Is Cesarean Section on Demand Justified?

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Is Cesarean Section on Demand Justified? Powered By Docstoc
					        Israel Family Practice
Cesarean Section On Maternal Request—
     Whose request is it anyhow?

             Michael C. Klein
  Centre Community Child Health Research
          Senior Scientist Emeritus
   Children and Family Research Institute
  Emeritus Professor of Family Practice and
       University of British Columbia
   Adjunct Professor of Family Medicine
    McGill University Faculty of Medicine
  What do these five
women have in common?
Besides being very rich and
“…So frequent these bad effects [of
labour] that I often wonder whether
nature did not deliberately intend
women to be used up in the process
of reproduction, in a matter analogous
to that of the salmon, which dies after
The public is demanding relief from the
 dangers to the childbearing woman.
 While we have decidedly improved
 maternal mortality and morbidity and
 have reduced fetal deaths somewhat,
 labor is still a painful and terrifying
 experience, still retains much
 morbidity that leaves permanent
 invalidism. The latter statement is
 also applicable to the child.”
“The prophylactic forceps operation is a
 technique with the defined purpose of
 relieving pain, supplementing and
 anticipating the efforts of nature, reducing
 hemorrhage and preventing and repairing
 damage. It is not a complete reversal of
 the watchful expectancy but I cannot deny
 that it interferes much with nature’s
 process. Were not the results I have
 achieved so gratifying, I myself would call
 it meddlesome midwifery. For unskilled
 hands, it is unjustifiable.” --DeLee 1920
Sultan 1993
   Elegant rectal ultrasound work
   showing collagen fiber disruption
   Vaginal childbirth damages the
   rectum and pelvic floor—even
   without symptoms
   Cesarean section does not
   Hence cesarean section--and
   why not on demand
  DeLee’s power and influence
    changed the paradigm
Childbirth became a disease
Obstetricians then had the tools and techniques
to gain control over childbirth
DeLee told the Chicago meeting in 1920 that if
obstetricians adopted these techniques they
would supplant incompetent midwives and
general practitioners and truly become childbirth
professionals—hard to resist!
The language of DeLee in 1920 has been
adopted in the new millennium to justify
Cesarean section on maternal request
  Al-Mufti 1997 survey of UK OB Consultants:

Showing that 33% of female and 10% of males
  would choose elective cxion for themselves or
  their partners
88% based on fear of perineal/pelvic floor damage
  and fear for their own sexual functioning

  But Scottish female consultant obstetricians
  don’t buy it. Virtually all opt for vaginal childbirth
  for themselves--even though they see the same
  diseases and consequences of childbirth. Very
  Interesting! What are they telling us?
Cesarean section on demand
is unethical---
FIGO 1999
It is ethically permissible to accede to
a request for an elective Cesarean
section from an informed woman—
 but it is also acceptable to refuse if
the surgeon feels it is not in the
woman’s interest.
  ----ACOG 2003
Cesarean section by choice acceptable
 alternative for some women and
 SOGC will be following ACOG
---CMAJ March 2004--Mary Hannah
SOGC March 2004: Vaginal birth remains the
 “preferred” approach and the “safest option for
 most women and carries with it less risk of
 complications in pregnancy and subsequent
 pregnancies than Cesarean births.”… The
 Society is concerned that a natural process
 would be transformed into a surgical
 process…The SOGC will continue to
 promote natural childbirth and make
 strong representation to have adequate
 resources available for women in labor
 and during childbirth in Canada.”
BC Women’s March 2004
 Placed a moratorium on Cesarean on
 demand while an interdisciplinary
 committee reviewed the literature,
 deliberated the issue and determined
 that preemptive Cesarean section
 results in increased risks for mother
 and fetus. That moratorium still
 stands today in 2007
Consequences of original Sultan research and
          ACOG now position?:
 Increased maternal demand for cesarean section without
 clear indications for mother or fetus
 British research in late 90s on early bowel and bladder
 outcomes changed the research and public landscape
 Pressure from some OB/GYN leaders to declare this to
 be a “civil rights” issue, even to equate it with “choice”, a
 very loaded term
 NIH Conference on Cesarean Section on “Maternal
 Rise of “no indication” cesarean sections in US and
 creative indications in Canada
Three lines of relevant research comparing
elective cesarean with planned vaginal birth:
  1. Classical surgical mortality/morbidity
  2. Newborn outcomes
  3. Pelvic floor issues
      Neglected are:
         -Value of vaginal birth—hard to
                measure: we measure what we
         -Spiritual and mastery/control issues
         -Physician convenience and
         inherent conflict of interest and
                truly informed consent remains
Research evidence: Pelvic floor
 Urinary Incontinence—many studies
 • Mostly only to 3 months postpartum and
   generally uncontrolled for prior UI
 • Population based studies show little
   difference or minimal benefit to Cxion
 • Even nuns have UI at the rate of 10-
 • Elective cxion vs cxion at various times
   in labor shows little difference in UI
Research evidence:
   Sexual outcomes—few studies of
      reasonable quality
   • BUT 3-6 months too early to compare a
     vaginal related outcome like sexual
     satisfaction after vaginal birth with a
     non-vaginal birth like cesarean
   • But no studies control for breast feeding--
     a low estrogen state
   • Nevertheless by 6 months the early
     postpartum slight benefits for cesarean
     section vs vaginal disappear
Research evidence:
 Surgical mortality/morbidity
 –Cesarean vs vaginal birth
  favoring vaginal birth
     6102 CS 1 extra thromboembolic event
     632 CS to prevent 1 transfusion
     37 CS 1 extra operative trauma
     159 CS 1 extra infection
     435 CS 1 extra case sepsis/DIC
     4330 CS 1 extra maternal death
Research evidence:
Surgical mortality/morbidity (2)
 – Cesarean vs vaginal birth favoring vaginal birth:
     156 CS 1 extra readmission
      444 CS 1 extra abruption
      489 CS 1 extra ectopic
      230 CS 1 extra placenta previa
      694 CS 1 extra invasive placenta
      2667 CS 1 extra hysterectomy
     Poorer outcomes in subsequent births for
     baby—increase stillbirth, prematurity and
     low birth weight
Research evidence:
    Newborn consequences that favor cesarean
    – Cesarean vs vaginal birth
        19,601 CS prevent 1 IVH

        7,549  CS prevent 1 subarachnoid
        10,613 CS prevent 1 neonatal convulsion
        5,666 CS prevent 1 newborn CNS depression
        22,641 CS prevent 1 subdural/intracranial bleed
        2,164 CS prevent 1 brachial plexus injury
Research evidence:
 Newborn consequences favoring vaginal birth
 Cesarean vs vaginal birth
     338 CS 1 extra severe feeding difficulty
      69 CS 1 extra respiratory problem
      80 CS 1 extra TTN
      129 CS 1 extra RDS
       247 CS 1 extra pneumonia
       162 CS 1 extra level III admission
      153 CS 1 extra 5 min Apgar less than 7
       317 CS 1 extra newborn on respirator >24
Problems with all these studies is that most have
difficulty separating elective from non-elective
cesarean sections
Ideal study would compare women planning
vaginal birth, regardless of outcome with those
planning elective non-indicated cesarean
sections. Does not exist! Except for new
Canadian study
An RCT impossible! What kind of woman would
not care what type birth she would have?
  Urinary and Sexual Outcomes in Vaginal vs
               Cesarean Birth
                     Michael C. Klein
                     Robert Gauthier
                   Janusz Kaczorowski
                     Sally Jorgensen,
            Maria Hubinette, Tabassum Firoz
             Centre Community Child Health
         Child and Family Research Institute and
        Department of Family Practice, University of
           British Columbia , McGill University,
          McMaster University, Bridgewater, NS
           Department of OB/GYN University of

JOGC 2005; 27 (4): 313-320
        Objectives our Study:
Determine if urinary incontinence (UI) is more
common 3 months PP among vaginal vs
cesarean births

Determine if the subjective sensation of bulging
is more common among vaginal vs cesarean

Determine if sexual difficulties are more common
3 months PP among vaginal vs cesarean births

Secondary analysis of all women who
were part of the only RCT of episiotomy in
North America—showed that episiotomy
caused the very problems it was supposed
to prevent
     This time not by intention to treat but
     according to various vaginal outcome
     cohorts vs cesarean section
       Subjects and Setting
N: 1044 women from The Montreal Episiotomy

Enrolled at 30-34 weeks – very “low risk”
– Studied antepartum, intrapartum, early and late
  postpartum and 3 months postpartum

Patients of 39 Obstetricians and Family
Practitioners practicing at three sites in Montreal
1990-91 (2/3rds at SJH)
    Population and Methods
But for purposes of this analysis, all
randomized and non-randomized women
were included
Data for 3 month questionnaires available for
999 women: 863 vaginal and 136 cesarean
births (95.7% follow-up rate)
79 to 81% of study women were breast
feeding, slightly more who had a vaginal
birth. Numbers too small for sub-analysis by
breast feeding
     Outcome Measures
        3 months PP
Urinary Incontinence (UI)
Subjective sensation of vaginal bulging
Sexual attractiveness
Time to resumption of sexual intercourse
Pain on sexual intercourse
Pain intensity if present or type of pain
Sexual satisfaction
  Demographics 999 women

Comparability for maternal age, weight,
weight gain, height, gestational age, birth
weight, education and social status--for the
three main outcome groups:
1. Intact/first/second degree tears
2. Episiotomy with or without extensions or
3. Cesarean section
          Are you currently having trouble with loss of
                   urine? (3 months) - YES
                                          p .221

                            Overall 162 or 16.3% had UI


                                                   25.9       29.5
                9.9        8.1
                Intact/     Epis/   C-xion          Intact/   Epis/   C-xion
                  1/2        Ext                      1/2      Ext
                          No Hx UI                            Hx UI
Are you currently having trouble with loss of
urine? (3 months postpartum) by Parity and
           by Two-way Analysis



                 p .003                 Caesarean

                 17.9         17.1 16
                 Primips      Multips

                    Unstratified by History of UI
          Stress Incontinence During First Three
                    Months Postpartum
            by Parity and by Two-way Analysis



                P <.001
                 34.5          38.2


                Primips        Multips

                        Unstratified by History of UI
Severe Urinary Incontinence at 3 months Postpartum
Women with any degree of UI (wears pad)
by Parity and by Two-way Analysis



                                  23.8 25
                        16 15.4

                       Primips    Multips

                       Unstratified by History of UI
Resumption of Sexual Intercourse
    by 3 months Postpartum

Very few women had resumed sexual
intercourse by 3 months
But among women of both parities:
 – Strong trend favoring resumption among
   those women who had a vaginal birth
 – OR 2.17 (CI 0.98-4.80) p .059
Desire for Sexual Intercourse at 3 months
Postpartum by Parity and by Two-way


                 46.2          44.4 44    Caesarean
            50          41.8

                 Primips       Multips

                        Unstratified by Prior Sexual
Sexual Dissatisfaction at 3 months
Postpartum by Parity and by Two-way
           100   p .003

                 70.1                 71.4


                 Primips        Multips

                        Unstratified by Prior Sexual
Frequency of Sexual Intercourse
at 3 months Postpartum by Parity and by
Two-way Analysis

                 66.8        61.4
                        62                 Vaginal

           50                              Caesarean

                 Primips     Multips

                        Unstratified by Prior Sexual
Pain on Sexual Intercourse
at 3 months Postpartum by Parity and by
Two-way Analysis


           50                                Caesarean

                 30.731.6   33.8

                                       0/5 women who had resumed
                 Primips    Multips

                     Unstratified by Prior Sexual
          If you are currently having trouble with loss
          of urine, is it severe enough to wear a pad?
          (3 months postpartum—three way analysis)

                                                     p .540


                  17.2          21.5         19

                Intact/1/2   Epis with or   C-xion
Are you currently having trouble with a feeling of
“bulging” or falling down in the vaginal area? (3
months postpartum—three way)


                                                     p .424


                   7.5           7.6         4.4
                Intact/1/2   Epis with or   C-xion
      Compared to before you were pregnant,
       how sexually attractive do you feel?
        (3 months postpartum—three way)

                                            p .256

          50      42.4                                42.2

                Intact/1/2      Epis with or         C-xion
                             without extensions
                     Sexual dissatisfaction?
                (3 months postpartum)—three way

          100                                    p .097

                    66.2              68.1


                  Intact/1/2   Epis with or without       C-xion

For each year education, 7% decrease in sexual satisfaction
      Pain and frequency of intercourse at
 3 months postpartum (mean scores—three way)

                  Intact/   Episiot/   Cxion    p
                   1o/2o     Exten
Frequency           2.3       2.2       2.3    .377
Pain on            1.7        1.9       1.6    .153
Are you experiencing pain or
discomfort during intercourse?
at 3 months--%YES
                              p <.001                p .012


           50      38.5                      40.7

                 Intact/1/2      Epis /Ext   Cxion            Intact
Urinary Incontinence (UI) structured review
literature using number needed to treat
Press, Klein et al BIRTH Sept 2007

     10.4 CS compared to VB to prevent one case of unspecified
     short-term UI
        - After removing instrumental births:
         11.6 CS to prevent one case of short-term UI

     109 CS to prevent one case of short-term urge

     14.6 CS compared to VB to prevent one case of short term
                Stress UI
   –    After removing instrumental births
        16 CS to prevent 1 case of short term Stress UI

   No difference for severe UI even short term by
   mode of delivery
      Fecal Incontinence

When we combined 13 studies of any
level of FI:
 CS compared to VB: to prevent one case of short
 term fecal incontinence need to do 32 CS
But after removing instrumental births
             NNT increased to 49 CS
Many more for long-term FI
          Sexual Dysfunction
11 CS compared to VB to prevent one case of
   short term sexual dysfunction
    After removing instrumental births 14 CS to prevent one case
    of short-term sexual dysfunction

10 CS compared to VB to prevent one case of
   short term sexual dissatisfaction
    No difference for sexual desire, frequency of intercourse, or
    sense of sexual attractiveness by mode of delivery

BUT, after 6 months postpartum, no sexual differences
 by mode of birth.
  Hospital-based research from Latin
Maternal/newborn Cesarean vs vaginal birth
        WHO study from all of Latin America
         Villar J et al Lancet 2006 and October 30 2007 BMJ
         97,095 births with CS rate of 33% in 120
          institutions in 8 countries found that
          hospitals with the highest CS rate had
          highest rates of maternal death and
          illness and highest rates of neonatal
          death and ICU admission.
        This study is being replicated for all of
        Canada under a WHO/CIHR grant
 Latin American Study in detail:

Maternal Severe Morbidity
   2x severe morbidity for elective
   CS vs. Vaginal Birth
       OR 2 (CI 1.6-2.5) for
       intrapartum CS
       Elective CS 2.3 (CI 1.7-3.1)
       X5 antibiotics CS vs. vaginal
 Latin American Study in detail:
Neonatal Morbidity/Mortality CS vs. Vaginal Birth
    Increased neonatal stay all CS OR 2.1
      (CI 1.8-2.6) CS
     Elective CS 1.9 (CI 1.6-2.3)

     Neonatal death OR 1.7 (CI 1.3-2.2) Intrapartum CS
     Elective CS OR 1.9 CI 1.5-2.6)
            3 per 1000 SVD
            6.1 per 1000 intrapartum CS
            8.0 per 1000 elective CS
  French study: Hospital-based maternal
                           outcomes CS vs.
     Deneux-Tharaux et al Obstet and Gynecol 2006;

     10,244 women: after adjustment for
     confounders and removal of women
     hospitalized before delivery, risk
     peripartum maternal death 3.6x higher
     after CS vs vaginal birth (mostly
     anaesthsia, infection & venous
Newborn consequences by mode of birth:
US data MacDorman et al BIRTH Sept 2006
Cesarean vs vaginal birth

      1998-2001 neonatal mortality vaginal vs.
     planned or elective CS—after controlling for
     indications for elective CS
     Based on 5,762,037 live births and 11,890
     deaths giving 0.62 neonatal deaths per 1000
     vaginal vs 1.77 per 1000 CS

     Employing Odds ratios--roughly twice the neonatal death
     rate for CS @1/1000 vaginal and 2/1000 CS, after
     controlling for CS indications
New US study maternal morbidity and
rehospitalization Cesarean vs vaginal birth
Declercq et al. in Obstetrics and Gynecology March 2007

      Rehospitalizations 19/1000 CS vs
      7.5/1000 vaginal
      Leading cause of rehospitalizations was
      wound infections/complications: CS 6.6
      vs : Vaginal 3.3/1000
  Best to data is Canadian!
New Canadian study of maternal
mortality and severe maternal morbidity
Elective cesarean vs planned vaginal birth
     First study truly planned vaginal birth vs. planned
     cesarean delivery (breech surrogate) Liu, Liston, Kramer
     et al CMAJ Feb 13, 2007 pgs 455-60
     46,766 elective breech vs. 2,292,420 planned
     After adjustment for confounders to make low
           risk in both groups:
             Planned CS had more cardiac arrests x5,
           hysterectomy x3.2, infection x3,
           thromboembolism x2.2, hemorrhage requiring
           hysterectomy x2.1, anesthetic complications
New Canadian data on neonatal
  outcomes by mode of birth
Nova Scotia all births 1988-2002 BMJ Fiona Liston
Archives Dis Child Fetal edition Oct 2007
142,971 births CS rate ~21% those years
CS mostly repeats (62%), breech (21%)
Adverse neonatal low at ~1% all comers
3x low 5 min Apgars but no difference ischemic
encephalopathy for CS with no labour (elective) vs.
spontaneous vaginal
CS 5.4x more likely to experience RDS and 2.4x more
TTN than newborns delivered spontaneously
NICU stays for newborn >24 hours greatest for CS
no matter if elective or in labour.
New Canadian data on neonatal outcomes by
         mode of birth (Liston cont)
Major neonatal trauma:
       SVD 3/1000
       Instrumental births 14/1000
       CS in labour 2/1000
       Elective CS 1/1000
       SVD 6/1000
       Elective CS 16/1000
NICU >24 hours:
       SVD 22/1000
       Instrumental 36/1000
       CS in labour 52/1000
       Elective CS 44/1000

Small problem may be the long duration of study from 1988 to
2002 leading to excess instrumental trauma and perhaps not
enough cesarean data from later years which would favor
cesarean outcomes from eras when less were done
 NIH Conference “Cesarean Delivery on Maternal
No data about maternal request: why a conference?
Inappropriate comparison groups (used Term-Breech as surrogate
for vaginal vertex births).
Failed to study subsequent pregnancies (previas, accretas,
abruptions, ectopics, infertility etc)
Employed large retrospective cohort studies of all births of
variable quality vs CS of higher quality
Did not compare best/physiologic birth practices with CS
Recommendations made no sense eg recommended no CS only
for women planning “several” births when data suggests “more than
Opened the door to CS on request—since not enough data on
vaginal vs CS in comparable groups—reason to accept CS on
Accepted pathological model of birth (birth is nothing more than
an opportunity for side effects or adverse outcomes)

 – No mention of powerful and transformative nature
   of vaginal birth
Inadvertently Term Breech Trial provided
natural experiment addressing both
maternal and newborn consequences of
mode of birth:
 While early for the newborn and at 3 months, the study
 showed urinary and sexual benefit to CS for breech
 compared with vaginal birth

 At 2 years postpartum NO DIFFERENCE baby or pelvic

 And vaginal breech birth harder on pelvic floor and
 perhaps baby

 Study demonstrates resilience and self-healing capacity
 of the pelvic floor and resilience of the newborn as well.
   Conclusion Pelvic Floor (1)
At 3 months PP, UI slightly less among women
with CS—but this is too early to measure this

Severe UI similar at 3 months PP for cxion and
vaginal births

At 3 months PP, sexual functioning is similar
among women with various vaginal outcomes
compared to cesarean section-- with the
exception of forceps births
Conclusion Pelvic Floor (2)
However, cesarean section as an
alternative to difficult forceps is
reasonable from point view of
sexual functioning. Other studies
also implicate forceps in UI and
suggest--Never too late for a
cesarean—don’t have to decide
in advance!!!!!!
                                      Changing Episiotomies per 100 Hospital Vaginal

Per 100 hospital vaginal deliveries

                                                                 55            55.4
                                      50                                       51.5
                                      40                                                                                                                                       39.2
                                                                                                                                                                27             25.4
                                                                                               Rectal Trauma Rates (3rd /4th
                                      10   4.2                        2.9                          degree tears) - USA                                               1.5









                                                                                                    Canada                    USA
Conclusion Pelvic Floor (3)
As the rate of intact perineum is rising and
rectal trauma rate is falling in current practice,
were the Montreal Episiotomy study repeated
today, we would expect even better outcomes
for vaginal birth vs CS than demonstrated by our
Optimal, physiologic birth rather than current
“industrialized” over-managed birth would also
be expected to enhance vaginal outcomes vs
CS (reduced closed glottis pushing, episiotomy,
physiological positions)
Conclusion (4) Newborn Outcomes by mode
of Birth
 There are slight short term benefits to the baby
 for delivery by elective CS in trauma reduction
 But this is at expense of longer NICU stays for
 RDS and TTN—with more parental separations
 And more placentation-related perinatal
 complications, even stillbirth in subsequent
 pregnancies for a policy of allowing, even
 encouraging CS on request.
Conclusion (5) Maternal Outcomes by mode
of Birth
 Elective CS is clearly more dangerous for
 the mother than planned vaginal birth
 Mothers are being placed in an impossible
     For marginal principally short-term benefits to the
     fetus in the first pregnancy and for high NNTs for
     benefits to her pelvic floor, she is being
     encouraged to expose herself to additional
     personal risks for herself in the present and for
     herself and her fetus in subsequent pregnancies.
 Some choice!
The precautionary principle of non-
 maleficence (first do no harm),
 requires that potentially harmful
 actions or routines in the
 “management” of vaginal birth be
 eliminated before recommending a
 potentially harmful intrusion like
 Cesarean on demand.

 e.g. unphysiological positions and
 pushing; unsupported labor; epidurals
 used routinely; routine episiotomy
What every pregnant woman needs to know
 about cesarean section. New York:
 Childbirth Connection, April 2004
Question: Is it possible that vaginal childbirth is
becoming an extreme sport? (      Modified from Vicki van Wagner)

  Midwives and family physicians will become
  ecotourist guides who will cater to those super-
  atheletes (read nuts), who will insist on subjecting
  themselves to obsolete and dangerous practices
  They will practice their arcane rites in secret, usually
  in rural and remote settings, with the back-to-the-
  landers and the end-of-the-worlders
  If caught, the caregivers will be have licenses
  removed, be prosecuted or burned at the stake,
  while the birthing women will be charged with child
  Sound absurd? Read, re-read Margaret Atwood’s “A
  Handmaid’s tale”
  What can we do? Education, research, analysis,
  critique, engage women in the struggle to get
  childbirth back on the women’s health agenda
   – Narratives???
Who cares?

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