"C-sections to be available on demand, CMA says"

[Guest Ian Wong]

Here's an interesting article by the Vancouver Sun, which discusses the possibility of pregnant women being able to opt for a Caesarian delivery, instead of a vaginal delivery, even if there may not be a specific medical indication for the procedure. I guess the question here really revolves around whether something that would, by definition not be medically necessary (ie. no medical indications) should be supported by our health care system, particularly in light of the fact that a Caesarian section is after all a surgical procedure with attendant risks and complications.

 

The CMAJ article does a good job of discussing the different risks and benefits of a vaginal delivery versus a Caesarian section, and it becomes clear that there are both good and bad facets to each method of delivery.

 

The CMAJ article concludes with the following statement:

In the meantime, what should physicians do? Most women prefer to plan for a vaginal birth.11 However, if a woman without an accepted medical indication requests delivery by elective cesarean section and, after a thorough discussion about the risks and benefits, continues to perceive that the benefits to her and her child of a planned elective cesarean outweigh the risks, then most likely the overall health and welfare of the woman will be promoted by supporting her request.

Anyway, here's both the Vancouver Sun article, as well as the CMAJ article:

 

Ian

 

www.canada.com/vancouver/vancouversun/news/story.html?id=3daa99c3-537a-40a4-b7bf-4c8c9d27b325

 

C-sections to be available on demand, CMA says

Sharon Kirkey

CanWest News Service

 

Tuesday, March 02, 2004

 

OTTAWA -- Canadian women will soon be widely offered the choice to deliver their babies by caesarean section even if there's no medical reason to justify it, Canada's top medical journal says.

 

New guidelines for so-called "elective" C-sections will be issued to Canadian doctors this spring, the Canadian Medical Association Journal reports today.

 

In the past, the surgery, which involves delivering babies through an incision in a woman's belly, has been reserved for high-risk deliveries alone. But, more and more Canadian women are seeking caesareans on demand, part of a trend critics have dubbed "too posh to push" after former Spice Girl Victoria (Posh Spice) Beckham and other celebrity mothers began popularizing the practice.

 

The American College of Obstetricians and Gynecologists recently concluded that women should be free to elect caesarean delivery in a normal pregnancy, "after adequate informed consent." Doctors are "ethically justified" in performing an elective C-section, the group said, if they believe it would benefit "the overall health and welfare of the woman and her fetus more than a vaginal birth."

 

The Society of Obstetricians and Gynecologists of Canada's ethics committee will release similar recommendations in late spring, the journal reports today.

 

Toronto obstetrician Dr. Mary Hannah says a planned caesarean section can let a woman avoid the pain of labour and reduce her fear and anxiety over giving birth.

 

But critics argue a C-section, once reserved as a last resort to save babies from dying mothers, is a major operation that can expose women and babies to unnecessary risks.

 

"Since when did surgery become the answer to pain?" says Abby Lippman, professor in the department of medicine at Montreal's McGill University and co-chair of the Canadian Women's Health Network.

 

"Where is the support for women who want to have births with midwives, or women who want to have home births? Why are we not working on making vaginal births much safer rather than immediately saying maybe C-sections are safer?"

 

After years of pressure on doctors to perform fewer, not more, C-sections, Canada's rate is climbing. Today, about 20 per cent of births in Canada -- about 66,300 babies -- are delivered via caesarean, compared to 15 per cent of births in 1994. The World Health Organization says any rate higher than 15 per cent signals "inappropriate usage."

 

The new Canadian position statement won't give doctors "blanket permission" to provide caesarean sections on demand, the journal reports. Rather, the option "is only for particular situations where it is at the behest of the patient, and doctors require guidance on how to deal with it," Dr. Vyta Senikas, acting executive director of the Society of Obstetricians and Gynecologists, told the journal.

 

Senikas doesn't expect more women to suddenly start clamouring for planned C-sections, but there's no question their popularity is growing: "Five years ago I'd get a request (for an elective caesarean) every year or two; now it's every month or two."

 

For women, the risks of caesareans can include a higher maternal death rate compared to vaginal births, Hannah, professor of obstetrics and gynecology at Toronto's Sunnybrook and Women's Health Sciences Centre, writes in a commentary in today's Canadian Medical Association Journal.

 

It takes longer to recover from a C-section, and complications such as bleeding or lacerations (cuts from a scalpel) occur in six per cent of planned caesareans. The operation also increases the risk of major bleeding in a subsequent pregnancy, Hannah says.

 

C-section babies can have more breathing problems after delivery, and there's a slight increased risk of stillbirth in a second pregnancy if the first child was born by caesarean.

 

The operation also increases the risk of major bleeding in a subsequent pregnancy, says Hannah, who is also director of the University of Toronto's Maternal, Infant and Reproductive Health Research Unit.

 

But women are more likely to experience urinary problems following a vaginal birth, and babies born by C-section may have a lower risk of labour-related complications, such as abnormal heart rate.

 

"Vaginal delivery is generally considered better for women," Hannah said in an interview.

 

Even when a woman plans for a vaginal birth, there's always a risk of a problem developing that will result in an emergency C-section. Often they have to be done in a hurry, or in the middle of the night, when doctors "may not be as alert as they would be at nine in the morning."

 

But critics worry that "patient choice" C-sections are being driven by doctors for their own convenience, or out of fear of being sued because of complications during a difficult delivery.

 

 

www.cmaj.ca/cgi/content/full/170/5/813

 

Planned elective cesarean section: A reasonable choice for some women?

Mary E. Hannah

 

Mary Hannah is with the Department of Obstetrics and Gynaecology, Sunnybrook and Women's College Health Sciences Centre, and the Maternal Infant and Reproductive Health Research Unit, Centre for Research in Women's Health, University of Toronto, Toronto, Ont.

 

A growing number of women are requesting delivery by elective cesarean section without an accepted "medical indication," and physicians are uncertain how to respond. This trend is due in part to the general perception that cesarean delivery is much safer now than in the past and to the recognition that most studies looking at the risks of cesarean section may have been biased, as women with medical or obstetric problems were more likely to have been selected for an elective cesarean section. Thus, the occurrence of poor maternal or neonatal outcomes may have been due to the problem necessitating the cesarean delivery rather than to the procedure itself. The only way to avoid this selection bias is to conduct a trial in which women would be randomly assigned to undergo a planned cesarean section or a planned vaginal birth. When this was done in the international randomized Term Breech Trial involving 2088 women with a singleton fetus in breech presentation at term, the risk of perinatal or neonatal death or of serious neonatal morbidity was significantly lower in the planned cesarean group, with no significant increase in the risk of maternal death or serious maternal morbidity.1

 

In response to the growing demand from women to have a planned elective cesarean section, the American College of Obstetricians and Gynecologists published a committee opinion 2 that states

 

If taken in a vacuum, the principle of patient autonomy would lend support to the permissibility of elective cesarean delivery in a normal pregnancy, after adequate informed consent. To ensure that the patient's consent is, in fact, informed, the physician should explore the patient's concerns. ... If the physician believes that cesarean delivery promotes the overall health and welfare of the woman and her fetus more than vaginal birth, he or she is ethically justified in performing a cesarean delivery. Similarly, if the physician believes that performing a cesarean delivery would be detrimental to the overall health and welfare of the woman and her fetus, he or she is ethically obliged to refrain from performing the surgery.

 

The Ethics Committee of the Society of Obstetricians and Gynaecologists of Canada is also preparing a statement.

 

What are the risks of cesarean delivery? The maternal mortality is higher than that associated with vaginal birth (5.9 for elective cesarean delivery v. 18.2 for emergency cesarean v. 2.1 for vaginal birth, per 100 000 completed pregnancies in the United Kingdom during 1994–1996).3Cesarean section also requires a longer recovery time, and operative complications such as lacerations and bleeding may occur, at rates varying from 6% for elective cesarean to 15% for emergency cesarean.1,4 Having a cesarean delivery increases the risk of major bleeding in a subsequent pregnancy because of placenta previa (5.2 per 1000 live births) and placental abruption (11.5 per 1000 live births).5 Among term babies, the risk of neonatal respiratory distress necessitating oxygen therapy is higher if delivery is by cesarean (35.5 with a prelabour cesarean v. 12.2 with a cesarean during labour v. 5.3 with vaginal delivery, per 1000 live births).6 Also, a recent study has reported that the risk of unexplained stillbirth in a second pregnancy is somewhat increased if the first birth was by cesarean rather than by vaginal delivery (1.2 per 1000 v. 0.5 per 1000).7 Lastly, birth by cesarean is not generally considered "natural" or "normal."

 

What are the benefits of cesarean section? It may reduce the risk of urinary incontinence, which is a common postpartum problem. In one study of primiparous women, 26% had urinary incontinence at 6 months post partum, the rate being lowest with elective cesarean (5%), higher with cesarean during labour (12%), higher still following a spontaneous vaginal birth (22%) and highest following a vaginal forceps delivery (33%).8 Although not as common as urinary incontinence, fecal incontinence, affecting about 4% of women giving birth, is usually a serious problem, and the risk may be reduced by cesarean section.9 Other maternal benefits from cesarean delivery include avoidance of labour pain, alleviation of fear and anxiety related to labour or birth10,11 and reduced worry about the health of the baby.12 Also, some women may just prefer the convenience and control of being able to plan the precise timing of the birth. The baby may also benefit. The risk of an unexplained or unexpected stillbirth may be reduced by cesarean section, as may be the risk of complications of labour such as clinical chorioamnionitis, fetal heart rate abnormalities and cord prolapse.1,13 Lastly, labour and vaginal birth, complete with hospital stay, continuous electronic fetal heart rate monitoring, induction or augmentation of labour, epidural analgesia, forceps delivery, episiotomy and multiple caregivers, may also not be considered "natural" or "normal."

 

However, this issue involves more than a simple comparison of risks and benefits of cesarean and vaginal birth. Planning for a vaginal birth may result in an emergency cesarean section, which carries higher risks for the mother than if an elective cesarean had been undertaken.3,14 For a term pregnancy with a breech presentation the risk of emergency cesarean is over 40%.1 If the baby is in a cephalic presentation, the risk of emergency cesarean may be less than 5% for a multiparous woman in spontaneous labour at 37 weeks' gestation, and as high as 35% for a primiparous woman who is having labour induced at 42 weeks' gestation.15 Other factors, such as maternal age, may also affect this risk.16If the mother has a vaginal birth, it may have required a forceps delivery or resulted in tearing of the anal sphincter, or both, thus increasing the risks of urinary and fecal incontinence.17 Although pelvic floor muscle training may reduce the risk of postpartum incontinence,18 these exercises are not always prescribed by obstetric care providers.

 

The important question, therefore, is whether a planned cesarean delivery will be more beneficial than harmful to a woman and her baby compared with a planned vaginal birth. To answer this question for women with a singleton fetus in breech presentation at term, we undertook the international randomized controlled Term Breech Trial involving 2088 women.1 Most (90.4%) of the women randomly assigned to the planned cesarean group delivered by cesarean section; however, only 56.7% of the women randomly assigned to the planned vaginal birth group actually delivered vaginally, the others having complications that necessitated a cesarean section. Compared with planned vaginal birth, the policy of planned cesarean delivery reduced the risk of perinatal or neonatal death (0.3% v. 1.3%, p = 0.01) and the risk of perinatal or neonatal death or serious neonatal morbidity (1.6% v. 5.0%, p < 0.0001). There was 1 maternal death in the planned vaginal birth group. The risk of maternal death or serious short-term maternal morbidity was low among all women and not increased among women in the planned cesarean group (3.9% v. 3.2%, p = 0.35).1 However, when these results were included in a Cochrane review with 2 other small randomized trials, the risk of short-term maternal morbidity was significantly higher with a policy of planned cesarean section than with planned vaginal birth (relative risk 1.29, 95% confidence interval 1.03–1.61).19 On the basis of this information, the American College of Obstetricians and Gynecologists issued a committee opinion on breech delivery stating that "patients with a persistent breech presentation at term in a singleton gestation should undergo a planned cesarean delivery." 20 And at 3 months after the birth, women in the planned cesarean group of the Term Breech Trial were less likely than women in the vaginal birth group to report urinary incontinence (4.5% v. 7.3%, p = 0.02).12

 

Unfortunately, for women not having a breech birth, such as those pregnant with twins, women who have had a previous cesarean section, older women, those who are having their first baby, those with incontinence problems and women who are afraid of labour, we have little information on the true benefits and risks of planned elective cesarean section compared with planned vaginal birth. Randomized studies are underway involving women with twins and women who have had a previous low-segment cesarean section, but the findings will not be available for several years.

 

In the meantime, what should physicians do? Most women prefer to plan for a vaginal birth.11 However, if a woman without an accepted medical indication requests delivery by elective cesarean section and, after a thorough discussion about the risks and benefits, continues to perceive that the benefits to her and her child of a planned elective cesarean outweigh the risks, then most likely the overall health and welfare of the woman will be promoted by supporting her request.