NIH
Maternal
Request
Cesarean
State
of Science Conference – draft report March 29, 2006
Critique – faith
Gibson, LM, CPM
First, it is odd that a
conference to which the public was invited, would produce such a technical
document by 5 pm of the last day. In fact, that would be impossible.
Obviously, the draft report existed before the State of the Science
conference. That means that a conclusion had already been reached before the
panel met and before there was any input from the public.
Second, all the
assumptions that informed the NIH’s inquiries, were based on the
uncritical acceptance of an unscientific premise -- business as usual OB
care for normal birth, in which the average healthy woman giving birth under
obstetrical management has 7 significant, potentially injurious
interventions during labor.
Bias in the use of
the word ‘attempted’ or ‘attempting’ before the words ‘vaginal
birth’, which again express a subtle disregard or disrespect for normal
birth.
Only in a system that has
normalized immobilizing laboring women in bed with continuous EFM, IVs,
Pitocin, epidural, automatic BP cuff and pulse oximetry, foley catheter,
routine use of anti-gravitational positions for 2nd stage, purple pushing,
episiotomy, forceps, vacuum extractions and CS could one dispassionately
consider that there was little difference between the risks of maternal
choice CS and totally screwed up vaginal birth and say, what the heck, lets
let the little woman decide whether she wants an incision in her perineium
-- episiotomy -- OR an incision in her abdomen -- a C-section.
This leads to oxymoronic
conclusions that planned CS would be safer than planned vaginal birth
pregnancy past the 39th week, labor or delivery. That fuzzy logic would
actually make early abortion the safest possible method to prevent
pregnancy-related medical problems or childbirth complications. No, I’m
wrong, contraception would be the safest strategy to avoid all
complications of pregnancy.
Specifically, the NIH
document continued to attribute an on-going and independent advantage to
each of several categories that were (of course) automatically eliminated by
the timing and route of delivery. CS is surgery, and one only need wait on
the OR. Vaginal birth is biology and it runs its own show. This is like
contrasting a 2 day train-trip cross-country versus a 4 hour plane flight.
Because train travel takes place in 'real time' over several days, one of
the 'advantages' that could be ascribe to plane travel is a vast reduction
opportunities to be mugged, in hangovers from spending sequential nights
drinking booze in the dinning car, coming down with the flu while traveling
and (big surprise!) from being in a train wreck. Interesting way to avoid
train wrecks – just take a plane. However, the plane can crash but in the
NIH model, there would be little
or no discussion of this ‘complication’!
Third, virtually every
complication or detriment associated with maternal choice CS was immediately
followed by a mitigating "However",
in which the authors opined that the data was shaky, that the problem wasn't
significant or could be simply overcome by tweaking some other aspect of
medical care.
Forth
was the evident bias that only identified
the vag birth side of the equation as having detriment, while not applying
that characteristic to CSs. The most glaring example was attributing reduced
perinatal deaths to schedule CS based on the theoretical possibility of
fetal demise due to 42 wk post-maturity. What this describes is a
projection, not a finding actually established in a bona fide study.
Here are the excerpts in
question, with the inevitable mitigating
"However / all you have to do is" in blue text.
Fetal mortality.
Based on epidemiologic modeling, there
is an increased risk of stillbirth in
the PVD group, because planned CD would result in delivery by 40 weeks,
and PVD could occur up to 42 weeks.
[Note:
this potential fetal mortality ascribed does not acknowledge or balance the
postdate risk (which is an NST vs
induction issue, rather then route of delivery) associated with
iatrogenic prematurity due to inadvertently scheduled CS before term.]
Iatrogenic prematurity. Uncertainty regarding
gestational dating is not uncommon and can lead to estimated dates that are
inaccurate by 2 or 3 weeks. There is an approximate doubling of the rates of
respiratory symptoms and other problems of neonatal adaptation (e.g.,
hypothermia, hypoglycemia) and NICU admissions for infants delivered by CD
for each week below 39-40 weeks. Therefore,
CDMR may be associated with a number of neonatal morbidities. These
effects can be minimized if gestational age is accurately known, lung
maturity is documented, and elective CD is not performed before 39 weeks of
gestational
Neonatal length
of hospital stay. Evidence indicates that neonatal length of hospital
stay is longer for “elective” CD than for
vaginal delivery. Length of stay is
increased when delivery is complicated [i.e. NIH doesn’t ‘count’ in
their minds!].
Neonatal
Outcomes Favor
CDMR Intracranial hemorrhage, neonatal asphyxia, and encephalopathy.
Consistently higher rates of intracranial hemorrhage are observed in
operative vaginal delivery and CD in labor, suggesting
CDMR should be associated with lower risk of intracranial hemorrhage than
the aggregate of spontaneous and assisted vaginal deliveries that comprise
PVD. Evidence indicates a lower risk of
neonatal asphyxia and encephalopathy with “elective”
CD compared to operative and spontaneous vaginal deliveries plus
“emergency” or “labored” cesareans, which comprise “planned
vaginal delivery.”
Birth injury and
laceration. The incidence of brachial plexus
injury is significantly lower in CD than in spontaneous vaginal delivery and
significantly lower than in assisted vaginal delivery. There is a
higher rate of fetal lacerations among emergency and labored cesareans than
among elective CD, suggesting that CDMR poses no
additional risk for fetal lacerations beyond those associated with PVD.
Neonatal
infection. Infants born by vaginal delivery will tend
to have more evaluations for and increased incidence
of infection than babies delivered by planned CD.
Next is the lamest section of all – the weak,
helpless plaintive complaint that is more like a wish list. It reads:
“A consequence of the increasing
rates of CD is that this mode of delivery may be perceived as the norm.
The perception that the risks of CD are similar or
lower than attempted VBAC and the shift away from vaginal breech deliveries
may further contribute to societal acceptance of cesarean births. Media
coverage may further increase concerns about the potential morbidity of PVD.
Such a shift in acceptance by patients and providers may
lead to an increase in CDMR.
This next paragraph has two glaring holes in their
theory. The idea that: “Fear
of labor and its potential complications as well as desire for control
stand at one end of the spectrum and may be influenced by a woman’s
personal experiences” This smacks me as wimpy and not accurate.
A woman may control the decision to have a scheduled CS but she certainly
doesn’t and can’t control the many layers of consequences – things
like intra-operative complications, op-op bleeding, pain, infection, need to
return to OR for second surgery for complications.
Secondly, I noticed that all the reasons/rationales for
the ever increasing rate of Cesareans never ever really acknowledge the role
of the doctor, hospital policies or staffing patterns, health care
reimbursement issues and malpractice company in influencing the constant
slippage away from normal vaginal birth and towards CS.
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