Monday, December 7, 2009

Life-threatening infant morbidity is lower with planned cesareans

This is a very important study of almost 40,000 term deliveries in Canada. So far, it has received no media attention here, but I think it deserves your attention - especially women who might be worried about a planned cesarean delivery for medical reasons but also women who chose to plan a cesarean and now face a constant stream of criticism by others.

What the researchers did
LS Dahlgren et al studied 1,046 pre-labor, planned cesarean deliveries for breech presentation and 38,021 planned vaginal deliveries with a cephalic-presenting singleton (i.e. a baby in the normal, head-down birth position).

What the researchers found
Life-threatening neonatal morbidity was decreased in the planned cesarean group: ‘elective pre-labour caesarean section... at full term decreased the risk of life-threatening neonatal morbidity compared with spontaneous labour with anticipated vaginal delivery.'

Why is this study so important?
Two reasons.

1) It found that 'life-threatening maternal morbidity was similar in each group'. In other words, that planned cesarean surgery - despite being complicated by a breech presentation - was no more dangerous for mothers than a planned vaginal delivery.

2) Because the vaginal delivery group consisted of straightforward pregnancies and was then compared with a cesarean delivery group of babies in the breech position, the fact that surgery STILL turned out to be the safest delivery method, raises the question how much wider the margin of benefit might have been if the cesarean group consisted of straightforward pregnancies too...

The researchers' conclusions
You can read more about this study, 'Caesarean section on maternal request: risks and benefits in healthy nulliparous women and their infants', here, but in brief, the researchers note that 'the increased neonatal risk was associated with operative vaginal delivery and intrapartum caesarean but not spontaneous vaginal delivery'.

So, if you have a spontaneous vaginal delivery, your baby will enjoy a safer arrival. Of course the problem always remains that spontaneous vaginal delivery can never be guaranteed. Therefore women need to be advised of ALL the potential health outcomes of a trial of labor (which in fairness, many will legitimately accept in preference to surgery), and not just the 'best case' scenario if everything goes according to plan.

Further research needed
Evidently, as the researchers conclude, the 63% of women who planned spontaneous labour and subsequently achieved a spontaneous vaginal delivery may/'would not have benefited from delivery by caesarean section' (I added the word 'may' since maternal morbidity factors such as pelvic floor damage must be considered too), and therefore it is suggested:

'Further research is needed to better identify women with an increased likelihood of an operative vaginal or intrapartum caesarean section, as this may assist maternity caregivers in decision-making about childbirth. Further research is also needed to determine if these findings can be confirmed in a prospective study.'

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