Amidst talk about the increasing cesarean rates in the developed world, it is all too easy to forget the plight of women in other countries where access to cesarean surgery is dangerously low.
An article this week in the International Herald Tribune, 'Project works to improve lives scarred by childbirth injury', describes the devastating injury fistula that occurs as a result of obstructed labor during vaginal delivery.
Denise Grady writes: "If prolonged, obstructed labor often kills the baby, which may then soften enough to fit through the pelvis, so that the mother delivers a corpse. Obstructed labor can kill the mother, too, or crush her bladder, uterus and vagina between her pelvic bones and the baby's skull. The injured tissue dies, leaving a fistula: a hole that lets urine stream out constantly through the vagina. In some cases, the rectum is damaged and stool leaks out. Some women also have nerve damage in the legs."
She continues: "Fistulas are a scourge of the poor, affecting two million women and girls, mostly in sub-Saharan Africa and Asia - those who cannot get a Caesarean section or other medical help in time."
Thursday, February 26, 2009
Tuesday, February 17, 2009
Risk of postpartum psychosis increases with age
This report appeared on the website EMax Health last week, and talks about new research led by Christina M. Hultman, PhD, of the Karolinksa Institutet, in Stockholm, Sweden.
Researchers found that half of women diagnosed with postpartum psychosis have no history of mental illness, and that the risk of postpartum psychosis is greater in women over age 35 who give birth for the first time.
Why is this important?
Other research has shown that women who achieve their preferred delivery method enjoy better psychological post-birth outcomes than women who don't. So if a woman plans a vaginal delivery and ends up needing an emergency cesarean, she may feel more negative about her birth experience than if she has a spontaneous vaginal delivery. Similarly, it has been shown that women who choose a cesarean delivery, and go on to have a cesarean delivery, have a much greater level of post-birth satisfaction than those who don't.
Women are not homogeneous creatures, and we should focus on supporting the individual's delivery preference rather than trying to enforce a 'one size fits all' approach to maternity care.
Researchers found that half of women diagnosed with postpartum psychosis have no history of mental illness, and that the risk of postpartum psychosis is greater in women over age 35 who give birth for the first time.
Why is this important?
Other research has shown that women who achieve their preferred delivery method enjoy better psychological post-birth outcomes than women who don't. So if a woman plans a vaginal delivery and ends up needing an emergency cesarean, she may feel more negative about her birth experience than if she has a spontaneous vaginal delivery. Similarly, it has been shown that women who choose a cesarean delivery, and go on to have a cesarean delivery, have a much greater level of post-birth satisfaction than those who don't.
Women are not homogeneous creatures, and we should focus on supporting the individual's delivery preference rather than trying to enforce a 'one size fits all' approach to maternity care.
Deaths of 6 women giving birth raise concerns in the NHS
On February 11th, Madeleine Brindley's report: "Serious concerns raised at NHS trust after six women die" appeared on WalesOnline. It perfectly illustrates the unpredictability of vaginal delivery that exacerabates an already unpredictable Mother Nature. I believe that it is not unreasonable that some women (myself included) decide to opt for a planned surgical delivery with a dedicated, guaranteed-to-be-present during the birth, team of health carers.
"The review team found that there was no common link between the deaths, although in two of the cases, if the women’s deteriorating condition had been spotted earlier and better advance preparations had been in place, the outcomes may have been different... The report revealed:
*The trust had the highest proportion of women reporting that they were left alone and worried, in labour or shortly after the birth of their child;
*Staff from lower risk wards are frequently transferred on shift to the higher-risk labour areas, leaving the areas from which they were drawn under staffed;
*Community midwives are frequently required to work in the hospital throughout their on-call shifts after doing a full days work in the community;
*Low-risk labouring women are sometimes left alone while staff attended to higher risk women - the HIW inspectors heard of occasions when induced labour had been halted to allow staff to be rescheduled to other work;
*The numbers of midwives on the labour ward at the Royal Gwent Hospital appear “inadequate” for the size and activity levels on the ward."
"The review team found that there was no common link between the deaths, although in two of the cases, if the women’s deteriorating condition had been spotted earlier and better advance preparations had been in place, the outcomes may have been different... The report revealed:
*The trust had the highest proportion of women reporting that they were left alone and worried, in labour or shortly after the birth of their child;
*Staff from lower risk wards are frequently transferred on shift to the higher-risk labour areas, leaving the areas from which they were drawn under staffed;
*Community midwives are frequently required to work in the hospital throughout their on-call shifts after doing a full days work in the community;
*Low-risk labouring women are sometimes left alone while staff attended to higher risk women - the HIW inspectors heard of occasions when induced labour had been halted to allow staff to be rescheduled to other work;
*The numbers of midwives on the labour ward at the Royal Gwent Hospital appear “inadequate” for the size and activity levels on the ward."
UK hospitals restrict cesareans based on inaccurate cost calculations
The weekend's Sunday's Times article, 'Hospitals curb caesarean births' (by Health Editor, Sarah-Kate Templeton) was just one of many to report on the decision by hospitals in the Greater Manchester area to "ration" cesarean deliveries so that only "women with specific medical conditions" are eligible to deliver their babies via this method.
The Daily Mail's Daniel Martin's report, 'Caesareans rationed: Women denied procedure on safety grounds - and because it's too dear', and The Telegraph's Sarah Knapton's report, 'Caesarean births rationed by hospitals in order to cut costs' were two others.
Personally, I think that this decision is a national disgrace, and I can only hope that there are more doctors in the UK that will ignore such irresponsible guidelines and support the views of Doctor Christoph Lees, an obstetrician and gynaecologist at Addenbrooke's hospital in Cambridge, who is quoted in these stories saying:
"I strongly disagree with this prescriptive condition setting. Sometimes well-informed women, often older and very unlikely to have further children, do request caesarean sections and it is unreasonable to refuse if they are fully informed."
Some reasons why COST is not a valid reason for cesarean rationing
The main issue is the inaccurate cost comparison between PLANNED vaginal delivery (PVD) and PLANNED cesarean delivery. I highlight the word planned because it is no use in comparing spontaneous delivery outcomes with cesarean delivery outcomes alone. The fact is that a PVD can have many different outcomes for mother and baby - regardless of how much a spontaneous delivery is desired or encouraged - such as instrumental delivery and most importantly, emergency cesarean delivery. The cost of the latter in particular is rarely, if ever, factored into the cost of a PVD, yet it should be.
Worse still, traditional cost comparisons actually take these PVD emergency cesarean outcomes and add them to all planned cesarean costs in order to demonstrate 'hospital cesarean costs'. More recent studies have at least separated emergency and planned cesarean costs, but even then, in the argument against healthy women being able to choose a planned cesarean delivery, they do not recognize that the vast majority of these planned cesareans were for medical reasons and were therefore likely to have extra costs associated with them that would not be the case in a healthy pregnancy. The best example of this is studies that look at the NICU costs of babies born at 38 weeks gestation and earlier - obviously these costs are high, but in a healthy pregnancy where a woman delivers at 39 weeks gestation (repeatedly shown to reduce respiratory distress - see ACOG and NIH statements and others), these costs are not applicable.
The truth about birth costs
No one wants to do the study that needs to be done - an analysis of cost of women who plan a vaginal delivery (and all their actual outcomes - short and long-term) and women who plan a cesarean delivery. Doctors in Australia in 2003 looked into whether such a study would be a good idea and raised concerns that one of the biggest dangers would be the fact that planned cesarean delivery may be proven to be safer than PVD - "what a disaster" that would be, they said.
It's also worth looking at Appendix C of the NICE 2004 Clinical Guideline on Caesarean Delivery - they actually admit that it is possible to take current cesarean cost data and demonstrate that
planned cesarean delivery can be cheaper than vaginal delivery, but in the very next sentence, they dismiss it as being an 'unrealistic conclusion' to draw. It is not referred to again.
When vaginal deliveries go wrong
The cost of obstetrics litigation in the NHS is enormous and yet this is also not accounted for in any cost analysis of PVD. When a cesarean is not done in time or is not done at all, and the baby dies or is severely injured, there is a financial cost associated with that - as well as a psychological cost.
When women suffer severe pelvic floor injuries, there is a financial cost associated with post-birth surgical repair, and even more minor injuries can result in long-term damage such as incontinence or pelvic organ prolapse. Again, not to mention the psychological trauma and need for post-birth counselling that many women experience.
Perhaps hospitals would do better to concentrate on supporting positive birth experiences, and rationing negative ones - and believe me, research shows that this is not achieved by forcing all women to have a vaginal delivery.
The Daily Mail's Daniel Martin's report, 'Caesareans rationed: Women denied procedure on safety grounds - and because it's too dear', and The Telegraph's Sarah Knapton's report, 'Caesarean births rationed by hospitals in order to cut costs' were two others.
Personally, I think that this decision is a national disgrace, and I can only hope that there are more doctors in the UK that will ignore such irresponsible guidelines and support the views of Doctor Christoph Lees, an obstetrician and gynaecologist at Addenbrooke's hospital in Cambridge, who is quoted in these stories saying:
"I strongly disagree with this prescriptive condition setting. Sometimes well-informed women, often older and very unlikely to have further children, do request caesarean sections and it is unreasonable to refuse if they are fully informed."
Some reasons why COST is not a valid reason for cesarean rationing
The main issue is the inaccurate cost comparison between PLANNED vaginal delivery (PVD) and PLANNED cesarean delivery. I highlight the word planned because it is no use in comparing spontaneous delivery outcomes with cesarean delivery outcomes alone. The fact is that a PVD can have many different outcomes for mother and baby - regardless of how much a spontaneous delivery is desired or encouraged - such as instrumental delivery and most importantly, emergency cesarean delivery. The cost of the latter in particular is rarely, if ever, factored into the cost of a PVD, yet it should be.
Worse still, traditional cost comparisons actually take these PVD emergency cesarean outcomes and add them to all planned cesarean costs in order to demonstrate 'hospital cesarean costs'. More recent studies have at least separated emergency and planned cesarean costs, but even then, in the argument against healthy women being able to choose a planned cesarean delivery, they do not recognize that the vast majority of these planned cesareans were for medical reasons and were therefore likely to have extra costs associated with them that would not be the case in a healthy pregnancy. The best example of this is studies that look at the NICU costs of babies born at 38 weeks gestation and earlier - obviously these costs are high, but in a healthy pregnancy where a woman delivers at 39 weeks gestation (repeatedly shown to reduce respiratory distress - see ACOG and NIH statements and others), these costs are not applicable.
The truth about birth costs
No one wants to do the study that needs to be done - an analysis of cost of women who plan a vaginal delivery (and all their actual outcomes - short and long-term) and women who plan a cesarean delivery. Doctors in Australia in 2003 looked into whether such a study would be a good idea and raised concerns that one of the biggest dangers would be the fact that planned cesarean delivery may be proven to be safer than PVD - "what a disaster" that would be, they said.
It's also worth looking at Appendix C of the NICE 2004 Clinical Guideline on Caesarean Delivery - they actually admit that it is possible to take current cesarean cost data and demonstrate that
planned cesarean delivery can be cheaper than vaginal delivery, but in the very next sentence, they dismiss it as being an 'unrealistic conclusion' to draw. It is not referred to again.
When vaginal deliveries go wrong
The cost of obstetrics litigation in the NHS is enormous and yet this is also not accounted for in any cost analysis of PVD. When a cesarean is not done in time or is not done at all, and the baby dies or is severely injured, there is a financial cost associated with that - as well as a psychological cost.
When women suffer severe pelvic floor injuries, there is a financial cost associated with post-birth surgical repair, and even more minor injuries can result in long-term damage such as incontinence or pelvic organ prolapse. Again, not to mention the psychological trauma and need for post-birth counselling that many women experience.
Perhaps hospitals would do better to concentrate on supporting positive birth experiences, and rationing negative ones - and believe me, research shows that this is not achieved by forcing all women to have a vaginal delivery.
Thursday, February 5, 2009
20-30% of women in Ludhiana request cesarean delivery
'For kids’ bright future, city women give thumbs up to caesarean' read the expreesindia.com headline by Sameer Kumar Sharma earlier this week. The article reports that women in Ludhiana, "with the knowledge of medical science making caesarean deliveries much safer, more urbane women are opting for caesarean on request even though they could have a normal delivery."
Sharma writes: "For the fear of labour pains, many ‘educated’ women are thronging hospitals to deliver babies without having to go through 10 to 12 hours of labour pain. The rough estimates suggest a sizeable chunk of expecting mothers - as much as 20 per cent - want to go in for caesarean delivery rather than normal vaginal delivery."
Gynaecologists there say that in the last 5 years, "there has been a major shift in the way women respond to childbirth. “Today more women ask on request to have a caesarean rather than waiting for the normal delivery,” says Dr Promila Jindal, professor and unit head, department of gyaenocology, Dayanand Medical College and Hospital."
Requests have doubled in the last few years
"Dr Mini Ahuja, consultant gyneacologist at Iqbal Nursing Home, says about 30 per cent of the pregnant women approaching them talk about the possibility of caesarean even though there are no complications involved. “Such queries and requests have almost doubled in the last couple of years,” she adds."
But Dr Vaneet Kaur, senior consultant and head of the department of obstetrics and gynaecology at SPS Apollo Hospitals, says: “We counsel such women who are afraid of labour pains and condition them to prepare for normal deliveries. Moreover, the normal delivery can also be made a painless experience through epidural analgesia and all they need is a little bit of more knowledge than they already have. Normal deliveries are a natural way of delivery and one should always prefer that.”
My view
Naturally, I don't agree with the idea that all women should share the same delivery preference, but I decided to blog about this article largely because it illustrates that women choosing cesarean delivery is a reality. The issue is not going to go away by pretending it isn't happening and in my opinion, it is unethical to brush aside women's concerns over the unpredictability of vaginal delivery or to dismiss their informed decision to choose cesarean surgery instead.
Sharma writes: "For the fear of labour pains, many ‘educated’ women are thronging hospitals to deliver babies without having to go through 10 to 12 hours of labour pain. The rough estimates suggest a sizeable chunk of expecting mothers - as much as 20 per cent - want to go in for caesarean delivery rather than normal vaginal delivery."
Gynaecologists there say that in the last 5 years, "there has been a major shift in the way women respond to childbirth. “Today more women ask on request to have a caesarean rather than waiting for the normal delivery,” says Dr Promila Jindal, professor and unit head, department of gyaenocology, Dayanand Medical College and Hospital."
Requests have doubled in the last few years
"Dr Mini Ahuja, consultant gyneacologist at Iqbal Nursing Home, says about 30 per cent of the pregnant women approaching them talk about the possibility of caesarean even though there are no complications involved. “Such queries and requests have almost doubled in the last couple of years,” she adds."
But Dr Vaneet Kaur, senior consultant and head of the department of obstetrics and gynaecology at SPS Apollo Hospitals, says: “We counsel such women who are afraid of labour pains and condition them to prepare for normal deliveries. Moreover, the normal delivery can also be made a painless experience through epidural analgesia and all they need is a little bit of more knowledge than they already have. Normal deliveries are a natural way of delivery and one should always prefer that.”
My view
Naturally, I don't agree with the idea that all women should share the same delivery preference, but I decided to blog about this article largely because it illustrates that women choosing cesarean delivery is a reality. The issue is not going to go away by pretending it isn't happening and in my opinion, it is unethical to brush aside women's concerns over the unpredictability of vaginal delivery or to dismiss their informed decision to choose cesarean surgery instead.
50% cesarean rate in Canada can't be ruled out, says Dr
I recently came across a September 2008 article on the Vancouver Sun's website, 'Canada's caesarean capital' (a report by Katherine Dedyna on the country's 26% cesarean rate), in which Dr. Jerome Dansereau, chief of obstetrics at the Vancouver Island Health Authority, says he "doesn't rule out the rate going to 50 per cent, given the continuing upward swing. "There is no one who could have predicted what we see today," he says, "and there is no one who can predict when it will stop.""
In the same article, midwife Lyons Richardson says she "won't be surprised if eventually women walk in cold with their first pregnancy and demand a C-section for any reason they want. "Give it 10 years and I don't think it's going to be that unusual.""
Victoria General Hospital is reported to have the highest rate in the country at 37%, and some of the reasons cited by doctors for this are: "older, heavier mothers; increasing numbers of women who don't want to labour long; technology that shows potential fetal problems; mothers who have had previous C-sections returning for a second; and the presence of worried fathers in the labour room."
Luba Lyons Richardson, vice-chairwoman of midwifery at VGH, remarks on a "culture shift in her 30 years of practice. "Women themselves have less tolerance for longer labours, for a baby that's a little bit in distress." ...She knows of women who ask for elective caesarean sections and get them, depending on extenuating circumstances. "That's another debate that rages on. If women have choice, then shouldn't they have that choice?""
Also of interest in the article: "Surgeons in Victoria will do C-sections rather than traumatic forceps delivery. Only 10 per cent or fewer of VGH births involve instruments such as forceps, far lower than the national average of 16 per cent."
The doctors cited in this report do not necessarily agree with prophylactic cesarean delivery with no medical indication, but it is clear that they do not expect to see Canada's cesarean rate being reduced to the WHO's controversial recommendation of 10-15% any time soon.
In the same article, midwife Lyons Richardson says she "won't be surprised if eventually women walk in cold with their first pregnancy and demand a C-section for any reason they want. "Give it 10 years and I don't think it's going to be that unusual.""
Victoria General Hospital is reported to have the highest rate in the country at 37%, and some of the reasons cited by doctors for this are: "older, heavier mothers; increasing numbers of women who don't want to labour long; technology that shows potential fetal problems; mothers who have had previous C-sections returning for a second; and the presence of worried fathers in the labour room."
Luba Lyons Richardson, vice-chairwoman of midwifery at VGH, remarks on a "culture shift in her 30 years of practice. "Women themselves have less tolerance for longer labours, for a baby that's a little bit in distress." ...She knows of women who ask for elective caesarean sections and get them, depending on extenuating circumstances. "That's another debate that rages on. If women have choice, then shouldn't they have that choice?""
Also of interest in the article: "Surgeons in Victoria will do C-sections rather than traumatic forceps delivery. Only 10 per cent or fewer of VGH births involve instruments such as forceps, far lower than the national average of 16 per cent."
The doctors cited in this report do not necessarily agree with prophylactic cesarean delivery with no medical indication, but it is clear that they do not expect to see Canada's cesarean rate being reduced to the WHO's controversial recommendation of 10-15% any time soon.
Monday, February 2, 2009
Top 5 reasons prophylactic elective caesarean delivery with no medical indication is a legitimate decision for informed women
As a speaker at a seminar on cesarean delivery the upcoming 'Controversies in Childbirth' conference in Fort Worth, Texas (March 27, 2009), I was asked to write my 'Top 5 reasons prophylactic elective cesarean delivery with no medical indication is a legitimate decision for informed women', and here they are:
1. There are risks and benefits associated with all birth plans. A healthy spontaneous vaginal delivery (even when desired) is never guaranteed since labor, even with healthy pregnancies, is entirely unpredictable.
2. The oft-quoted risks associated with cesarean delivery frequently refer to emergency surgery or deliveries with pre-existing medical indications. These risks are not the same in healthy pregnancies with delivery at 39 weeks gestation for women planning small families.
3. Birth data compiled in the U.S. does not separate emergency and planned cesareans, only primary and repeat cesareans, which muddles the true assessment of risk as it relates to birth PLAN and the corresponding birth OUTCOME. Research from overseas demonstrates vastly reduced risks with planned surgeries, although we are yet to witness a move towards research that applies emergency cesarean outcomes to the planned vaginal delivery data set, which would be more relevant.
4. The risks (and costs) associated with planned vaginal delivery are grossly underestimated, both in the short- and long-term (in fact long-term risks and costs, financial and psychological, are rarely applied in comparative birth analysis). For example, shoulder dystocia, Erb’s palsy, fetal trauma, neonatal encephalopathy, asphyxiation, intrauterine fetal demise; damage to pelvic floor, POP, sexual health; infant and maternal severe morbidity associated with emergency cesareans; litigation trauma and cost following death or injury.
5. Research has shown high levels of birth satisfaction with planned cesarean delivery and birth trauma websites illustrate high levels of dissatisfaction with planned vaginal delivery. A ‘good birth outcome’ is not commensurate with ‘vaginal delivery for all women’ and genuine birth educators should not make this assumption. For true birth autonomy to exist, cesarean delivery must not be viewed as a second-rate outcome, and at a time in history when maternal and fetal characteristics are leading to more cesarean deliveries (e.g. increased maternal age and obesity; also birth weights), it is not only potentially dangerous to focus on drastically reducing the numbers of ‘unwanted’ surgeries, it is moreover unethical to reduce rates by discouraging or denying those surgeries that are in fact ‘wanted’.
1. There are risks and benefits associated with all birth plans. A healthy spontaneous vaginal delivery (even when desired) is never guaranteed since labor, even with healthy pregnancies, is entirely unpredictable.
2. The oft-quoted risks associated with cesarean delivery frequently refer to emergency surgery or deliveries with pre-existing medical indications. These risks are not the same in healthy pregnancies with delivery at 39 weeks gestation for women planning small families.
3. Birth data compiled in the U.S. does not separate emergency and planned cesareans, only primary and repeat cesareans, which muddles the true assessment of risk as it relates to birth PLAN and the corresponding birth OUTCOME. Research from overseas demonstrates vastly reduced risks with planned surgeries, although we are yet to witness a move towards research that applies emergency cesarean outcomes to the planned vaginal delivery data set, which would be more relevant.
4. The risks (and costs) associated with planned vaginal delivery are grossly underestimated, both in the short- and long-term (in fact long-term risks and costs, financial and psychological, are rarely applied in comparative birth analysis). For example, shoulder dystocia, Erb’s palsy, fetal trauma, neonatal encephalopathy, asphyxiation, intrauterine fetal demise; damage to pelvic floor, POP, sexual health; infant and maternal severe morbidity associated with emergency cesareans; litigation trauma and cost following death or injury.
5. Research has shown high levels of birth satisfaction with planned cesarean delivery and birth trauma websites illustrate high levels of dissatisfaction with planned vaginal delivery. A ‘good birth outcome’ is not commensurate with ‘vaginal delivery for all women’ and genuine birth educators should not make this assumption. For true birth autonomy to exist, cesarean delivery must not be viewed as a second-rate outcome, and at a time in history when maternal and fetal characteristics are leading to more cesarean deliveries (e.g. increased maternal age and obesity; also birth weights), it is not only potentially dangerous to focus on drastically reducing the numbers of ‘unwanted’ surgeries, it is moreover unethical to reduce rates by discouraging or denying those surgeries that are in fact ‘wanted’.
Saturday, January 31, 2009
Cesarean complications rise in line with changes in mothers
A number of studies have been published recently, which, if read in the context and knowledge of other applicable studies, would inform women more accurately than many media reports have managed to do.
Take for example this week's highly publicized U.S. report, 'Severe Obstetric Morbidity in the United States: 1998-2005', by EV Kuklina et al. They found that the "prevalence of delivery hospitalizations (per 1,000) complicated by at least one severe obstetric complication increased from 0.64% (n=48,645) in 1998-1999 to 0.81% (n=68,433) in 2004-2005." And that
Perception of risk - actual increase versus percentage increase
Clearly, these numbers in real terms - especially when you consider that they take into account ALL delivery complications (including emergency cesareans) - are relatively small (less than 1%), but what many media reports concentrated on was the '% increase' number, which of course looks a lot higher - and riskier - when reported without the 'per 1000' figures.
For example, renal failure increased "by 21% (from 0.23 to 0.28), pulmonary embolism by 52% (0.12 to 0.18), adult respiratory distress syndrome by 26% (0.36 to 0.45), shock by 24% (0.15 to 0.19), blood transfusion by 92% (2.38 to 4.58), and ventilation by 21 % (0.47 to 0.57).
The authors conclude that: "Rates of severe obstetric complications increased from 1998-1999 to 2004-2005. For many of these complications, these increases were associated with the increasing rate of cesarean delivery.
But is cesarean surgery the reason for greater severe morbidity - or are other factors to blame?
Adding to a growing body of evidence on this subject, a Scottish review this month by A Poobalan et al, 'Obesity as an independent risk factor for elective and emergency caesarean delivery in nulliparous women - systematic review and meta-analysis of cohort studies' tells us that cesarean delivery "risk is increased by 50% in overweight women and is more than double for obese women compared with women with normal BMI."
And in 2003, KS Joseph et al's Canadian study, 'Changes in maternal characteristics and obstetric practice and recent increases in primary cesarean delivery', which set out to "estimate the contribution of changes in maternal characteristics (namely, age, parity, prepregnancy weight, weight gain in pregnancy, smoking status) and obstetric practice (namely, labor induction, epidural anesthesia, delivery by an obstetrician, midpelvic forceps delivery) to recent increases in primary cesarean delivery rates", concluded that "Recent increases in primary cesarean delivery rates are a consequence of changes in maternal characteristics. Obstetric practice, which has altered due to changes in maternal characteristics and concerns related to fetal and maternal safety, has also contributed to increases in primary cesarean delivery."
Specifically, the researchers noted a 14% increase in cesarean deliveries for dystocia, 24% for breech, 21% for suspected fetal distress, 47% for hypertension, and 73% for miscellaneous indications between 1988 and 2000. Importantly: "Adjustment for maternal characteristics reduced the temporal increase" in cesarean rates from 21% to 2% [and] Additional adjustment for obstetric practice factors further reduced period effects."
The future of cesarean rates
A review by Rebecca Simmons, MD., 'Perinatal Programming of Obesity', published in the U.S. in October 2008, reminds us that the prevalence of obesity "has risen dramatically over the last decade [and a] number of epidemiological studies have shown that there is a direct relationship between birth weight and BMI in childhood and in adult life." I would suggest that with no sign of a decline in obesity rates (in fact, quite the opposite) and with women continuing to have their babies later and later in life, we are not going to see any significant reduction in primary cesarean rates at all, and we need to be very careful about implementing strategies to drastically reduce them since this will result in greater morbidity and mortality for these women and their babies.
Take for example this week's highly publicized U.S. report, 'Severe Obstetric Morbidity in the United States: 1998-2005', by EV Kuklina et al. They found that the "prevalence of delivery hospitalizations (per 1,000) complicated by at least one severe obstetric complication increased from 0.64% (n=48,645) in 1998-1999 to 0.81% (n=68,433) in 2004-2005." And that
Perception of risk - actual increase versus percentage increase
Clearly, these numbers in real terms - especially when you consider that they take into account ALL delivery complications (including emergency cesareans) - are relatively small (less than 1%), but what many media reports concentrated on was the '% increase' number, which of course looks a lot higher - and riskier - when reported without the 'per 1000' figures.
For example, renal failure increased "by 21% (from 0.23 to 0.28), pulmonary embolism by 52% (0.12 to 0.18), adult respiratory distress syndrome by 26% (0.36 to 0.45), shock by 24% (0.15 to 0.19), blood transfusion by 92% (2.38 to 4.58), and ventilation by 21 % (0.47 to 0.57).
The authors conclude that: "Rates of severe obstetric complications increased from 1998-1999 to 2004-2005. For many of these complications, these increases were associated with the increasing rate of cesarean delivery.
But is cesarean surgery the reason for greater severe morbidity - or are other factors to blame?
Adding to a growing body of evidence on this subject, a Scottish review this month by A Poobalan et al, 'Obesity as an independent risk factor for elective and emergency caesarean delivery in nulliparous women - systematic review and meta-analysis of cohort studies' tells us that cesarean delivery "risk is increased by 50% in overweight women and is more than double for obese women compared with women with normal BMI."
And in 2003, KS Joseph et al's Canadian study, 'Changes in maternal characteristics and obstetric practice and recent increases in primary cesarean delivery', which set out to "estimate the contribution of changes in maternal characteristics (namely, age, parity, prepregnancy weight, weight gain in pregnancy, smoking status) and obstetric practice (namely, labor induction, epidural anesthesia, delivery by an obstetrician, midpelvic forceps delivery) to recent increases in primary cesarean delivery rates", concluded that "Recent increases in primary cesarean delivery rates are a consequence of changes in maternal characteristics. Obstetric practice, which has altered due to changes in maternal characteristics and concerns related to fetal and maternal safety, has also contributed to increases in primary cesarean delivery."
Specifically, the researchers noted a 14% increase in cesarean deliveries for dystocia, 24% for breech, 21% for suspected fetal distress, 47% for hypertension, and 73% for miscellaneous indications between 1988 and 2000. Importantly: "Adjustment for maternal characteristics reduced the temporal increase" in cesarean rates from 21% to 2% [and] Additional adjustment for obstetric practice factors further reduced period effects."
The future of cesarean rates
A review by Rebecca Simmons, MD., 'Perinatal Programming of Obesity', published in the U.S. in October 2008, reminds us that the prevalence of obesity "has risen dramatically over the last decade [and a] number of epidemiological studies have shown that there is a direct relationship between birth weight and BMI in childhood and in adult life." I would suggest that with no sign of a decline in obesity rates (in fact, quite the opposite) and with women continuing to have their babies later and later in life, we are not going to see any significant reduction in primary cesarean rates at all, and we need to be very careful about implementing strategies to drastically reduce them since this will result in greater morbidity and mortality for these women and their babies.
Monday, January 26, 2009
New research on cesarean surgery techniques
Hypotension and Nausea during surgey
When I saw this new study from Canada by M Tanaka et al, 'ED95 of phenylephrine to prevent spinal-induced hypotension and/or nausea at elective cesarean delivery', it reminded me of my own experience during the birth of my daughter in 2007. The anesthetist had warned me prior to the start of surgery that I may experience some nausea, and to let him know if I did as he would be able to administer something for it. Well, I did, and he did, and in truth, I have no idea what the drug was, but I felt better almost immediately.
For those of who would like to be able to discuss this occurence of nausea and its treatment during your cesarean surgery in more detail (with your OBGYN or anesthetist), you might find this study interesting. It set out to "determine the 95% effective dose (ED95) of phenylephrine by intermittent i.v. bolus, to prevent spinal-induced hypotension and/or nausea at elective cesarean delivery" and involved 50 patients undergoing elective cesarean delivery under spinal anesthesia.
The study results
"The ED95 of phenylephrine was estimated as 159 mug (95% confidence interval: 122-371 mug), although the largest dose given in the study was only 120 mug. Hypertension (systolic blood pressure >120% of baseline) was observed in 14 cases, immediately after intrathecal injection and prophylactic phenylephrine administration in all cases." The authors conclude that the "safety of this dose warrants further studies."
Blood loss following surgery
This second study from Iran, 'Efficacy of tranexamic acid in reducing blood loss after cesarean section' by L Sekhavat et al, was conducted on 90 primiparas divided into two groups who underwent cesarean delivery. "The study group, 45 women, received tranexamic acid immediately before CS, whereas the control group, 45 women received placebo" and then blood loss volume for each group was measured from the end of surgery to 2 hours postpartum.
Study conclusions
The authors conclude that: "Tranexamic acid statistically reduces blood loss from end to 2 h after CS and its use was not associated with any side effects or complications. Consequently, tranexamic acid can be used safely and effectively to reduce bleeding resulting from CS." My second baby is due shortly, and a cesarean delivery is planned, so I will certainly be asking my doctor about whether the findings in this study are relevant to my potential recovery experience.
When I saw this new study from Canada by M Tanaka et al, 'ED95 of phenylephrine to prevent spinal-induced hypotension and/or nausea at elective cesarean delivery', it reminded me of my own experience during the birth of my daughter in 2007. The anesthetist had warned me prior to the start of surgery that I may experience some nausea, and to let him know if I did as he would be able to administer something for it. Well, I did, and he did, and in truth, I have no idea what the drug was, but I felt better almost immediately.
For those of who would like to be able to discuss this occurence of nausea and its treatment during your cesarean surgery in more detail (with your OBGYN or anesthetist), you might find this study interesting. It set out to "determine the 95% effective dose (ED95) of phenylephrine by intermittent i.v. bolus, to prevent spinal-induced hypotension and/or nausea at elective cesarean delivery" and involved 50 patients undergoing elective cesarean delivery under spinal anesthesia.
The study results
"The ED95 of phenylephrine was estimated as 159 mug (95% confidence interval: 122-371 mug), although the largest dose given in the study was only 120 mug. Hypertension (systolic blood pressure >120% of baseline) was observed in 14 cases, immediately after intrathecal injection and prophylactic phenylephrine administration in all cases." The authors conclude that the "safety of this dose warrants further studies."
Blood loss following surgery
This second study from Iran, 'Efficacy of tranexamic acid in reducing blood loss after cesarean section' by L Sekhavat et al, was conducted on 90 primiparas divided into two groups who underwent cesarean delivery. "The study group, 45 women, received tranexamic acid immediately before CS, whereas the control group, 45 women received placebo" and then blood loss volume for each group was measured from the end of surgery to 2 hours postpartum.
Study conclusions
The authors conclude that: "Tranexamic acid statistically reduces blood loss from end to 2 h after CS and its use was not associated with any side effects or complications. Consequently, tranexamic acid can be used safely and effectively to reduce bleeding resulting from CS." My second baby is due shortly, and a cesarean delivery is planned, so I will certainly be asking my doctor about whether the findings in this study are relevant to my potential recovery experience.
Thursday, January 22, 2009
Pelvic organ prolapse risk with vaginal delivery - are women made aware of it?
A new American study, Relation between vaginal birth and pelvic organ prolapse (by Eddie H. M. Sze and Gerry Hobbs), set out to "evaluate the relation between vaginal birth and pelvic organ prolapse quantification (POPQ) stages III and IV prolapse and whether each additional vaginal birth is associated with an increase in pelvic support defects."
Study conclusions
The researchers conclude that "Vaginal birth is not associated with POPQ stages III and IV prolapse, but it is associated with an increase in POPQ stage II defect."
Birth risk/benefit analysis
This study demonstrates that there IS a link between vaginal delivery and subsequent pelvic organ prolapse (POP), and is in fact one of a number of studies to do so. Unfortunately, women planning vaginal deliveries are not always advised of this risk. In fact, in the U.S. December 2006 'Pelvic Organ Prolapse Topline Summary by ICR', an Ethicon Women's Health & Urology survey found that among the total female population age 21 and older, only 1 in 5 (19%) are even aware that such a female condition exists.
Furthermore, 2 out of 3 (68%) women diagnosed with POP were not aware of its existence before experiencing symptoms, and the majority (81%) of women who have given birth did not receive education about the relationship between a vaginal delivery and possible pelvic organ prolapse from their OB/GYN.
Are we truly informing women of the risks associated with vaginal delivery?
"Only 15% of women who have given birth report that their OB/GYN educated them about the relationship between a vaginal delivery and the condition [yet the] greatest risk factor for pelvic organ prolapse is a vaginal delivery, at any age."
Study results
Sze and Hobbs analyzed 458 nulliparas (first-time mothers) and 892 multiparas, including 272 with one, 299 with two and 321 with at least three term vaginal deliveries, and found that the "prevalence of POPQ stage II defect among nulliparas and multiparas that had one, two, and at least three term vaginal deliveries was 25% (119/458), 50% (137/272), 66% (198/299), and 69% (220/321), respectively (p<0.001), p="0.618)." style="font-weight: bold; color: rgb(0, 0, 102);">
Study conclusions
The researchers conclude that "Vaginal birth is not associated with POPQ stages III and IV prolapse, but it is associated with an increase in POPQ stage II defect."
Birth risk/benefit analysis
This study demonstrates that there IS a link between vaginal delivery and subsequent pelvic organ prolapse (POP), and is in fact one of a number of studies to do so. Unfortunately, women planning vaginal deliveries are not always advised of this risk. In fact, in the U.S. December 2006 'Pelvic Organ Prolapse Topline Summary by ICR', an Ethicon Women's Health & Urology survey found that among the total female population age 21 and older, only 1 in 5 (19%) are even aware that such a female condition exists.
Furthermore, 2 out of 3 (68%) women diagnosed with POP were not aware of its existence before experiencing symptoms, and the majority (81%) of women who have given birth did not receive education about the relationship between a vaginal delivery and possible pelvic organ prolapse from their OB/GYN.
Are we truly informing women of the risks associated with vaginal delivery?
"Only 15% of women who have given birth report that their OB/GYN educated them about the relationship between a vaginal delivery and the condition [yet the] greatest risk factor for pelvic organ prolapse is a vaginal delivery, at any age."
Study results
Sze and Hobbs analyzed 458 nulliparas (first-time mothers) and 892 multiparas, including 272 with one, 299 with two and 321 with at least three term vaginal deliveries, and found that the "prevalence of POPQ stage II defect among nulliparas and multiparas that had one, two, and at least three term vaginal deliveries was 25% (119/458), 50% (137/272), 66% (198/299), and 69% (220/321), respectively (p<0.001), p="0.618)." style="font-weight: bold; color: rgb(0, 0, 102);">
Severe vaginal tears common during birth in Utah
An article by Heather May in The Salt Lake Tribune on January 7th reports on a study in which "almost 4,000 Utah women suffered severe vaginal tears last year while giving birth after their doctors used forceps or vacuum devices to deliver the baby." This number translates to a reported "14% injury rate".In releasing the figures, the Utah Department of Health is reported as saying that 14% is "lower than expected compared to national figures. But the tears can cause long lasting problems, including painful sex and fecal incontinence."
The article also cites comments from Ashley Nelson, a women's health physical therapist in Salt Lake City, who says: "It's hush, hush. Most people don't talk about this". She sees women seeking help to strengthen their pelvic floor muscles or who have irritated or damaged nerves because of scarring from tearing or subsequent care. "A lot of times they may sew them up too tight [and women experience] pain [from] penetration. Or just the way they've been sewn back up - it's irritated nerves and [they] constantly have pelvic pain," she said.
14% is the risk for SEVERE tears - many more women experience "minor tearing"
"...While minor tearing during delivery is common, the health department report focused on third and fourth-degree lacerations, which extend from the vagina to the anus. Using instruments increases the risk of severe tears. So does delivering large babies or having an episiotomy, a surgical cut between the vagina and anus. Doctors use instruments if the baby's heart beat drops dangerously or if the mother is worn out from pushing.
Some Utah hospitals have a 29% vaginal tear rate
"Utah hospitals' rate of vaginal tears range from 4.5 percent at Ogden Regional Medical Center to nearly 29 percent at Uintah Basin Medical Center in Roosevelt. "
The full report, '2007 Utah Hospital Comparison Report: Maternity and Newborns', can be accessed here.
Wednesday, January 21, 2009
Long-term benefits outweigh risks, says Malaysian doctor
You may have read my criticism of recent reports on the increased risk of asthma in children born by cesarean delivery, and how research in this area is still incomplete and inconsistent. Now the president of the Obstetrical and Gynaecological Society of Malaysia, Dr A. Baskaran, has criticized a media report by Datuk Dr Rajen M, titled 'C-Section babies risk becoming asthmatic'.
He says: "The article gives the impression that Caesarean section is detrimental to the health of the baby and should not be resorted to at all. Our greatest concern is that mothers may refuse to give consent when a Caesarean section is indicated in times of emergency after reading the article."
He continues: "In any operative delivery or, for that matter, in any operation, the benefits from the operation must be weighed against the short-term and long-term risks of the operation. Perhaps, one of the long-term risks to a baby born by Caesarean section may very well be a higher incidence of asthma but this must be balanced against the immediate and long-term risks to the baby when there is delay or no intervention by Caesarean section.
We do not want a baby to be forever mentally handicapped for fear of a higher risk of asthma.
The study quoted in the report, from the Dec 3 issue of the medical journal Thorax, showed that Dutch children born by Caesarean section were 80 per cent more likely to develop asthma by the time they are 8 years old. This study, together with another Norwegian study published in June last year in the Journal of Pediatrics, has shown an increased risk.
However, previous studies have shown conflicting evidence. More prospective, multi-central studies from many different countries need to be done before this risk is accepted into evidence-based practice. More importantly, other aspects such as failure to breast-feed a baby after a Caesarean section need to be considered.
Nevertheless, the increase in Caesarean section rates in the past couple of decades cannot be denied. It has always been an important and heavily debated topic of discussion in practically every obstetrics conference all over the world. The reason for this is complex and every attempt has been made by the fraternity to reduce this rate. But its judicious use has saved many a mother and baby."
My thoughts
I agree with a great deal of what Dr Baskaran says, but it would be interesting to learn more about his views on planned cesarean delivery with no medical indication. He does mention above that "every attempt has been made by the fraternity to reduce this [cesarean] rate" and it concerns me that women making legitimate decisions to choose one set of birth risks and benefits over another may be not be supported in Malaysia. I only hope that this is not the case.
He says: "The article gives the impression that Caesarean section is detrimental to the health of the baby and should not be resorted to at all. Our greatest concern is that mothers may refuse to give consent when a Caesarean section is indicated in times of emergency after reading the article."
He continues: "In any operative delivery or, for that matter, in any operation, the benefits from the operation must be weighed against the short-term and long-term risks of the operation. Perhaps, one of the long-term risks to a baby born by Caesarean section may very well be a higher incidence of asthma but this must be balanced against the immediate and long-term risks to the baby when there is delay or no intervention by Caesarean section.
We do not want a baby to be forever mentally handicapped for fear of a higher risk of asthma.
The study quoted in the report, from the Dec 3 issue of the medical journal Thorax, showed that Dutch children born by Caesarean section were 80 per cent more likely to develop asthma by the time they are 8 years old. This study, together with another Norwegian study published in June last year in the Journal of Pediatrics, has shown an increased risk.
However, previous studies have shown conflicting evidence. More prospective, multi-central studies from many different countries need to be done before this risk is accepted into evidence-based practice. More importantly, other aspects such as failure to breast-feed a baby after a Caesarean section need to be considered.
Nevertheless, the increase in Caesarean section rates in the past couple of decades cannot be denied. It has always been an important and heavily debated topic of discussion in practically every obstetrics conference all over the world. The reason for this is complex and every attempt has been made by the fraternity to reduce this rate. But its judicious use has saved many a mother and baby."
My thoughts
I agree with a great deal of what Dr Baskaran says, but it would be interesting to learn more about his views on planned cesarean delivery with no medical indication. He does mention above that "every attempt has been made by the fraternity to reduce this [cesarean] rate" and it concerns me that women making legitimate decisions to choose one set of birth risks and benefits over another may be not be supported in Malaysia. I only hope that this is not the case.
Friday, January 16, 2009
More Women Choosing Birth Without Labor
Dr. Michael J. McGlynn of the Eden Medical Center in Castro Valley has written an article on the Castro Valley Forum this week, in which he comments on changes he's noticed in recent years. He says: "More and more pregnant women are requesting caesarean sections without labor. This is especially true for first-time mothers who are apprehensive about the pain associated with labor as well as injury to the birth canal with a vaginal birth. Many mothers also want a Csection to control the delivery date."
Dr. McGlynn makes the valid point that "information about choices to make as pregnant women enter into labor and delivery is not... straightforward." He says, "Questions about the birth process and whether to accept pain medication during labor or bypass labor altogether and have an elective caesarian section are very personal choices."
His advice?: "With so many decisions to make, pregnant women should be comfortable enough with their obstetricians to make sure they [are] even writing questions down in advance. After all, a healthy mom and a healthy baby is everyone’s ultimate goal."
My thoughts
I completely agree with Dr. McGlynn's advice; in fact, this is exactly what I did ahead of my visits with my OBGYN. I read as many medical studies on cesarean risks and benefits as I could find, and was fortunate enough to have a doctor who was willing to answer all my questions and help me to understand my own individual health risks. Pregnancy and childbirth are not without risk, but understanding and feeling comfortable with the decisions you make has been shown in studies (10,11,13,15) to help increase women's likelihood of post-birth satisfaction.
Dr. McGlynn makes the valid point that "information about choices to make as pregnant women enter into labor and delivery is not... straightforward." He says, "Questions about the birth process and whether to accept pain medication during labor or bypass labor altogether and have an elective caesarian section are very personal choices."
His advice?: "With so many decisions to make, pregnant women should be comfortable enough with their obstetricians to make sure they [are] even writing questions down in advance. After all, a healthy mom and a healthy baby is everyone’s ultimate goal."
My thoughts
I completely agree with Dr. McGlynn's advice; in fact, this is exactly what I did ahead of my visits with my OBGYN. I read as many medical studies on cesarean risks and benefits as I could find, and was fortunate enough to have a doctor who was willing to answer all my questions and help me to understand my own individual health risks. Pregnancy and childbirth are not without risk, but understanding and feeling comfortable with the decisions you make has been shown in studies (10,11,13,15) to help increase women's likelihood of post-birth satisfaction.
Support for a cesarean/vaginal delivery comparative trial?
Australian Researchers Catherine Turner et al have recently published 'Willingness of pregnant women and clinicians to participate in a hypothetical randomised controlled trial comparing vaginal delivery and elective caesarean section', in which they conclude that a "randomised controlled trial comparing vaginal delivery and elective caesarean section may not be feasible due to low levels of willingness to participate, particularly among pregnant women."
This type of comparative trial has been criticized for being unethical and/or unfeasible in the past (by other researchers and doctors), but this latest research from Australia isn't all negative. The authors begin by stating that "Elective caesarean section is controversial in the absence of compelling evidence of the relative benefits and harms compared with vaginal delivery. A randomised trial of the two procedures to compare outcomes for women and babies would provide the best quality scientific evidence to confirm this debate but it is not known whether such a trial would be feasible."
They set out to ascertain what proportion of pregnant women and clinicians would participate in a hypothetical randomised controlled trial comparing the two delivery methods by asking pregnant women (via interviews) and midwives, obstetricians, urogynaecologists and colorectal surgeons (via a mailed, self-administered questionnaire).
How many support a hypothetical trial?
Out of 100 pregnant women, 84 midwives, 166 obstetricians, 12 urogynaecologists and 87 colorectal surgeons, 14% of pregnant women and 31% of clinicians indicated that they would participate in a randomised controlled trial.
Is this enough?
14% is a very low number, but I would be interested to learn whether the 100 women questioned already had a birth plan in mind, and also whether the hypothetical trial (as explained to them) meant that they would get to choose between each delivery or whether that delivery method would be allocated to them. These factors are crucial and could make a huge difference to the final percentage tally.
31% is almost a third of clinicians saying 'yes', and this is actually a sizeable proportion. If nothing else, it indicates that aversion to such a trial is no longer in the minority.
Trial alternatives?
The number of healthy women electing to have cesarean deliveries with no medical indication is reportedly low. However, these women do exist and their health outcome data is on record at hospitals (especially private hospitals) throughout the world. If we could gather the data available for some or all of these deliveries, this would go a long way to informing risk and benefit analysis as compared to planned vaginal deliveries in healthy women (the data of which is readily available at numerous large hospitals).
Trial fears?
In 2003, doctors in Australia asked the question 'Should obstetricians support a 'term cephalic trial'? (Robson S, Ellwood D. Aust N Z J Obstet Gynaecol. 2003 Oct;43(5):341-3.) In subsequent media reports, they were quoted as saying:
Dr Robson: 'What a disaster it would be if it was found elective cesarean was safer than vaginal birth.'
Dr Ellwood: 'There is an increasing trend towards elective cesareans, and there have been discussions over the last couple of years about mounting the so-called term-cephalic trial, which would be a randomised trial comparing cesarean versus planned vaginal birth for women having their first babies. We're concerned that the impact of such a trial could well be quite far reaching, and that it needs to be well thought through before such a trial is mounted.' [The reporter continued:] His fear is that if caesarean sections were found to be safer in such a trial, doctors and patients might feel compelled to go that way.
This type of comparative trial has been criticized for being unethical and/or unfeasible in the past (by other researchers and doctors), but this latest research from Australia isn't all negative. The authors begin by stating that "Elective caesarean section is controversial in the absence of compelling evidence of the relative benefits and harms compared with vaginal delivery. A randomised trial of the two procedures to compare outcomes for women and babies would provide the best quality scientific evidence to confirm this debate but it is not known whether such a trial would be feasible."
They set out to ascertain what proportion of pregnant women and clinicians would participate in a hypothetical randomised controlled trial comparing the two delivery methods by asking pregnant women (via interviews) and midwives, obstetricians, urogynaecologists and colorectal surgeons (via a mailed, self-administered questionnaire).
How many support a hypothetical trial?
Out of 100 pregnant women, 84 midwives, 166 obstetricians, 12 urogynaecologists and 87 colorectal surgeons, 14% of pregnant women and 31% of clinicians indicated that they would participate in a randomised controlled trial.
Is this enough?
14% is a very low number, but I would be interested to learn whether the 100 women questioned already had a birth plan in mind, and also whether the hypothetical trial (as explained to them) meant that they would get to choose between each delivery or whether that delivery method would be allocated to them. These factors are crucial and could make a huge difference to the final percentage tally.
31% is almost a third of clinicians saying 'yes', and this is actually a sizeable proportion. If nothing else, it indicates that aversion to such a trial is no longer in the minority.
Trial alternatives?
The number of healthy women electing to have cesarean deliveries with no medical indication is reportedly low. However, these women do exist and their health outcome data is on record at hospitals (especially private hospitals) throughout the world. If we could gather the data available for some or all of these deliveries, this would go a long way to informing risk and benefit analysis as compared to planned vaginal deliveries in healthy women (the data of which is readily available at numerous large hospitals).
Trial fears?
In 2003, doctors in Australia asked the question 'Should obstetricians support a 'term cephalic trial'? (Robson S, Ellwood D. Aust N Z J Obstet Gynaecol. 2003 Oct;43(5):341-3.) In subsequent media reports, they were quoted as saying:
Dr Robson: 'What a disaster it would be if it was found elective cesarean was safer than vaginal birth.'
Dr Ellwood: 'There is an increasing trend towards elective cesareans, and there have been discussions over the last couple of years about mounting the so-called term-cephalic trial, which would be a randomised trial comparing cesarean versus planned vaginal birth for women having their first babies. We're concerned that the impact of such a trial could well be quite far reaching, and that it needs to be well thought through before such a trial is mounted.' [The reporter continued:] His fear is that if caesarean sections were found to be safer in such a trial, doctors and patients might feel compelled to go that way.
When Childbirth Was Natural, and Deadly
This January 10th article by Druin Burch in Natural History Magazine concentrates on the history of diseases that were associated with deaths in childbirth, but if nothing else, it provides yet another reminder that while women may indeed have been giving birth since the beginning of time with bodies that were designed to do so, natural birth has always been inextricably associated with death too.
Pregnancy is risky; childbirth is risky. It is a woman's progagative to decide which set of delivery risks (vaginal or cesarean) is most tolerable to her.
Pregnancy is risky; childbirth is risky. It is a woman's progagative to decide which set of delivery risks (vaginal or cesarean) is most tolerable to her.
0.5% risk of deep vein thrombosis with cesarean delivery
A new North American study by Winnie Siaa et al, 'The incidence of deep vein thrombosis in women undergoing cesarean delivery', set out to determine the incidence of deep vein thrombosis (DVT) post cesarean delivery since venous thromboembolism (VTE) is one of the leading causes of maternal mortality in the United States and Canada, and cesarean delivery is a known risk factor.
The autors found an incidence proportion of DVT post cesarean delivery of 0.5% and say this is the largest study to date that uses Doppler compression ultrasound to diagnose DVT in women after cesarean deliveries.
Study highlights
The research is certainly worth a read, but I've highlighted some of the interesting points made by the researchers in the 'Comment' section of their presentation:
The autors found an incidence proportion of DVT post cesarean delivery of 0.5% and say this is the largest study to date that uses Doppler compression ultrasound to diagnose DVT in women after cesarean deliveries.
Study highlights
The research is certainly worth a read, but I've highlighted some of the interesting points made by the researchers in the 'Comment' section of their presentation:
*A Swedish prospective study found an incidence of DVT post cesarean delivery at 1.8% using impedance plethysmography, which is known to have high false positive rate compared to Doppler ultrasound. However, four other studies using Doppler ultrasound did not find any DVT in their cesarean delivery population... [many more studies are cited]
*This incidence of post cesarean delivery DVT is much lower than that reported among general surgical patients... This disparity between general surgical patients and patients undergoing CD may be due to many factors. First, patients undergoing CD are generally younger. This is still true even though 20% of our population would be described as “advanced maternal age” for being over 35 years old. Age is both an independent risk factor of VTE and is associated with increased likelihood of co-morbidities. Second, most cesarean deliveries are now performed under regional anesthesia, which is known to have a lower risk of postoperative DVT compared with general anesthesia. Third, postpartum mothers are more likely to be out of bed early and frequently (because of the needs of their newborn) as compared to patients who have undergone other abdominal surgeries.
*It is interesting to note that while our study population appears to have few VTE risk factors, 78% would have warranted thromboprophylaxis after cesarean delivery per RCOG guideline. The preeclampsia rate of nearly 10% in our study is higher than that of the general obstetric population likely because preeclampsia increases the risk of cesarean delivery and our participants all had cesarean deliveries.
Epidural risk lower than thought
A BBC News article on the 12th January reports on a study by researchers at Bath's Royal United Hospital, which suggests that the "risk of epidurals and spinal anaesthetics to expectant mothers and patients undergoing surgery may be being overstated."
The researchers analysed the complications from the 700,000 pain-killing injections given each year and "found the risk of harm was at least as low as one in 23,000 - 10 times less than tends to be estimated. Experts said it was important patients were told about the true risk."
You can read the article in full here, but it continues: "Researchers said expectant mothers, in particular, should not be overly concerned as their risk of permanent harm was as low a one in 80,000."
Spinal anesthesia
Spinal anesthesia rather than an epidural is often used in planned cesarean deliveries today, but this research is worth being aware of for both cesarean and vaginal delivery risk information.
The researchers analysed the complications from the 700,000 pain-killing injections given each year and "found the risk of harm was at least as low as one in 23,000 - 10 times less than tends to be estimated. Experts said it was important patients were told about the true risk."
You can read the article in full here, but it continues: "Researchers said expectant mothers, in particular, should not be overly concerned as their risk of permanent harm was as low a one in 80,000."
Spinal anesthesia
Spinal anesthesia rather than an epidural is often used in planned cesarean deliveries today, but this research is worth being aware of for both cesarean and vaginal delivery risk information.
Rate of Unnecessary C-Sections Far Lower Than Thought
This December article by Serena Gordon of HealthDay News is a fascinating glimpse at what might be closer to the truth about cesarean delivery rates in the U.S: That the term 'unnecessary' may be being overused and based on inaccurate data.
Gordon reports that current estimates put the figure of unnecessary cesareans at nearly 60%, while the real number may be as low as 4%. Why the huge difference?
Mainly because of inaccuracies cited on birth certificates. When government experts analyzed birth certificates and hospital discharge data, they found the actual number of [unnecessary cesarean] deliveries was closer to 4%. The study author, Emily Kahn, an epidemiologist with the U.S. Centers for Disease Control and Prevention's division of reproductive health, explains that "You can't use the birth certificate alone to determine whether or not a woman is at risk for primary caesarean delivery."
"...The CDC researchers sifted through data on 565,767 births from women who were considered at low risk for needing a C-section. The women were all 37 weeks' to 41 weeks' pregnant when they went into labor and had singleton pregnancies. All of the women delivered in Georgia hospitals between 1999 and 2004. More than 70,000 of these women ended up having a Caesarean delivery, and almost 41,000 were listed on the birth certificate as having no risk factors. Yet, in the hospital discharge data, nearly 90 percent of these women had a risk factor listed. Overall, 58.3 percent of birth certificates suggested no risk factors. But when the researchers pooled the data and combined both birth certificate data and hospital discharge data, they found the rate of Caesareans with no reported risk factors at just 3.9 percent."
Doctors don't touch birth certificates
..."Kahn said there are several possible reasons for this discrepancy. One is that the main purpose of a birth certificate is simply to record the birth. Birth certificates aren't completed by physicians, but instead rely on worksheets filled out by the mother. And, she said, hospital discharge data is used to bill the insurance companies and doctors must be very detailed on these reports to get paid, which might make them more accurate. "Doctors don't touch birth certificates," said Dr. Miriam Greene, an obstetrician at New York University Langone Medical Center and author of the book Frankly Pregnant. "The person who writes up the birth certificate might not be knowledgeable about all the risk factors for C-section, and they see the baby is fine and may think there was no issue."
My view - U.S. birth data collation is unhelpful
The story above illustrates one disadvantage with the reliance on birth certificates for analyzing cesarean delivery occurence in the U.S., but I have long talked about another area for improvement. That is, separating the number of elective/planned cesarean deliveries and the number of emergency cesarean deliveries. Many European countries already separate these types of cesarean deliveries, and this has helped to inform research into the differences in risks between the two.
Even better would be to separate 'planned cesarean deliveries in healthy women with no medial indication' (since we now know they DO exist), as this would help us to compile actual outcome data of this group without waiting for agreement to a controversial clinical trial comparing planned vaginal and cesarean deliveries in healthy women.
On a positive note, the U.S. does separate primary and repeat cesarean deliveries, which has been useful for researching health risk outcomes in multiple deliveries. It now just needs to go a few steps further in order to ensure clarity and accuracy in its cesarean data collation.
Gordon reports that current estimates put the figure of unnecessary cesareans at nearly 60%, while the real number may be as low as 4%. Why the huge difference?
Mainly because of inaccuracies cited on birth certificates. When government experts analyzed birth certificates and hospital discharge data, they found the actual number of [unnecessary cesarean] deliveries was closer to 4%. The study author, Emily Kahn, an epidemiologist with the U.S. Centers for Disease Control and Prevention's division of reproductive health, explains that "You can't use the birth certificate alone to determine whether or not a woman is at risk for primary caesarean delivery."
"...The CDC researchers sifted through data on 565,767 births from women who were considered at low risk for needing a C-section. The women were all 37 weeks' to 41 weeks' pregnant when they went into labor and had singleton pregnancies. All of the women delivered in Georgia hospitals between 1999 and 2004. More than 70,000 of these women ended up having a Caesarean delivery, and almost 41,000 were listed on the birth certificate as having no risk factors. Yet, in the hospital discharge data, nearly 90 percent of these women had a risk factor listed. Overall, 58.3 percent of birth certificates suggested no risk factors. But when the researchers pooled the data and combined both birth certificate data and hospital discharge data, they found the rate of Caesareans with no reported risk factors at just 3.9 percent."
Doctors don't touch birth certificates
..."Kahn said there are several possible reasons for this discrepancy. One is that the main purpose of a birth certificate is simply to record the birth. Birth certificates aren't completed by physicians, but instead rely on worksheets filled out by the mother. And, she said, hospital discharge data is used to bill the insurance companies and doctors must be very detailed on these reports to get paid, which might make them more accurate. "Doctors don't touch birth certificates," said Dr. Miriam Greene, an obstetrician at New York University Langone Medical Center and author of the book Frankly Pregnant. "The person who writes up the birth certificate might not be knowledgeable about all the risk factors for C-section, and they see the baby is fine and may think there was no issue."
My view - U.S. birth data collation is unhelpful
The story above illustrates one disadvantage with the reliance on birth certificates for analyzing cesarean delivery occurence in the U.S., but I have long talked about another area for improvement. That is, separating the number of elective/planned cesarean deliveries and the number of emergency cesarean deliveries. Many European countries already separate these types of cesarean deliveries, and this has helped to inform research into the differences in risks between the two.
Even better would be to separate 'planned cesarean deliveries in healthy women with no medial indication' (since we now know they DO exist), as this would help us to compile actual outcome data of this group without waiting for agreement to a controversial clinical trial comparing planned vaginal and cesarean deliveries in healthy women.
On a positive note, the U.S. does separate primary and repeat cesarean deliveries, which has been useful for researching health risk outcomes in multiple deliveries. It now just needs to go a few steps further in order to ensure clarity and accuracy in its cesarean data collation.
Cesarean section rate growing in Czech Republic
The Prague Daily Monitor has reported that that in "2007, 114,632 children were born in the Czech Republic with one-fifth of them being born by cesarean section... According to the Institute of Medical Information and Statistics (UZIS), 22,428 women gave birth to their babies via cesarean section in 2007, which is 1.4 percent more than in 2006."
Interestlingly, the report state that according "to medical statistics, some doctors perform cesarean section at women's requests or when they need to ensure successful delivery, but some specialists disagree with the practice."
Other 2007 statistics cited
With 1.44 children per woman being born, this is a record high since 1993.
Women's average age at delivery has increased by 0.2% to 27.1 years at first delivery and 29.1 years in general.
Interestlingly, the report state that according "to medical statistics, some doctors perform cesarean section at women's requests or when they need to ensure successful delivery, but some specialists disagree with the practice."
Other 2007 statistics cited
With 1.44 children per woman being born, this is a record high since 1993.
Women's average age at delivery has increased by 0.2% to 27.1 years at first delivery and 29.1 years in general.
Tuesday, January 13, 2009
39 is the magic number
It's been the recommended time of delivery for cesarean-born babies for many years now, but a new study has reiterated the importance of waiting until confirmed 39 weeks gestation before commencing surgery. Tita et al's American study, 'Timing of Elective Repeat Cesarean Delivery at Term and Neonatal Outcomes', concludes that "Elective repeat cesarean delivery before 39 weeks of gestation is common and is associated with respiratory and other adverse neonatal outcomes."
What the research found
The researchers "studied a cohort of consecutive patients undergoing repeat cesarean sections performed at 19 centers of the Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network from 1999 through 2002. Women with viable singleton pregnancies delivered electively (i.e., before the onset of labor and without any recognized indications for delivery before 39 weeks of gestation) were included. The primary outcome was the composite of neonatal death and any of several adverse events, including respiratory complications, treated hypoglycemia, newborn sepsis, and admission to the neonatal intensive care unit (ICU)."
"Of 24,077 repeat cesarean deliveries at term, 13,258 were performed electively; of these, 35.8% were performed before 39 completed weeks of gestation (6.3% at 37 weeks and 29.5% at 38 weeks) and 49.1% at 39 weeks of gestation. One neonatal death occurred. As compared with births at 39 weeks, births at 37 weeks and at 38 weeks were associated with an increased risk of the primary outcome... The rates of adverse respiratory outcomes, mechanical ventilation, newborn sepsis, hypoglycemia, admission to the neonatal ICU, and hospitalization for 5 days or more were increased by a factor of 1.8 to 4.2 for births at 37 weeks and 1.3 to 2.1 for births at 38 weeks."
Obviously, some of these early deliveries are necessitated due to emerging or pre-existing medical conditions (either with the mother and/or the baby), but certainly wherever possible, doctors advise waiting until 39 weeks to deliver.
What the research found
The researchers "studied a cohort of consecutive patients undergoing repeat cesarean sections performed at 19 centers of the Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network from 1999 through 2002. Women with viable singleton pregnancies delivered electively (i.e., before the onset of labor and without any recognized indications for delivery before 39 weeks of gestation) were included. The primary outcome was the composite of neonatal death and any of several adverse events, including respiratory complications, treated hypoglycemia, newborn sepsis, and admission to the neonatal intensive care unit (ICU)."
"Of 24,077 repeat cesarean deliveries at term, 13,258 were performed electively; of these, 35.8% were performed before 39 completed weeks of gestation (6.3% at 37 weeks and 29.5% at 38 weeks) and 49.1% at 39 weeks of gestation. One neonatal death occurred. As compared with births at 39 weeks, births at 37 weeks and at 38 weeks were associated with an increased risk of the primary outcome... The rates of adverse respiratory outcomes, mechanical ventilation, newborn sepsis, hypoglycemia, admission to the neonatal ICU, and hospitalization for 5 days or more were increased by a factor of 1.8 to 4.2 for births at 37 weeks and 1.3 to 2.1 for births at 38 weeks."
Obviously, some of these early deliveries are necessitated due to emerging or pre-existing medical conditions (either with the mother and/or the baby), but certainly wherever possible, doctors advise waiting until 39 weeks to deliver.
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