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Cesarean delivery on maternal request


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Cesarean delivery on maternal request

  1. 1. Lisa Hanson, PhD, CNM, FACNM Associate Professor Marquette University Milwaukee, Wi Senior Staff Midwife Aurora Midwifery and Wellness Center Milwaukee, WI
  2. 2. However, the rising cesarean rate has not improved perinatal morbidity and mortality
  3. 5. <ul><li>A primary elective cesarean birth </li></ul><ul><li>“ MEDICALLY ELECTIVE CESAREAN” (Menacker etal 2006) </li></ul><ul><ul><li>Cesarean performed without medical or obstetric indication as well as CDMR </li></ul></ul>
  4. 6. <ul><li>1-18% of all C-S worldwide </li></ul><ul><li>1-3 % of C-S in the U.S. </li></ul><ul><ul><li>Childbirth Connection survey showed rate of </li></ul></ul><ul><ul><ul><li>< 0.08% CDMR . </li></ul></ul></ul><ul><li>Hospital discharge codes and birth certificate may not reflect if the C-S was by maternal request (Norwitz, 2010) </li></ul><ul><li>>50% of Physicians have either provided CDMR or would be willing to (Miesnik, 2007) </li></ul><ul><li>Appears to be a direct relationship between CDMR and maternal affluence </li></ul>
  5. 8. <ul><li>Mixed method UK study (Weaver etal 2007) </li></ul><ul><ul><li>Women and Obstetricians ( directly and not directly involved ) surveyed and interviewed concerning CDMR </li></ul></ul><ul><li>408 women indicated on a written form that they had participated in decisions about a C-S </li></ul><ul><ul><li>44 were interviewed </li></ul></ul><ul><ul><li>The woman universally viewed the request for C-S as having a clinical or psychological indication </li></ul></ul><ul><ul><ul><li>“ Perception of Risk” </li></ul></ul></ul><ul><ul><ul><ul><li>Fear for themselves or the baby were major factors self-identified </li></ul></ul></ul></ul><ul><li>The obstetricians reported few actual CDMR but viewed it as the major factor in the rising C-S rate. </li></ul>
  6. 9. <ul><li>“ Premium pregnancy” </li></ul><ul><li>“ Protection of the pelvic floor” </li></ul>
  7. 10. <ul><ul><li>Too Posh to Push ? </li></ul></ul><ul><ul><li>“ Some have accused stars such as Victoria “Posh Spice” Beckham, Claudia Schiffer, Elizabeth Hurley and Madonna of endangering their babies for vanity by choosing early C-sections over old-fashioned childbirth in order to avoid </li></ul></ul><ul><ul><li>abdominal stretching .” </li></ul></ul><ul><ul><li>[Friday, June 06, 2003,Jennifer D'Angelo Fox News] </li></ul></ul>History?
  8. 11. <ul><li>Planned timing of birth: known endpoint </li></ul><ul><li>Avoidance of labor </li></ul><ul><li>Reduced: </li></ul><ul><ul><li>Postterm pregnancy </li></ul></ul><ul><ul><li>Risk of postpartum hemorrhage </li></ul></ul><ul><ul><li>Risk related to emergency c-s </li></ul></ul><ul><ul><li>Risk of still birth </li></ul></ul><ul><ul><li>Nonrespiratory neonatal morbidity </li></ul></ul><ul><ul><li>Pelvic floor injury </li></ul></ul>
  9. 12. <ul><li>Critique of the Benefits </li></ul>
  10. 13. <ul><li>No studies of CDMR that compare risks and benefits to planned vaginal birth </li></ul><ul><ul><li>Not feasible </li></ul></ul><ul><li>Therefore, studies of planned C-S for Breech are used for comparisons </li></ul>
  11. 14. <ul><li>POINT </li></ul><ul><li>Fear of labor pain </li></ul><ul><ul><li>“ Tocophobia : an unreasoning dread of childbirth” (Hofberg & Brockington, 2000) </li></ul></ul><ul><ul><ul><li>Prior traumatic birth experiences </li></ul></ul></ul><ul><ul><ul><li>Fear of losing control </li></ul></ul></ul><ul><ul><ul><li>Abuse history </li></ul></ul></ul><ul><li>Fear of pain during labor and birth as rationale for CDMR </li></ul><ul><ul><ul><li>36% of 28 Swedish women (Ryding, 1993) </li></ul></ul></ul><ul><ul><ul><li>44% of 100 Finish women (Sjögren, 1997) </li></ul></ul></ul><ul><li>COUNTERPOINT </li></ul><ul><li>Pain scores post C-S and NSVD were similar in the Breech RCT(Hannah et al 2002) </li></ul>
  12. 15. <ul><li>Listening to Mothers Survey II (2007) (Declercq, etal 2008) </li></ul><ul><ul><li>1,573 women (200 phone, 1,373 online surveys)who experienced hospital birth in 2005 </li></ul></ul><ul><ul><li>32% of the sample gave birth by c-s (16% primary/16% repeat) </li></ul></ul><ul><ul><ul><li>79% experienced incisional pain for 2 months postpartum </li></ul></ul></ul><ul><ul><ul><ul><li>33% described this as a major problem </li></ul></ul></ul></ul><ul><ul><ul><ul><li>18% reporting pain persisting 6 mo postpartum </li></ul></ul></ul></ul><ul><ul><ul><li>19% reported incisional infection </li></ul></ul></ul><ul><ul><li>68% Vaginal birth (6% operative assisted) </li></ul></ul><ul><ul><ul><li>Perineal pain was a major problem for 23.6% (no epis)/32.9% (epis) of primeps and 5.1%(no epis)/17.9% (epis) multips </li></ul></ul></ul><ul><ul><ul><li>Only 1% of women with NSVD reported any pain that persisted for 6 months </li></ul></ul></ul><ul><ul><ul><li>Pain was significantly associated with episiotomy and assisted vaginal birth </li></ul></ul></ul><ul><ul><ul><ul><li>17% of this subgroup reported pain persisting for 6 months </li></ul></ul></ul></ul>
  13. 16. <ul><li>POINT </li></ul><ul><li>Elective C-S done between 39-40 weeks </li></ul><ul><ul><li>Avoids morbidity and mortality related to postterm pregnancy (Norwitz, 2010) </li></ul></ul><ul><li>COUNTERPOINT </li></ul><ul><li>IOL may be a reasonable alternative (Norwitz, 2010) </li></ul><ul><li>Careful assessment and monitoring of pregnancies beyond 41 weeks </li></ul><ul><li>Realistic expectations of pregnancy duration </li></ul><ul><ul><li>40 is not “the new 42” weeks gestation </li></ul></ul>
  14. 17. <ul><li>POINT </li></ul><ul><li>Lower risk of hemorrhage with planned C-S versus planned vaginal and emergency C-S (AHRQ, 2007) </li></ul><ul><ul><li>Uterine atony reduced in planned C-S (Norwitz, 2010) </li></ul></ul><ul><li>COUNTERPOINT </li></ul><ul><li>Expected blood loss post C-S is >500cc </li></ul><ul><ul><li>1000 (Miesnik et al 2007) </li></ul></ul>
  15. 18. <ul><li>POINT </li></ul><ul><li>Emergency C-S associated with (Norwitz, 2010) : </li></ul><ul><ul><li>Infection </li></ul></ul><ul><ul><li>Injury to the fetus </li></ul></ul><ul><ul><li>Injury to abdominal organs </li></ul></ul><ul><ul><li>Hemorrhage </li></ul></ul><ul><ul><li>Anesthesia complications </li></ul></ul><ul><li>COUNTERPOINT </li></ul><ul><li>Avoiding surgery avoids surgical risks </li></ul><ul><li>Lowering the overall C-S rate would lower the rate of all C-S related complications </li></ul>
  16. 19. <ul><ul><li>POINT </li></ul></ul><ul><ul><li>Prophylactic c-s may save those babies who would otherwise succumb to perinatal disasters (Norwitz, 2010) </li></ul></ul><ul><ul><li>Risk of mature fetus experiencing a catastrophic neurologic event or perinatal death 1/500 to 1/1750 </li></ul></ul><ul><ul><li>Risk of intrapartum fetal death is 1 in 5000 </li></ul></ul><ul><ul><li>COUNTERPOINT </li></ul></ul><ul><ul><li>It would take 1000 elective C-S to prevent one stillbirth (Norwitz, 2010) </li></ul></ul>
  17. 20. <ul><li>POINT </li></ul><ul><li>C-S avoids vaginal birth related morbidity and mortality </li></ul><ul><ul><li>Shoulder dystocia related traumatic injury </li></ul></ul><ul><ul><li>Bone fractures (eg. Clavical) </li></ul></ul><ul><ul><li>Intrapartum asyphxia </li></ul></ul><ul><ul><li>Vertical transmission of some infectious diseases (eg. HIV) </li></ul></ul><ul><li>COUNTERPOINT </li></ul><ul><li>Passive immunity and neonatal immunization protects the fetus from some infections </li></ul><ul><li>C-S has not been proven to protect against HPV and Hep C </li></ul>
  18. 21. <ul><li>POINT </li></ul><ul><li>Short term urinary incontinence C-S<Vaginal birth </li></ul><ul><li>Term Breech Trial (Hannah et al 2002) </li></ul><ul><li>3 mo post C-S (4.5% relative risk 0.62; 95% CI, 0.41-.93) </li></ul><ul><li>compared with planned vaginal delivery (7.3%) </li></ul><ul><li>Systematic review (Press etal 2007) </li></ul><ul><li>C-S reduced postpartum stress incontinence from 16 to 9.8% (OR=0.56[0.45, 0.68] </li></ul><ul><li>COUNTERPOINT </li></ul><ul><ul><li>Short term severe symptoms were equivalent between NSVD and C-S (Press etal 2007) </li></ul></ul><ul><li>Urinary incontinence rates are not significantly different between elective C-S and NSVD at 2 and 5 years (Hannah etal, 2004; McMahon etal 1996) </li></ul><ul><li>C-S does not appear to be protective against fecal incontinence (Hannah etal, 2004; McMahon etal 1996) </li></ul><ul><li>Evidence-based second stage management would improve pelvic floor outcomes </li></ul>
  19. 22. <ul><li>Critique of the Risks </li></ul>
  20. 23. <ul><li>Increased Morbidity </li></ul><ul><ul><li>27.3/1000 compared to vaginal delivery 9/1000 (OR 3.1, 95% CI 3.0-3.3) (Liu et al 2007) </li></ul></ul><ul><ul><ul><li>Cardiac arrest (OR 5.1) </li></ul></ul></ul><ul><ul><ul><li>Hematoma (OR 5.1) </li></ul></ul></ul><ul><ul><ul><li>Hysterectomy (OR 3.2) </li></ul></ul></ul><ul><ul><ul><li>Major infection (OR 3.0) </li></ul></ul></ul><ul><ul><ul><li>Severe hemorrhage with hysterectomy (OR 2.1) </li></ul></ul></ul><ul><ul><li>Longer hospital stays </li></ul></ul><ul><ul><li>Hospital readmissions </li></ul></ul><ul><ul><li>Bowl obstruction </li></ul></ul><ul><ul><li>Acute and chronic pain </li></ul></ul>
  21. 24. <ul><li>Decrease fertility (Goer 2001) </li></ul><ul><li>Increased miscarriage </li></ul><ul><ul><li>25% increased risk (Hemminki & Merilanen, 1996) </li></ul></ul><ul><li>Increased placental abruption (Hemminki & Merilanen, 1996) </li></ul><ul><li>Risk of uterine rupture in subsequent pregnancy </li></ul><ul><li>Increased placenta previa </li></ul>
  22. 25. Note: General population incidences; Previa 1/200 births; Acreta 1/500 births. Adapted from Silver etal OB/GYN 2006; 107:1226 # C-S Previa % Acreta % Acreta in patients with previa% 2 1.33 0.31 11 3 1.14 0.57 40 4 2.27 2.13 61 5 2.33 2.33 67 6 or more 3.37 6.74 67
  23. 26. <ul><li>POINT </li></ul><ul><li>Women’s choice and autonomy in decision-making should take precedence </li></ul><ul><li>COUNTERPOINT </li></ul><ul><li>“ The issues are more complex the words “choice” or “request”” because “Informed consent” may be biased (Bewley &Cockburn, 2002) </li></ul><ul><li>No studies have systematically examined the information provided to inform consent (Gamble, 2007) </li></ul><ul><ul><li>Research that does not consider the manner of consent including the power imbalance between women and their providers should be interpreted with caution (Gamble, 2007) </li></ul></ul><ul><li>Evidence is lacking to support equivalent safety </li></ul><ul><ul><li>Some argue that if the risks/benefits of CDMR and vaginal birth were truly equal then all women should be counseled for both as viable options (Bewley &Cockburn, 2002) </li></ul></ul>
  24. 27. <ul><li>Random sample 1,500 Norwegian general public/women, 1500 physicians and 423 surgeons; survey asking if their own children were born by C-S (Finsen, Storeheier, & Aasland, 2008) </li></ul><ul><ul><li>78% response rate </li></ul></ul><ul><ul><li>C-S rate: </li></ul></ul><ul><ul><ul><li>Women in general public12% </li></ul></ul></ul><ul><ul><ul><li>Physicians 19% </li></ul></ul></ul><ul><ul><ul><ul><li>Surgeons 26% </li></ul></ul></ul></ul><ul><ul><ul><ul><li>OB/Gyns 27% </li></ul></ul></ul></ul><ul><ul><li>The authors concluded that the rate of C-S in the general public is unlikely to fall if the rate of C-S among physicians remains high </li></ul></ul>
  25. 28. <ul><li>Iatrogenic prematurity </li></ul><ul><li>Accidental surgical wound </li></ul><ul><li>Increased risk of respiratory distress </li></ul><ul><ul><li>6.7X that of vaginal delivery (MacDorman etal 2006) </li></ul></ul><ul><li>Difficulty initiating breastfeeding </li></ul><ul><ul><li>Separation of the mother and baby </li></ul></ul><ul><li>Increased risk of childhood asthma </li></ul>
  26. 29. <ul><li>Retrospective cohort study of 672 women with one prior </li></ul><ul><ul><li>C-S were grouped by intention of birth mode (VBAC/C-S) </li></ul></ul><ul><ul><li>Compared with NSVD, infants born after elective C-S have significantly higher rates of respiratory illness and longer hospital stays (Level II evidence) (Kamath etal 2009) </li></ul></ul><ul><li>Timing of elective C-S linked to adverse outcomes (Tita etal 2009): </li></ul><ul><li>Retrospective cohort analysis of 24,077 repeat cesareans at term. </li></ul><ul><ul><li>13,258 performed electively </li></ul></ul><ul><ul><ul><li>35.8 before 39 weeks gestation. </li></ul></ul></ul><ul><li>Rates of respiratory morbidity, mechanical ventilation, sepsis, hypoglycemia, NICU admissions and hospital stay >5 days or more were increased: </li></ul><ul><ul><li>37 weeks 1.8-4.2 X more </li></ul></ul><ul><ul><li>38 weeks 1.3-2.1 X more </li></ul></ul>
  27. 30. <ul><ul><li>Retrospective cohort study of 672 women ≥37 weeks gestation with one prior C-S were grouped by intention of birth mode (VBAC vs.C-S) </li></ul></ul><ul><ul><ul><li>CONCLUSION: </li></ul></ul></ul><ul><ul><ul><li>Compared with NSVD, infants born after elective C-S have significantly higher rates of respiratory illness and longer hospital stays </li></ul></ul></ul><ul><ul><ul><li>(Level II evidence) (Kamath etal 2009) </li></ul></ul></ul>Mode of Birth NICU Admissions Supplemental oxygen for resuscitation Supplemental oxygen after NICU admission C-S 9.3% 41.5% 5.8% VBAC+ 4.9% 23.2% 2.4% Significance p=0.25 p<.01 p<0.28
  28. 31. <ul><li>No evidence: </li></ul><ul><ul><li>to support the safety of CDMR over NSVD </li></ul></ul><ul><ul><li>that CDMR will prevent urinary or fecal incontinence later in life </li></ul></ul><ul><li>No national databank that links subsequent complications to the original surgical procedure. </li></ul><ul><li>Need more information about fear and informed consent process used in decision-making </li></ul>
  29. 32. <ul><li>In March 2006 the United States National Institutes of Health held a conference discussing the scientific basis for maternal and fetal risks and benefits to a cesarean on request. </li></ul><ul><ul><li>High quality evidence was lacking to inform the discussion (Weber, 2007) </li></ul></ul><ul><ul><li>“ Moderate quality evidence” </li></ul></ul><ul><ul><ul><li>Reduction in PPH favored C-S </li></ul></ul></ul><ul><ul><ul><li>Reduction in length of hospital stay favored vaginal birth </li></ul></ul></ul><ul><ul><ul><li>Reduction in neonatal respiratory morbidity favored vaginal birth </li></ul></ul></ul><ul><li>The findings of the conference were: </li></ul><ul><li>“ The available information comparing the risks and benefits of Cesarean delivery on maternal request (CDMR) versus planned vaginal birth (VB) does not provide a basis for a recommendation in either direction”. </li></ul><ul><li>“ Women who plan several children should be advised against CDMR because of the increased risks of Placenta Previa, Placeta Acreta, decreased fertility, still birth, and uterine rupture in future pregnancies.” (Catalinotto, 2007) </li></ul>
  30. 33. <ul><li>The International Federation of Gynecology and Obstetrics found that CDMR is unethical </li></ul><ul><li>American College of Obstetricians and Gynecologists supported informed consent . ACOG also believes that an obstetrician should not perform the procedure if they do not feel it is in the patient’s best interest. </li></ul><ul><li>The Society of Obstetricians and Gynecologists of Canada supports vaginal birth as the preferred method of delivery. </li></ul>
  31. 34. <ul><li>“ Maternal request for cesarean delivery is a surgical indication that is not clearly defined and is probably a result of inadequate information or misrepresentation of the options available, and in some cases, is the result from coercion based on the preferences of the providers and institutions that find spontaneous vaginal delivery a major inconvenience .” </li></ul><ul><li>[Katherine Camacho Carr, CNM, PhD, FACNM,president of the American College of Nurse-Midwives (ACNM), at a media briefing on March 20th in Washington, D.C. March 21, 2006] </li></ul>
  32. 35. <ul><li>THE ACNM REDUCE CAMPAIGN: “RESEARCH AND EDUCATION TO DECREASE UNNECESSARY CESAREAN SECTIONS” </li></ul>“ There is no convincing evidence to endorse…’ primary elective cesarean’ and there is concern for harm… [ACNM] therefore, identifies vaginal birth as the optimal mode of birth for women who do not have a health indication for cesarean section.”