006 that there was insufficient evidence to evaluate fully the benefits and risks of elective caesarean delivery stimulated many workers to try to find this elusive evidence. Most studies before and after this statement and until the publication of this article were fundamentally flawed by including outcomes from emergency and elective surgeries in women (and babies) with pre-existing medical conditions and not including in the vaginal delivery group those that did not deliver vaginally and their respective morbidity and mortality. Additionally, there was a tendency to place more emphasis on caesarean morbidities such as haemorrhage and infection and less emphasis on the more commonly occurring post-delivery pelvic floor dysfunction and pain. The continued use of morbidity/mortality statistics from primary caesarean for breech presentation as the surrogate for caesarean section on maternal request can no longer be justified and is positively misleading if one analyses the paper by Liu et al. Furthermore, the most recent paper by Lumbiganon et al. after detailed analysis demonstrates the bias directed against the proposal of primary elective caesarean on maternal request. Whilst there has been considerable emphasis placed on examining maternal morbidity and mortality in this context, it would seem that the study by Hankins et al. has reassured most practitioners that perinatal morbidity and mortality is not compromised and indeed may be improved in women requesting elective caesarean section at 39 weeks gestation. I believe that there is now a legitimate case for women to request elective caesarean section at 39 weeks gestation and that, as responsible obstetricians, we should be striving to reduce the number of caesarean sections in women who do not wish to have a caesarean section, particularly increasing our resolve against the flawed Term Breech Trial and the impaired retrospective studies favouring elective caesarean section for twin pregnancies and giving these women a choice to deliver vaginally!
Maternal Outcomes Associated with Planned Vaginal Versus Planned Primary Cesarean Delivery. Geller EJ, Wu JM, Jannelli ML, Nguyen TV, Visco AG. Am J Perinatol. 2010 Mar 16. Division of Urogynecology and Reconstructive Pelvic Surgery, Department of Obstetrics and Gynecology.
"We compared maternal morbidity between planned vaginal and planned cesarean delivery. A university hospital's database was queried for delivery outcomes. Between 1995 and 2005, 26,356 deliveries occurred. Subjects were divided into two groups: planned vaginal and planned cesarean delivery. This was based on intent to deliver vaginally or by cesarean, despite actual route of delivery. Planned vaginal delivery included successful vaginal delivery and labored cesarean delivery intended for vaginal delivery. Planned cesarean delivery included unlabored and labored cesarean delivery and vaginal delivery intended for cesarean. Chart abstraction confirmed the delivery plan. Primary outcomes were chorioamnionitis, postpartum hemorrhage, and transfusion. Secondary outcomes were also measured. A subanalysis compared actual vaginal delivery, labored cesarean delivery, and unlabored cesarean delivery. There were 3868 planned vaginal deliveries and 180 planned cesarean deliveries. Planned cesarean delivery had less chorioamnionitis (2.2% versus 17.2%), postpartum hemorrhage (1.1% versus 6.0%), uterine atony (0.6% versus 6.4%), and prolonged rupture of membranes (2.2% versus 17.5%) but a longer hospital stay (3.2 versus 2.6 days). There were no differences in transfusion rates. For healthy primiparous women, planned cesarean delivery decreases certain morbidities. Labored cesarean delivery had increased risks compared with both vaginal delivery and unlabored cesarean delivery."
Neonatal outcomes associated with planned vaginal versus planned primary cesarean delivery. Geller EJ, Wu JM, Jannelli ML, Nguyen TV, Visco AG. J Perinatol. 2010 Apr;30(4):258-64. Epub 2009 Oct 8. Division of Urogynecology and Reconstructive Pelvic Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7570, USA.
"Objective: To determine whether planned route of delivery leads to differences in neonatal morbidity. Study design: Analysis was based on planned route of delivery, not actual route of delivery. A total of 4048 subjects were divided into two groups: planned vaginal delivery and planned cesarean delivery. Primary outcomes were neonatal intensive care unit (NICU) admission, respiratory morbidity and neurologic morbidity. Result: There were 3868 planned vaginal and 180 planned cesarean deliveries. Planned vaginal delivery had decreased NICU admission... Conclusion: Planned vaginal delivery led to more meconium passage and low 1 min Apgar but less NICU admissions, oxygen resuscitation and jaundice. Multicenter trials are needed to assess rare but serious outcomes based on planned route of delivery."