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Edmonton May 7 th 2011 Cesarean Section On Maternal Request— Whose request is it anyhow? Michael C. Klein Centre Community Child Health Research Senior.

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Presentation on theme: "Edmonton May 7 th 2011 Cesarean Section On Maternal Request— Whose request is it anyhow? Michael C. Klein Centre Community Child Health Research Senior."— Presentation transcript:

1 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 University of British Columbia Adjunct Professor of Family Medicine McGill University Faculty of Medicine

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8 What do these five women have in common? Besides being very rich and beautiful?

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20 “…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.”

21 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.”

22 “ 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

23 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

24 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

25 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?

26 Cesarean section on demand is unethical--- FIGO 1999

27 It is ethically permissible to accede to a request for an elective Cesarean section from an informed woman— 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. but it is also acceptable to refuse if the surgeon feels it is not in the woman’s interest. ----ACOG ACOG 2003

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

29 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.”

30 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 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

31 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

32 Research evidence: Three lines of relevant research comparing elective cesarean with planned vaginal birth : 1. Classical surgical mortality/morbidity 1. Classical surgical mortality/morbidity 2. Newborn outcomes 2. Newborn outcomes 3. Pelvic floor issues 3. Pelvic floor issues Neglected are: Neglected are: -Value of vaginal birth—hard to measure: we measure what we can -Value of vaginal birth—hard to measure: we measure what we can -Spiritual and mastery/control issues -Spiritual and mastery/control issues -Physician convenience and inherent conflict of interest and truly informed consent -Physician convenience and inherent conflict of interest and truly informed consent

33 Research evidence : Pelvic floor Research evidence : Pelvic floor Urinary Incontinence—many studies Urinary Incontinence—many studies Mostly only to 3 months postpartum and generally uncontrolled for prior UIMostly only to 3 months postpartum and generally uncontrolled for prior UI Population based studies show little difference or minimal benefit to CxionPopulation based studies show little difference or minimal benefit to Cxion Even nuns have UI at the rate of %Even nuns have UI at the rate of % Elective cxion vs cxion at various times in labor shows little difference in UIElective cxion vs cxion at various times in labor shows little difference in UI

34 Research evidence: Research evidence: Sexual outcomes—few studies of reasonable quality 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 cesareanBUT 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 stateBut 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 Nevertheless by 6 months the early postpartum slight benefits for cesarean section vs vaginal disappear

35 Research evidence: Surgical mortality/morbidity –Cesarean vs vaginal birth 4330 CS 1 extra maternal death 4330 CS 1 extra maternal death 6102 CS 1 extra thromboembolic event 6102 CS 1 extra thromboembolic event 632 CS to prevent 1 transfusion 632 CS to prevent 1 transfusion 37 CS 1 extra operative trauma 37 CS 1 extra operative trauma 159 CS 1 extra infection 159 CS 1 extra infection 435 CS 1 extra case sepsis/DIC 435 CS 1 extra case sepsis/DIC

36 Research evidence: Surgical mortality/morbidity (2) –Cesarean vs vaginal birth 156 CS 1 extra readmission 444 CS 1 extra abruption 444 CS 1 extra abruption 489 CS 1 extra ectopic 489 CS 1 extra ectopic 230 CS 1 extra placenta previa 230 CS 1 extra placenta previa 694 CS 1 extra invasive placenta 694 CS 1 extra invasive placenta 2667 CS 1 extra hysterectomy 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: )

37 Urinary Incontinence (UI) structured review literature Press, Klein et al BIRTH Sept 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 109 CS to prevent one case of short-term urge incontinence 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

38 Fecal Incontinence When we combined 13 studies of any level of FI: 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 But after removing instrumental births NNT increased to 49 CS Many more CS to prevent long-term FI Many more CS to prevent long-term FI

39 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.

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

41 Research evidence: Research evidence: Newborn consequences favoring vaginal birth Cesarean vs vaginal birth 338 CS 1 extra severe feeding difficulty 338 CS 1 extra severe feeding difficulty 69 CS 1 extra respiratory problem 69 CS 1 extra respiratory problem 80 CS 1 extra TTN 80 CS 1 extra TTN 129 CS 1 extra RDS 129 CS 1 extra RDS 247 CS 1 extra pneumonia 247 CS 1 extra pneumonia 162 CS 1 extra level III admission 162 CS 1 extra level III admission 153 CS 1 extra 5 min Apgar less than CS 1 extra 5 min Apgar less than CS 1 extra newborn on respirator for more than 24 hours 317 CS 1 extra newborn on respirator for more than 24 hours

42 Research evidence: Research evidence: WHO study from all of Latin America Villar J et al Lancet 2006 May 23 rd 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 study Deneux-Tharaux et al Obstet and Gynecol 2006; 108: ,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.

43 Research evidence: Research evidence: Newborn consequence US data Cesarean vs vaginal birth research on neonatal mortality vaginal vs. planned or elective CS—after controlling for indications for elective CS (truly no indication CS) 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 vaginal and 2/1000 CS, after controlling for CS indications

44 Research evidence: 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 Leading cause rehospitalizations wound infections/complications: 6.6 vs : 3.3/1000

45 Research evidence: 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 ,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

46 Consequences of increasing CS on Request for USA for each 5% increase or from 29%to 34% Plante L. Obstet Gynecol Survey 61 (12) 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.

47 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.

48 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 of Montreal JOGC 2005; 27 (4):

49 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

50 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

51 Subjects and Setting N: 1044 women from The Montreal Episiotomy RCT Enrolled at 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

52 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

53 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

54 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 forceps 3. Cesarean section

55 Are you currently having trouble with loss of urine? (3 months) - YES p.221 No Hx UIHx UI Overall 162 or 16.3% had UI

56 Are you currently having trouble with loss of urine? (3 months postpartum) by Parity and by Two-way Analysis (Why 2-way?) p.003 Unstratified by History of UI

57 Stress Incontinence During First Three Months Postpartum by Parity and by Two-way Analysis P <.001 Unstratified by History of UI

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

59 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 ) p.059

60 Desire for Sexual Intercourse at 3 months Postpartum by Parity and by Two-way Analysis Unstratified by Prior Sexual History

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

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

63 Pain on Sexual Intercourse at 3 months Postpartum by Parity and by Two-way Analysis Unstratified by Prior Sexual History 0/5 women who had resumed

64 If you are currently having trouble with loss of urine, is it severe enough to wear a pad? (3 months postpartum—three way) p.540

65 Are you currently having trouble with a feeling of “bulging” or falling down in the vaginal area? (3 months postpartum—three way) p.424

66 Compared to before you were pregnant, how sexually attractive do you feel? (3 months postpartum—three way) p.256

67 Sexual dissatisfaction? (3 months postpartum)—three way p.097 For each year education, 7% decrease in sexual satisfaction

68 Pain and frequency of intercourse at 3 months postpartum (mean scores—three way) Intact/ 1 o /2 o Episiot/ Exten Cxionp Frequency 3=same Pain on intercourse 1=mild 2=discomforting

69 Are you experiencing pain or discomfort during intercourse? at 3 months--%YES p <.001 p.012

70 Episiotomies per 100 Hospital Vaginal Deliveries Rectal Trauma Rates (3 rd /4 th degree tears) - USA

71 Conclusion (1) At 3 months PP, UI slightly less among women with cxion—but this is too early to measure this outcome 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

72 Conclusion (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!!!!!!

73 Conclusion (3) As the rate of intact perineum is rising and rectal trauma rate is falling in current practice, were this study repeated today, we would expect even better outcomes for vaginal birth vs CS than demonstrated by our study Optimal, physiologic birth rather than current “industrialized” birth would also be expected to enhance vaginal outcomes vs CS Informed decisions require unbiased presentation of benefits and risks of alternative birth modes

74 The most comprehensive review to date on Cesarean compared with spontaneous and assisted vaginal birth has been completed by The Maternity Center Association (MCA), now Childbirth Connection. In April 2004, MCA published a booklet, What every pregnant woman needs to know about Cesarean section. The most comprehensive review to date on Cesarean compared with spontaneous and assisted vaginal birth has been completed by The Maternity Center Association (MCA), now Childbirth Connection. In April 2004, MCA published a booklet, What every pregnant woman needs to know about Cesarean section. Using systematic review, MCA concluded that in the absence of a clear, compelling and well- supported rationale for Cesarean section, vaginal birth is far safer for mothers and babies.

75 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

76 What every pregnant woman needs to know about cesarean section. New York: Childbirth Connection, April 2004

77 NIH Conference “Cesarean Delivery on Maternal Request 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 one” Opened the door to CS on request—since not enough data on vaginal vs CS in comparable groups—reason to accept CS on request? 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

78 Question: Is it possible that vaginal childbirth is becoming an extreme sport? ( 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 abuse 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???

79 Who cares?


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