| May 2008 BLOG |
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This has been a busy month for cesarean news, and as you'll read in the links below, there has been some important research highlighting the benefits of elective cesarean delivery versus PVD. Keep in mind whenever you are reading articles or studies on cesarean delivery outcomes, that they have not always separated emergency and elective outcomes. Also, dig a little deeper beyond the headlines and summaries provided whenever possible, as you'll often find that you can better evaluate whether the data content truly reflects the authors' conclusions/analysis of the figures, and you can better quantify how the reported risk or benefit relates specifically to you and your pregnancy.
NEW CESAREAN RESEARCH
*FEWER MATERNAL DEATHS WITH ELECTIVE CESAREAN DELIVERY Research by the UK's Birth Trauma Association found that the maternal death rate for women who underwent scheduled or elective caesarean was lower than for other women giving birth between 2003-2005. 'Out of the 2,113,8311 women who delivered a baby after 24 weeks gestation between 2003 and 2005, 10.6% underwent a caesarean prior to the commencement of labour. Seven women who underwent a scheduled or elective caesarean died as a direct result of obstetric causes resulting in a maternal mortality rate of 0.31 per 10,000. In the 89.4% women who did not undergo elective or scheduled caesarean, 74 women died of direct causes giving a rate of 0.39 per 10,000. Although maternal deaths are extremely rare, this does challenge the government's policy of reducing caesarean rates.' EC VIEW I have been saying for years that if we isolate elective cesarean delivery outcomes (and particularly maternal request in healthy pregnancies), PVD advocates would no longer be able to claim that there are higher maternal mortality rates with cesarean delivery and use it as a reason for discouraging CDMR. *CESAREAN MATERNAL MORTALITY CAN BE FURTHER REDUCED Research in the U.S. found that 95 maternal deaths occurred in 1,461,270 pregnancies (6.5 per 100,000 pregnancies.) 'Leading causes of death were complications of preeclampsia, pulmonary thromboembolism, amniotic fluid embolism, obstetric hemorrhage, and cardiac disease. Only 1 death was seen from placenta accreta. 27 deaths (28%) were deemed preventable (17 by actions of health care personnel and 10 by actions of non-health care personnel). The rate of maternal death causally related to mode of delivery was 0.2 per 100,000 for vaginal birth and 2.2 per 100,0000 for cesarean delivery, suggesting that the number of annual deaths resulting causally from cesarean delivery in the United States is about 20. Conclusion: Most maternal deaths are not preventable. Preventable deaths are equally likely to result from actions by nonmedical persons as from provider error. Given the diversity of causes of maternal death, no systematic reduction in maternal death rate in the United States can be expected unless all women undergoing cesarean delivery receive thromboembolism prophylaxis. Such a policy would be expected to eliminate any statistical difference in death rates caused by cesarean and vaginal delivery.' EC VIEW Remembering that the deaths recorded here take into account ALL cesarean deliveries - emergency and elective - and therefore the statistical difference between CDMR and PVD is most likely already less than the figures being quoted here - it is interesting to note that further safety improvements may be achievable for all cesarean deliveries. *SEXUAL HEALTH RISK ASSOCIATED WITH PVD This U.S. research into sexual function 6 months after first delivery found that although most (459 [90%]) of those women with partners reported sexual activity at the 6-month visit..., pain (responses of "sometimes," "usually," or "always") during sex affected one of three sexually active women (164 [36%]). Furthermore, the study concluded that at '6 months postpartum, primiparous women who delivered with anal sphincter laceration are less likely to report sexual activity.' EC VIEW Many women return to pain-free sexual activity following vaginal delivery but the risk of post-birth complications does exist; anal sphincter laceration for example is a risk associated with PVD, not CDMR. For more information on research into cesarean delivery versus PVD in relation to your sexual health, see our Sexual Health section. *LINK BETWEEN PRETERM BIRTHS AND CESAREAN DELIVERY The March of Dimes has called for more research into 'non-medical' cesareans 'at the request of the mother or based on an inappropriate recommendation from the doctor' following the publication of research which reports that 'the proportion of preterm births increased from 9.7% to 10.7% between 1996 and 2004...' alongside an increase in the national cesarean delivery rate, yet astonishingly, no other avenues for investigation are cited in its press release. EC VIEW I would urge you to take a look at Amy Tuteur's comments on this subject, which explain that 'Late prematurity has been rising as babies are delivered earlier to prevent stillbirth from underlying medical problems, and the stillbirth rate has fallen markedly in response.' She also explains other reasons for preterm deliveries, such as 'attempting to prevent or manage fetal distress, maternal bleeding, infections, or severe preeclampsia.' I'd also like to highlight this extract from the research above: 'Singleton cesarean section rates for non-Hispanic black women increased at a faster pace among all preterm gestational age groups compared with non-Hispanic white and Hispanic women.' According to the National Newspaper Publishers Association, nearly 100,000 black newborns are affected every year and are three times more likely to die within 12 months. 'Physicians and researchers have yet to reach a clear consensus on why black babies are more likely to suffer from premature birth, but there are several established risk factors such as having delivered a premature baby once before, multiple births, high blood pressure, diabetes, multiple miscarriages, previous abortions, fluctuating weight, uterine or cervical deformities, drug and alcohol use, maternal or fetal stress and age.' Finally, I suggest you read some of the latest statistics in this 2007 U.S. report into Women's Health; it's clear from this data that we cannot continue to draw simple associations between rates of cesarean delivery and birth outcomes in the U.S. (or other countries for that matter). I will write more on this topic in a future BLOG, but suffice to say that the changing maternal landscape - maternal age, maternal weight, ethnicity, poverty, intolerance of risk etc. - must take its share of accountability for rising cesarean delivery rates (particularly unwanted cesareans) along with litigation, PVD management and maternal/doctor preference. *NO LINK BETWEEN STILLBIRTH AND REPEAT CESAREAN DELIVERY A retrospective cohort study of a Canadian perinatal database [158,502 second births] concluded that: ‘Caesarean section in the first birth does not increase the risk of unexplained antepartum stillbirth in second pregnancies.' EC VIEW This is not the first time that the oft-quoted link between subsequent stillbirth and cesarean delivery has been challenged, and it is good news that this confirmation of no link has finally been widely accepted. Please see our Stillbirth page for information on previous studies. [June note: The BBC reports that 'a mother's obesity - not whether she has a caesarean - may instead be the key factor' [for stillbirth], which echoes the conclusions of a 2007 study on maternal obesity and the risk of stillbirth: 'Maternal obesity is associated with an increased risk of stillbirth, although the mechanisms to explain this association are not clear.' *RISK OF STROKE WITH CESAREAN DELIVERY A study in Taiwan has concluded: ‘Our data indicates that cesarean section delivery is an independent risk factor for stroke.' However, a Reuters report on this data illustrates the actual numbers behind the risk. Of 987,010 singleton deliveries from 1998-2002, 34% were delivered by c-section. ‘At 3, 6, and 12 months after delivery, rates of stroke among the mothers were 67%, 61%, and 49% higher, respectively, following cesarean rather than vaginal birth, the investigators report... However, they also point out that the absolute risk of stroke was very low. The cumulative rate for the entire 12-month period was only 0.05% after vaginal delivery and 0.08% after cesarean delivery. Nonetheless, ‘a strategy of prevention should be developed for those mothers in the cesarean section delivery group who are at a higher risk of stroke,' Lin and associates conclude.' EC VIEW Although the risk of stroke exists, it is clear from these figures (and the researchers' comments) that the risk is small and of greatest concern for a specific group of pregnant women. I know I say this repeatedly, but pregnancy and childbirth (of any kind) are not risk-free; after careful examination of both sets of risks and benefits, I chose CDMR but many other women would make a different choice. *ASTHMA RISK WITH CESAREAN DELIVERY A possible biological explanation of the link between asthma and cesarean birth has been reported by the American Thoracic Society, while in another study, German researchers report that mothers who spend time on farms while pregnant seem to confer protection from allergies on their newborns. EC VIEW The risk of asthma for children born via cesarean delivery remains unclear and research into this area continues. It is a risk that should not be ignored - please read our Asthma and Allergies page for details of other research in this area - but it is a risk that will be weighed against other risks for the infant associated with PVD. *VBAC VERSUS REPEAT CESAREAN DELIVERY - DEBATE CONTINUES There are numerous studies on this subject (see our VBAC page for more details) and the conclusions of the two studies below illustrate the continuing conflict in some medical opinion. Rossi et al conclude: 'Outcomes were more favorable in S-VBAC than ERCS. These findings show that a higher risk of UR/D in women planning VBAC than ERCS is counterbalanced by reduction of MM, UR/D. and hysterectomy when VBAC is successful.' Grobman et al conclude: 'Factors that were available before or at admission for delivery cannot be used to predict accurately the relatively small proportion of women at term who will experience a uterine rupture during an attempted vaginal birth after cesarean delivery.' EC VIEW It is my personal prefernce to have a repeat cesarean delivery, but these studies actually highlight one of the main reasons I chose my primary cesarean delivery too, and that is the unpredictable nature of vaginal delivery. The fact is, it is impossible to guarantee that a woman will have a successful vaginal delivery, whether it's a primary PVD, repeat PVD or VBAC. For some women, this is an acceptable risk; for others, it is not.
OTHER STORIES IN THE MEDIA
*BIRTH LITIGATION CONCERNS CANNOT BE IGNORED EC VIEW All too often, I read reports on cesarean delivery in the U.S. (and other countries) in which OBGYN litigation concerns are heavily criticized as an unwarranted, selfish or money-grabbing reason behind a seemingly ever-increasing national rate. It is my understanding that cesarean delivery prior to 39 weeks EGA should be avoided whenever possible, and this is certainly advised with elective cesarean delivery, but there are many cases where a doctor must make a critical decision during (pre-term, term and post-term) vaginal deliveries - of whether or when to perform an emergency cesarean. Some may say that this is simply their job to know, but it seems to me that after the birth, doctors are frequently criticized by those women who believe it was unnecessary or preventable, and criticized by others who believe it should have been enacted sooner. If morbidity or mortality ensues, lawyers are employed, and consequently, fear of litigation has become a reality in hospitals and something doctors must face on a daily basis. Some years ago, I began compiling a list of cases where compensation has been sought and won following births with absent or late emergency cesareans in order to illustrate this situation [see it here]. In fact in May 2008 alone, I found the stories listed below. Personally, and in an ideal world, medical practice is not best governed by fear of litigation, but in the world as it is, can we really blame doctors and hospitals for protecting themselves against the lawsuits described here? $5 million compensation: for severe brain damage... Aubrey's birth was set up as a ‘VBAC' - vaginal birth after cesarean. According to independent obstetrician experts who reviewed the childbirth records, Nurse Bennett, in response to the baby's failure to descend in the birth canal, repeatedly increased the dosage of a drug to stimulate uterine contractions - Pitocin or oxytocin - despite warning signs that the uterus was overly stimulated. The uterus eventually ruptured, cutting off oxygen to the fetus through the placenta... Aubrey then was delivered by an emergency cesarean section, but it was too late to prevent her brain injury. £4.9 million compensation: David Hemingway, of Morsiton, Swansea, was born with severe spastic quadriplegic cerebral palsy and sight and hearing problems after his mum, Sandra, suffered a placental haemorrhgae shortly before his birth in 1983... [Judge]: "if reasonable care had been exercised, the clinical staff would have completed the tests, which would have shown to them that the foetus was at risk of a developing situation and they would have assessed that by no later than about 1pm. "A caesarian section would have followed and, taking into account it took one-and-a-half hours for assessment, preparation and delivery, I'm prepared to say that it would have followed by no later than 2.30pm." $22.6 million compensation: to a Cincinnati woman whose daughter suffered brain damage as a result of medical birthing mistake. In 1997 Heather Grow, pregnant with her first child, was diagnosed with a narrow pelvic arch. Despite this diagnosis and the fact that her baby was going to be big, nine pounds, she was allowed to have natural childbirth. During the delivery the baby's head became stuck in the birth canal and remained lodged there for 13 hours before finally being delivered by cesarean section. Maternal death: Ana Maria Denzo, 30, died as a result of severe bleeding after John O'Riordan told a midwife to induce contractions, then left her alone. At the inquest at Hornsey Coroner's Court, the consultant admitted he should have realised that, with the baby weighing 8.4lb, there could have been problems. He said: ‘I should have personally paid more attention to the fact it was a big baby.' ...Doctors and midwives had hoped she would give birth naturally despite signs that the baby was becoming distressed. Syntocinon was given to Mrs Denzo via a drip and the dosage increased every half an hour to strengthen contractions. By 2pm, she had received 36 units. Richard Partridge, representing Mrs Denzo's family, said she had been given so much of the drug she was "hyper-stimulated", which increased the chances of haemorrhage. At 3.40pm, Mrs Denzo underwent an emergency caesarean but suffered severe internal bleeding for weeks. [Coroner]: "If you had been back in two hours you might have been able to stop this and turn it in to a caesarean." Compensation sought: ...Jordan was eventually delivered by emergency caesarean section, and took his first breath 25 minutes after delivery. The writ brands the trust "negligent", and says he should have been delivered earlier. $17.5 million compensation: to a 37-year-old woman who claimed that surgical errors by doctors damaged her organs during a caesarean delivery. The state Supreme Court jury awarded the money for Brenda Schenk's past and future injuries resulting from the actions of doctors at Strong Memorial Hospital in October 2003. Schenk, who had a kidney and pancreas transplant in 1995, claimed doctors failed to plan properly for her high-risk pregnancy. She also said they neglected to notice that they cut the connection between her pancreas and bladder during the delivery of a healthy baby girl. HIV scare: Nearly 200 new mothers are being tested for HIV after a medic who helped deliver their babies was found to have the virus. The women have been asked to undergo a fingerprick blood tests to see if they have been infected. They all had caesarean operations at Southend or Basildon hospitals in Essex and were in contact with the health worker at some stage in the last two years.
THE LAST WORD...
USA Today report: About three infants of every 1,000 delivered are injured during birth. Nearly 80% of the injuries might be preventable, DeVore says. Though some problems are minor, others can cause paralysis. Research shows most injuries stem from five central problems: failing to recognize when a baby is in distress; failing to perform a c-section in time; failing to properly resuscitate a baby; using drugs to induce labor inappropriately; and using a vacuum or forceps inappropriately, Premier says. EC VIEW Of the five 'central problems' associated with infant injuries (cited in this report), the majority occur during a planned vaginal delivery. |
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