Israel Family Practice Cesarean Section On Maternal Request

1
Israel Family PracticeCesarean Section On
Maternal RequestWhose 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
  Pediatrics
• University of British Columbia
• Adjunct Professor of Family Medicine
• McGill University Faculty of Medicine

2
(No Transcript)
3
(No Transcript)
4
(No Transcript)
5
(No Transcript)
6
(No Transcript)
7
(No Transcript)
8
What do these five women have in common?

• Besides being very rich and beautiful?

9
(No Transcript)
10
(No Transcript)
11
(No Transcript)
12
(No Transcript)
13
(No Transcript)
14
(No Transcript)
15
(No Transcript)
16
(No Transcript)
17
(No Transcript)
18
(No Transcript)
19
(No Transcript)
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 natures 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 ultrasound work showing collagen
  fiber disruption
• Vaginal childbirth damages the rectum and pelvic
  flooreven without symptoms
• Cesarean section does not
• Hence cesarean section--and why not on demand

24
DeLees 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
  professionalshard to resist!
• The language of DeLee in 1920 has been adopted in
  the new millennium to justify Cesarean section on
  maternal 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
  dont 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
• but it is also acceptable to refuse if the
  surgeon feels it is not in the womans interest.
• ----ACOG 2003

28

• Cesarean section by choice acceptable alternative
  for some women and SOGC will be following ACOG
• ---CMAJ March 2004--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 processThe 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 Womens 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

31
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
  Request
• Rise of no indication cesarean sections in US
  and creative indications in Canada

32

• 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 birthhard to
  measure we measure what we can
• -Spiritual and mastery/control issues
• -Physician convenience and
  inherent conflict of interest and
  truly informed consent remains
  unexplored!

33
Research evidence Pelvic floor

• Urinary Incontinencemany 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

34
Research evidence

• Sexual outcomesfew 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

35
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

36
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
  babyincrease stillbirth, prematurity and low
  birth weight

37
Research evidence

• Newborn consequences that favor cesarean
• Cesarean vs vaginal birth
• 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
• 22,641 CS prevent 1 subdural/intracranial bleed
  
• 2,164 CS prevent 1 brachial plexus injury

38
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 gt24
  hours

39
Problem!

• 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?

40
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 Montreal

• JOGC 2005 27 (4) 313-320

41
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

42
Design

• Secondary analysis of all women who were part of
  the only RCT of episiotomy in North
  Americashowed 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

43
Subjects and Setting

• N 1044 women from The Montreal Episiotomy RCT
• 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)

44
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

45
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

46
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 Outcomes 1. Intact/first/second
degree tears 2. Episiotomy with or without
extensions or forceps 3. Cesarean section
47
Are you currently having trouble with loss of
urine? (3 months) - YES
p .221
Overall 162 or 16.3 had UI
No Hx UI
Hx UI
48
Are you currently having trouble with loss of
urine? (3 months postpartum) by Parity and by
Two-way Analysis
p .003
Unstratified by History of UI
49
Stress Incontinence During First Three Months
Postpartum by Parity and by Two-way Analysis
P lt.001
Unstratified by History of UI
50
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
51
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

52
Desire for Sexual Intercourse at 3 months
Postpartum by Parity and by Two-way Analysis
Unstratified by Prior Sexual History
53
Sexual Dissatisfaction at 3 months Postpartum by
Parity and by Two-way Analysis
p .003
Unstratified by Prior Sexual History
54
Frequency of Sexual Intercourse at 3 months
Postpartum by Parity and by Two-way Analysis
Unstratified by Prior Sexual History
55
Pain on Sexual Intercourse at 3 months
Postpartum by Parity and by Two-way Analysis
0/5 women who had resumed
Unstratified by Prior Sexual History
56
If you are currently having trouble with loss of
urine, is it severe enough to wear a pad? (3
months postpartumthree way analysis)
p .540
57
Are you currently having trouble with a feeling
of bulging or falling down in the vaginal area?
(3 months postpartumthree way)
p .424
58
Compared to before you were pregnant, how
sexually attractive do you feel? (3 months
postpartumthree way)
p .256
59
Sexual dissatisfaction?(3 months
postpartum)three way
p .097
For each year education, 7 decrease in sexual
satisfaction
60
Pain and frequency of intercourse at 3 months
postpartum (mean scoresthree way)
Intact/ 1o/2o Episiot/ Exten Cxion p
Frequency 3same 2.3 2.2 2.3 .377 .153
Pain on intercourse 1mild 2discomforting 1.7 1.9 1.6 .377 .153
61
Are you experiencing pain or discomfort during
intercourse?at 3 months--YES
p .012
p lt.001
62
Urinary Incontinence (UI) structured review
literature using number needed to treatPress,
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

63
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

64
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.

65
Hospital-based research from Latin America

• 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

66
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

67
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

68
French study Hospital-based maternal
outcomes CS vs. Vaginal

• Deneux-Tharaux et al Obstet and Gynecol 2006
  108541-8
• 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).

69

• 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 CSafter 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 _at_1/1000 vaginal and 2/1000 CS,
  after controlling for CS indications

70

• 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

71
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
  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

72
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 gt24 hours greatest for CS
  no matter if elective or in labour.

73
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
• TTN
• SVD 6/1000
• Elective CS 16/1000
• NICU gt24 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

74
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 requestsince not enough
  data on vaginal vs CS in comparable groupsreason
  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

75
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 floor
• 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.

76
Conclusion Pelvic Floor (1)

• At 3 months PP, UI slightly less among women with
  CSbut 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

77
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 cesareandont have to decide in
  advance!!!!!!

78
Changing Episiotomies per 100 Hospital Vaginal
Deliveries
Rectal Trauma Rates (3rd /4th degree tears) - USA
4.2
2.9
1.5
79
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 study
• 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)

80
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 TTNwith more parental separations
• And more placentation-related perinatal
  complications, even stillbirth in subsequent
  pregnancies for a policy of allowing, even
  encouraging CS on request.

81
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
  position.
• 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!

82

• 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

83

• What every pregnant woman needs to know about
  cesarean section. New York Childbirth
  Connection, April 2004
• http//www.maternitywise.org/booklet/.

84
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 Atwoods A
  Handmaids tale
• What can we do? Education, research, analysis,
  critique, engage women in the struggle to get
  childbirth back on the womens health agenda
• Narratives???

85
Who cares?