School asks parents how child was born - cesarean or vaginal?

Yes - as part of its elementary school application process, Dry Creek School District in California is reported to have asked parents how their child was born.

You can read the story in full at CBS' School Application Criticized For Birth Questions, but as the reporter says, unfortunately there is no word yet from the school district.

Induced birth research is irrelevant to maternal request cesareans

An article on the Citizens Report website yesterday, 'New Study Warns of Risks from Unnecessary Cesarean Births, and while I don't have an issue with efforts to reduce cesarean rates for women who desperately want to have a vaginal delivery (unless the surgery is needed in order to save the baby's or mother's life), I am critical of reports that make a connection between the term 'unnecessary cesarean' and women who 'choose' cesarean delivery.

My comment on the article
As far as I can ascertain, this research relates to planned vaginal deliveries that were induced (it is stated that the researchers “excluded women who had scheduled or previous cesarean deliveries”). Therefore, it is irrelevant to make a connection between this research and the legitimate decision made by women to plan a cesarean delivery and avoid a trial of labor. The research does not even include the latter type of birth in its analysis.

The advice for women considering a maternal request cesarean delivery is to ensure that they do not have surgery prior to 39 weeks (in order to ensure that the baby’s lungs have developed properly). This research reinforces the established medical opinion that risks are lower for women delivering after 39 weeks gestation.

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.

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.