I'm a first-year nursing student, and I just read an article in the Nov. issue of Vogue on a small but increasing number of women choosing to have elective c-sections for various reasons, including avoiding labor, and decreasing the likelihood of shoulder dystocia for the baby and eventual lady partsl prolapse for the mom.
Vogue doesn't publish their non-beauty/fashion articles online, so I can't provide a link for the whole text of the article. It does point out that, no matter which "ideology" you buy into, "there's only one standard that truly matters: a successful birth is a birth in which mother and child emerge alive and healthy."
I personally was floored that anyone would choose major abdominal surgery when it wasn't absolutely necessary.
Insurance companies will never go for the elective C section thing so I'll bet they will continue to be the exception. However docs can often manipulate the labor to cause a failure to progress and get a section so they get out at a decent hour. I read an article in Cosmo about a year ago that talked about normal vulvar changes after lady partsl deliveries as deformities (!) and a reason to go CS.Wouldn't want your honey to be turned off by an episiotomy scar:uhoh3:
Of course the docs are all for elective C-sections. Who wouldn't want to practice OB with the hours of a dermatologist? Problem is that they're looking out for their own interests, not their patients'.
Mount Sinai Hospital/University of Toronto, Canada
Guidelines vs. Practice
Over the last ten years there have been several recommendations that the cesarean section rate should be lower and set at a given rate. The recommended rates were often with the magic number of 15%. Such recommendations came from the WHO, Healthy People 2000 U.S. and the Ontario Minister of Health.
In contrast the cesarean section rates that increased about 40 years ago from about 5% to rates above 20% keep going up after a short period of decline in the late 80's to mid 90's. The cesarean section rate exceeds the recommended rate of 15% in most countries. In Canada and the U.S. it was 22% in 1999. In the UK - 19% and in Australia (1997) 18 - 23%. In South America it is much higher (Brazil - 27%, Mexico - 24%, Columbia - 33%, Chile - 40%) and these figures would be even higher if only private deliveries are counted. (Belizan 1999)
There are a multitude of reasons for this temporal trend. Some of the reasons include:
The safety of cesarean delivery. There is a series of more than 10,000 consecutive cesarean sections without a single death (Frigoletto 1980). In a review of 1,000,000 births and 100,000 cesarean deliveries Rosen (1981) found that the maternal death was 9.8/100,00 deliveries for lady partsl deliveries, 40.0 for all cesarean deliveries and 18.4 for repeat cesareans. This is contrast to the documented relatively small but significant risk of instrumental deliveries - especially the mid cavity ones.
The reduced risk for the fetus.. In the setting of trial of labor after VBAC the meta-analysis on 31 studies (n=1,417) performed by Rosen et al (1991) found that the perinatal mortality was x 2.1 (CI 1.3-3.4) in the trial of labor arm.
Avoiding damage to the pelvic floor
Convenience to obstetrician in terms of timing and duration of delivery
Accommodating the concerns and wishes of the patients.
It is quite clear that an uncomplicated lady partsl delivery is much more desirable than a cesarean delivery provided both the maternal and neonatal outcomes are favorable. Unfortunately our ability to predict either CPD or fetal distress in labor is quite limited.
The risks of cesarean delivery include:
Immediate
Risks of anesthesia
Blood loss
Bowel or bladder injury
Amniotic or air embolism
Scalpel damage to the baby -1 - 2% (Smith 1997)
Post operative risks
Infection
Bleeding
Neonatal RDS/Wet lung
Risks in subsequent pregnancy
Placenta previa and/or accreta in subsequent pregnancy
Rupture of a uterine scar in subsequent pregnancy
Risk for recurrent C/S
Remote risks:
Infertility due to adhesions
Bowel obstruction
Risks of lady partsl delivery:
These risks include:
The risk of severe morbidity or mortality of the neonate (as outlined above)
The possible damage to the perineal floor and subsequent urinary or fecal incontinence (Suliman 1993)
Concerns over pain and stress of labor
These risks were discussed in the paper by Dr. Fisk in the 1st International Conference on Controversies in Ob/Gyn in Prague 1999.
New Indications for C/S:
There are several new or expended indications for cesarean delivery:
Breech (already 12% of all C/S) - The term breech trial documented in a properly designed and conducted RCT that it is safer to choose abdominal delivery over lady partsl delivery in a singleton breech presentation at term. The data is outlined by Dr. Hannah in this symposium.
Vertical transmission of HIV - A recent meta-analysis demonstrated that an elective cesarean delivery with specific techniques aimed at reducing the exposure of the fetus to maternal blood intra-peratively resulted in a reduction of vertical transmission by 50 - 87% (NEJM 340:977, 1999).
Patient request (Paterson Brown 1998) - There seemed to be a debate of cesarean delivery without obvious medical indication that is based mainly on the wishes of the patient. Although this indication is not accepted by many obstetricians it has become a standard practice - although it contributes to a very small number of cesarean deliveries. Dr. Fisk reviews this topic in depth elsewhere in this book.
Indications for C/S:
The numbers used below were derived from U.S. data but they are quite similar in several series in the last 20 years.
Repeat - 35%
Dystocia/CPD - 30%
Breech - 12%
Non reassuring FHR - 9%
MMWR 1995:44:303
Factors effecting VBAC or repeat cesarean section rates:
There is a multitude of reasons that effect the selection of the mode of delivery. These include:
The safety of the selected mode
The impact of adverse outcome on the mother and baby
The setting of the practice in terms of the ability to mount an immediate cesarean delivery and management of complications
Medicolegal concerns
The time element - there are several different elements relating to time. These include:
Education - In order to select a VBAC there is a need for proper education of the patient and a partner. This requires usually more than one session especially in a patient with previous poor outcome or strong bias. In the absence of institutional, educational and support programs this may be quite time consuming
A cesarean delivery is planned for convenient times to all parties
Caesarean delivery takes less time than labour
Aside from its duration, labour is often at inconvenient time periods (e.g. nights)
Cost - This is a complex and interesting issue. The cost is usually neither to the patient or the physician but to a third party. Attempts to regulate costs by these parties using legislation or administrative directives were proven often to be non-rewarding.
There is a more fundamental issues and they relate to how these costs were calculated. These costs in any analysis never included any of the effects of the subsequent pregnancy or the long-term effect. These calculations do not take into account the cost of litigation. The frequency of successful medico-legal cases is low but the cost is millions of dollars that may offset the gain from hundreds or thousand of deliveries. Furthermore, the trend for shorter post-partum stay altered the basis for these calculations as well. The lengths of stay following lady partsl delivery is often 1 - 2 days while that following cesarean delivery is 3 - 4 days. However, most of the stay following elective cesarean section is on the post- partum ward (except for the few hours spent in preparation for surgery, intra-op and post-op) while normal delivery entails an additional day on the labor floor with its high intensity costs (the cost was suggested to be $5,000/24 hours). In addition, emergency cesarean deliveries are associated with higher risk for complications and prolonged stay. Another element that is never considered in such analysis is the costs for the extended family that is more often than not present peripartum. Therefore, an argument could be made for elective cesarean deliveries on the basis of immediate costs. Once again not including long term effects (that negates this argument) will be flawed.
New medical data that is relevant to selection of VBAC:
Time from previous C/S:
In a retrospective (n=2,409) study of VBAC vs. TOL it was found that uterine rupture
occurred in 1.05% of TOL if the interval was more than 18 months from the last
delivery. In contrast, a shorter interval (
2.25%
(Shipp 2001)
How was the uterus closed:
It is well known that the risk of a vertical incision to rupture is significantly increased to the rate of about 5%. The risk of ante-partum rupture is even further increased. A recent study performed in Montreal looked at the effect of the number of layers of uterine closure and the risk of rupture in subsequent pregnancy. This was a retrospective study (n=1649) performed during 1990-2000 in St. Justine Hospital. The risk of uterine rupture was 0.6% if the uterus was closed in 2 layers. In contrast - 1 layer closure was linked to a 3.3% risk of uterine rupture in a subsequent pregnancy
(Bujold 2001)
3. VBAC and obesity:
In a recent presentation in the SMFM Davis et al (2001) looked at obese patients (>100 kg) and their outcome in a subsequent delivery after a cesarean birth.
This data suggests that in the "extremely Rubenesque" patient an elective repeat cesarean may be indicated.
4. VBAC- Should we induce?
Lydon-Rochelle et al. (2001) found, in a recent population based retrospective study (n=20,095) looking at data from 1987-1996, that the risk for coded uterine rupture was as follows:
Elective C/S - 0.16%
Spont. Labor - 0.52%
Induction - 0.77%
PG induction - 2.45%
This data and other suggest that induction in labour in general and especially with prostaglandins may be associated with an increased risk of uterine rupture. The major flaw with this particular study is that the code for uterine rupture was probably used not only for rupture and dehiscence but also for extensions of the incisions. However, there are several other series documenting a risk of uterine rupture for up to 3%.
5. VBAC - role of ultrasound:
A prospective blinded (n = 642) study of ultrasound assessment of the thickness of the lower uterine segment at or close to term (gestational age: 36 - 38 weeks) in women with previous cesarean deliveries. The study found that the thickness of the lower segment was inversely related to the risk of dehiscence. A thickness of 3.5 mm was found to be the cut-off point with a Sens. 88% Spec.73% +pv 11.8% -pv 99.3%. (Rozenberg 1996)
The following relationship was found:
ThicknessSubsequent rupture
>4.5 (n=278) - 0%
3.6-4.5 (n=177) - 2%
2.6-3.5 (n=136) - 10%
This approach was shown later to improve selection and outcome of VBAC (Rozenberg 1999)
6. Neonatal intracranial injury and mode of delivery
A large cohort study looked at California data from 1992-1994 (n=583,340). The risk for intra cranial hemorrhage (ICH) in the newborn was correlated to the mode of delivery (Towner 1999). The findings included:
Vacuum 1:860
forceps 1:664
CS in labor 1:907
CS no labor - 1:2750
SVD - 1:1900
This data that is quite limited by its retrospective nature suggested that labor per se does increase the risk for ICH as the risks for instrumental deliveries and cesarean delivery with labor were significantly higher then either spontaneous delivery or elective cesarean section
Regardless of how we all feel about c-sections over lady partsl deliveries...the main point is that this is the mothers choice. Not anyone elses. I also read the article in Vogue. The doctors interviewed said that today- women are getting more information and they are more prepared for what will happen after the surgery. If they still want to go that route, by all means let them.
I get annoyed by all the "I'm better than you..I had my baby naturally...I had my baby lady partslly....Can't you take pain?...." bullcrap. After that child comes into this world it no longer matters, it's like some women are more focused on pregnancy than actual parenthood.
Dreamon, I totally agree that labor is not the end all and be all of life, and having a baby by c-section does not mean any woman is inferior to another. But, in an absolute sense, this is not just the woman's choice. We don't generally do unecessary surgery on people without a medical reason, because this is not burger king. I am sure that eventually the "customer"'s desires will completely eclipse the medical staff's professional judgement, but it hasn't happened here yet.
I strongly agree that women should have the right to choose what they want. Epidural , no epidural, pain meds, music playing, lights on or off, eat the placenta don't eat it, feed it to the cat... etc..
BUT all these choices (with the exception of pain meds)we support for our patients are things that they do them selves. Surgery is not something that they do them selves it is something Doctors and nurses do to them. So thats a big difference. Pain meds while we do take active part in giving them we would never knowingly give a med that posed more then a minimal risk to mom or baby.
Dreamon I have to disagree with you. It's not just people saying that they are better because they experienced natural child birth.
Saying that elective c/s is an alternative to lady partsl delivery is like saying that walking in the middle of traffic is an alternative to walking on the sidewalk. When you do that you trade one set of risks for another.The risks of C/S are scarier then those of most deliveries just as walking in traffic is scarier then on the sidewalk.
The only time C/S should be considered is when complications bring the possible risks of vag delivery up to or above the risks of C/S.
I think there are allot of factors contributing to this idea that C/S is better then vag delivery.
1. people want to plan the day they will go to the hospital. allot of patients tell me that their employers hassle them about maternity leave. So for some this would make that a bit easier. however I think the employer should just stuff it, I mean people shouldn't have to worry so much about their jobs.
2. With all the elective surgery we do ie. nose jobs, liposuction, hair transplants etc. the public has started to see medical procedures as fast food drivethrews. On one hand its nice that these things can be done for people but on another its kinda scary to think how flippantly people consent to going under a knife.
3. The least of which is not, All the horror stories people tell about there delivery. For some reason there is a group of people out there that likes to scare the hell out of 1st timers. Some people come in so scared and they think that a c/s will avoid all this pain there friends have told them about.
I find the whole thought erie in an Outer Limits/ Twilight zone kind of way. Imagine a world where all children are born in the OR, surgically extracted threw holes in there mothers. Weird...
After that child comes into this world it no longer matters, it's like some women are more focused on pregnancy than actual parenthood.
But it does matter. Maybe not to you, but to many mothers who's birth experiences did not pan out as they desired. There are many women who have "birth trauma", not neccesarily because they had traumatic deliveries, because it just wasn't what they had planned for. Birth is not just a medical event, it is an emotional one. A woman will never, ever be able to experience that birth of that child again, and if she has a hard time coming to terms with the way things went, we need to respect that. Mothers may be overjoyed with their healthy babies, but it doesn't automatically mean they were satisified with their birth experience. I think if you cannot recognize that birth is an emotional roller coaster, and that the means to the end does matter, you should rethink your part in the birth experience.
And Dayray, I totally agree with your reply. And I especially appreciate the analogy about walking down the middle of the street.
But it does matter. Maybe not to you, but to many mothers who's birth experiences did not pan out as they desired. There are many women who have "birth trauma", not neccesarily because they had traumatic deliveries, because it just wasn't what they had planned for. Birth is not just a medical event, it is an emotional one. A woman will never, ever be able to experience that birth of that child again, and if she has a hard time coming to terms with the way things went, we need to respect that. Mothers may be overjoyed with their healthy babies, but it doesn't automatically mean they were satisified with their birth experience. I think if you cannot recognize that birth is an emotional roller coaster, and that the means to the end does matter, you should rethink your part in the birth experience.
And Dayray, I totally agree with your reply. And I especially appreciate the analogy about walking down the middle of the street.
:)
In the middle of my 5th month, my water broke- I had to be flown to a hospital almost 3 hours away from my husband and friends. I was on bedrest in that hospital for a month before my daughter was born. She was 1 pound 15 ounces. I was alone in that delivery room- with no one I knew or recognized- depressed that I had to be alone day after day in that hospital room. The nurses asking me why I didn't want my blinds pulled up or why I didn't have any visitors. When i pushed my daughter out, I didn't even get to hold her or see her..... until six hours later.
So I think it is safe to say that I had a VERY emotional and unsatisfying birth experience. But I still stand by my statement.
So I think it is safe to say that I had a VERY emotional and unsatisfying birth experience. But I still stand by my statement.
I am sorry that you had to go through such an experience w/o the support of someone close to you. I think that when birth is an emergency, babies have special needs, and/or spend time in the NICU, then the birth experience is not the most significant part to those parents.
However, when babies are healthy and the only thing "traumatic" is the labor and delivery, then Moms do carry birth "baggage". I have seen it over and over. Moms disappointed with their experience, even though they ended up with a "healthy Mom and babe", which is what is always said to be most important. I'm just saying many Moms focus on the means to the end, regardless of the end.
fourbirds4me
347 Posts
Although I haven't been able to find one, our chief OB was talking about an ACOG positions statement along the lines of supporting elective section.
Personally I think it's nuts and how in the world have women started thinking that major surgery is easier than the labor process. ugghhhhhhh