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Edmonton May 7 th 2011 Cesarean Section On Maternal Request— Whose request is it anyhow?

Edmonton May 7 th 2011 Cesarean Section On Maternal Request— Whose request is it anyhow?. Michael C. Klein Centre Community Child Health Research Senior Scientist Emeritus: BC Research Institute for Children’s and Women’s Health Emeritus Professor of Family Practice and Pediatrics

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Edmonton May 7 th 2011 Cesarean Section On Maternal Request— Whose request is it anyhow?

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  1. Edmonton May 7th 2011Cesarean Section On Maternal Request—Whose request is it anyhow? Michael C. Klein Centre Community Child Health Research Senior Scientist Emeritus: BC Research Institute for Children’s and Women’s Health Emeritus Professor of Family Practice and Pediatrics University of British Columbia Adjunct Professor of Family Medicine McGill University Faculty of Medicine

  2. What do these five women have in common? • Besides being very rich and beautiful?

  3. “…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 spawning.”

  4. 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.”

  5. “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

  6. Sultan 1993 • Elegant rectal u/s work; collagen fiber disruption • Vaginal childbirth damages the rectum and pelvic floor • Cesarean section does not • Hence cesarean section--and why not on demand

  7. DeLee’s power and influence changed the paradigm • Childbirth became a disease • The obstetricians had the tools and techniques to give themselves hegemony over childbirth • DeLee specifically told the Chicago meeting in 1920 that if obstetricians adopted these techniques they would supplant incompetent midwives and general practitioners and truly become a profession • The language of DeLee in 1920 has been adopted in the new millennium to justify Cesarean section on request

  8. 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?

  9. Cesarean section on demand is unethical--- FIGO 1999

  10. 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

  11. Cesarean section by choice acceptable alternative for some women and SOGC will be following ACOG ---CMAJ March 2004--Mary Hannah

  12. 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.”

  13. 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. Hence, it will only be possible a woman to obtain Cesarean on demand after she receives structured counseling by a trained and counselor in the context of a research

  14. Consequences: • 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 landscape • Pressure from some OB/GYN leaders to declare this to be a women’s “civil rights” issue, even to equate it with “choice”, a very loaded term • NIH Conference on Cesarean Section on “Maternal Request” • Rise of no indication cesarean sections in US and creative indications in Canada

  15. Research evidence: • 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 can -Spiritual and mastery/control issues -Physician convenience and inherent conflict of interest and truly informed consent

  16. 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 10-20% • Elective cxion vs cxion at various times in labor shows little difference in UI

  17. 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

  18. Research evidence: • Surgical mortality/morbidity • Cesarean vs vaginal birth • 4330 CS 1 extra maternal death • 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

  19. Research evidence: • Surgical mortality/morbidity (2) • Cesarean vs 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 prematurity and low birth weight (Hemminki Am J Obs and Gyn 2005; 193: 169-77)

  20. Urinary Incontinence (UI) structured review literature 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 incontinence • 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

  21. 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 CS to prevent long-term FI

  22. 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.

  23. Research evidence: • Newborn consequences that favor CS • Cesarean vs vaginal birth • 22,641 CS prevent 1 subdural/intracranial bleed • 19,601 CS prevent 1 IVH • 7,549 CS prevent 1 subarachnoid hemorrhage • 10,613 CS prevent 1 neonatal convulsion • 5,666 CS prevent 1 newborn CNS depression • 2,164 CS prevent 1 brachial plexus injury

  24. 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 for more than 24 hours

  25. Research evidence: WHO study from all of Latin America Villar J et al Lancet 2006 May 23rd 97,000 CS in 120 institutions 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 • French studyDeneux-Tharaux et al Obstet and Gynecol 2006; 108:541-8 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 thromboembolism). • We are replicating this for all of Canada.

  26. Research evidence: Newborn consequence US data Cesarean vs vaginal birth • 1998-2001 research on neonatal mortality vaginal vs. planned or elective CS—after controlling for indications for elective CS (truly no indication CS) • 0.62 neonatal deaths per 1000 vaginal vs 1.77 per 1000 CS • Based on 5,762,037 live births and 11,890 deaths MacDorman et al BIRTH Sept 2006 • Employing Odds ratios--roughly twice the neonatal death rate for CS @1/1000 vaginal and 2/1000 CS, after controlling for CS indications

  27. Research evidence: US study maternal morbidity and rehospitalization Cesarean vs vaginal birth • Rehospitalizations 19/1000 CS vs 7.5/1000 vaginal Declercq et al. in Obstetrics and Gynecology March 2007 pgs 669-77 • Leading cause rehospitalizations wound infections/complications: 6.6 vs : 3.3/1000

  28. Research evidence: Cesarean vs vaginal birth • First study truly planned vaginal birth vs. planned cesarean delivery (breech surrogate) Liu, Liston Kramer etc CMAJ Feb 13, 2007 pgs 455-60 • 46,766 elective breech vs. 2,292,420 planned vaginal • 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 x2.3

  29. Consequences of increasing CS on Request for USA for each 5% increase or from 29%to 34%Plante L. Obstet Gynecol Survey 61 (12) 2006 • 14 to 32 more maternal deaths • 5000 to 24,0000 more surgical complications; • 4000 to 6000 more postoperative infections; • 2200 more postpartum readmissions to the hospital; • 200 to 300 additional venous thromboses; • 33,000 more neonatal intensive care unit admissions; • 8000 more cases of neonatal respiratory complications; • 930,000 more hospital days • (for women; have not calculated infant length of stay) • Between $750 million and $1.7 billion in extra healthcare expenditures; • Higher rates of hospital occupancy; • Longer waiting times for elective operations of all kinds; and • Potential for an overall increase in medical error related to higher • hospital occupancy rates.

  30. However—Term Breech Trial provided natural experiment addressing both maternal and newborn consequences of mode of birth: • While at 3 months study showed bowel, urinary and sexual benefit to CS for breech compared with vaginal birth • At 2 years postpartum NO DIFFERENCE • And vaginal breech birth harder on pelvic floor • Study demonstrates resilience and self-healing capacity of the pelvic floor and resilience of the newborn as well.

  31. Urinary and Sexual Outcomes in Vaginal vs Cesarean Birth Michael C. Klein Janusz Kaczorowski Sally Jorgensen, Robert Gauthier Maria Hubinette, Tabassum Firoz Centre Community Child Health BC Research Institute for Children’s and Women’s Health and Department of Family Practice, University of British Columbia , McGill University, McMaster University, Bridgewater, NS Department of OB/GYN University ofMontreal JOGC 2005; 27 (4): 313-320

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

  33. Design • 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 • According to various vaginal outcome cohorts vs cesarean section

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