Consortium for the Evidence-based practice of Obstetrics -- 
C.E.O. is dedicated to bringing science-based 
maternity care to all childbearing women
 

 Quotes and Excerpts from www.eObGynNews.com and 
 other respected sources  of professional information
on safety, complications & practice trends for obstetricians  

Bibliography, Recommended Reading and Scientific Citation from obstetrical sources: 

Cesarean Surgery ~ Immediate Complications and Long-term Risks -- the 'gift' that keeps on giving...


Route of Delivery as a Risk Factor for Emergent Peripartum Hysterectomy
 
– a case-control study Obstetrics & Gynecology: 2003 Jul;102(1):141-5

C-Section Linked to Stillbirth in Next Pregnancy, Ob.Gyn.News May 15, 2003, Vol 38, No 10

Maternal Death after CS  ~ gangrenous necrosis of uterus after cesarean
ob-gyn-l@obgyn.net  ~ 22 May 1997  

Other Reports of Post- Cesarean Maternal Deaths ~ Email Comment list for discussion of obstetrics and gynecology & media sources

Double-Layer Cesarean Closures May be Safer Uterine rupture more likely with one-layer closure; Ob.Gyn.News, Mar 15, 2002, Vol 37, No 6;
 

Perinatal Death Risk in Term VBAC Pegged at 1:1,000, Risk was twice as high as that seen in other multiparous women; Ob.Gyn.News, May 1, 2002, Vol 37;  

Higher Rates of Respiratory Distress Seen with Cesarean;  Ob.Gyn.News, Dec 1, 2001, Vol 36, No 23;  

Elective deliveries / One-Third of Severe RDS Cases May Be Preventable / 
Failure to test for lung maturity faulted ~  June 15 2001 • Volume 36 • Number 12 

Asthma Associated with Planned Cesarean Large retrospective study on children born by CS Ob.Gyn.News May 15, 2003, Vol 36, No 10;

Cesarean Birth Associated with Adult Asthma, Ob.Gyn.News Jun 15, 2001, Vol 36, No 12  


Route of Delivery as a Risk Factor for Emergent Peripartum Hysterectomy
                                           
~ A case-control study.


Obstet Gynecol. 2003 Jul;102(1):141-5.

Kacmar J, Bhimani L, Boyd M, Shah-Hosseini R, Peipert J.
Women & Infants Hospital, Providence, Rhode Island, USA

Conclusion:

Cesarean delivery is a significant risk factor for postpartum hysterectomy. To evaluate whether cesarean delivery is a risk factor for emergent postpartum hysterectomy, we performed a case-control study of patients who delivered at Women & Infants Hospital between January 1989 and February 2000.

Fifty cases of emergent postpartum hysterectomy performed within 14 days of delivery met our inclusion criteria. Using a computer-generated list, two patients admitted to the labor department at a time point similar to that of each case patient were selected as controls (n = 100). We reviewed medical records for demographic data, route of delivery, labor characteristics, surgical history, and indication for hysterectomy. Cases and controls were compared, and logistic regression was used to calculate the odds ratio (OR) and the 95% confidence interval (CI) for the association of delivery route and emergent hysterectomy.

Cesarean delivery was associated with a 13-fold increased risk of emergent hysterectomy when we controlled for previous cesarean delivery, dilation and curettage or abortion before the index pregnancy, use of prostaglandin, and use of pitocin (OR 12.9; 95% CI 5.2, 32.3).   


C-Section Linked to Stillbirth in Next Pregnancy -- Ob.Gyn.News May 15, 2003, Vol 38, No 10  

Women who have a cesarean delivery are at increased risk for an unexplained stillbirth in their next pregnancy, results of a larger retrospective study suggest. Abnormal placentation due to uterine scarring maybe the case of these stillbirths. 

There's a growing body of evidence that suggests that placentation problems after cesarean section can cause problems for the fetus." her said in an interview. "This is the first time that this has been linked to unexplained stillbirth."

"...when women are considering whether to plan a cesarean section, they should be counseled that the surgery might be risky for a future pregnancy

They tend to think of a section as always being protective for the baby but it may not be so the their next baby." Dr Smith said.


Subject: gangrenous necrosis of uterus after cesarean
X-Comment: list for discussion of obstetrics and gynecology

Date: Thu, 22 May 1997 22:19:09 -0500
Sender: ob-gyn-l@obgyn.net
From: joanandEd@aol.com (Ed Miller, MD)

Has anyone ever heard of gangrenous necrosis and rupture of the uterus 10 days after a cesarean, leading to maternal death? This patient had her left uterine artery ligated because of its being torn, and this patient never once had a fever!! She didn't see any doctors in the 3 days before her death.  Has anyone ever heard of metritis without a fever?
--
Ed Miller, MD

 

Double-Layer Cesarean Closures May be Safer Uterine rupture more likely with one-layer closure;
Ob.Gyn.News, Mar 15, 2002, Vol 37, No 6;  

Single-layer closure after low transverse cesarean sections may leave women 5 times more susceptible to uterine rupture in a subsequent trial of labor compared with double-layer closure. 

Obstetricians moved away from two-layer closures after C-section because one-layer closures seemed sufficient and shortened operative time. The alarming study results should prompt further investigation of the safety of their approach….  

Three percent of the 398 women (12) who had a one-layer closure after C-section developed symptomatic uterine rupture during trial of labor, compared to 0.6% (3) of the 1,251 women whose C-sections were closed with two layers of sutures.(5B)  


Perinatal Death Risk in Term VBAC Pegged at 1:1,000, Risk was twice as high as that seen in other multiparous women; Ob.Gyn.News, May 1, 2002, Vol 37;

The absolute risk of perinatal death due to any cause for a healthy singleton fetus in cephalic presentation at term in a woman attempting vaginal birth after a prior cesarean section is similar to the risk in nulliparous women. That risk—about 1 fetal death per 1,000 deliveries (for healthy first time mother) —was based on findings from a study of more than 300,000 

The risk of perinatal death due to uterine rupture specifically was eight times higher in women attempting VBAC—1 death per 2,000 deliveries—compared with the risk in nulliparous women or in other multiparous women.  … 

study did not include figures on the number of inductions that were performed. A previously published study .. showed that, compared with women undergoing repeat elective C-section, those attempting VBAC with spontaneous labor were at three times the risk of uterine rupture. 

Women who were induced had 4.9 times the risk if prostaglandins weren't used, and their risk increased almost 15 times if prostaglandins were used. This is the first large study of VBAC risks in otherwise uncomplicated pregnancies at term, he said. 

The perinatal death rate with VBAC due to mechanical causes including uterine rupture (4.5%) was a little lower in this study than has been reported by other investigators, perhaps because the current study excluded preterm births (30)  


Elective deliveries / One-Third of Severe RDS Cases May Be Preventable / Failure to test for lung maturity faulted. June 15 2001 • Volume 36 • Number 12 


One-third of severe neonatal respiratory distress cases could be avoided if physicians tested for fetal lung maturity before performing elective deliveries, results of a large, retrospective study suggest. 

"Many people consider 37 weeks a term pregnancy. However, it's not until 39 weeks that you can be assured of fetal lung maturity," commented Dr. Joseph Wax, a perinatologist who presented his findings in poster form at the annual meeting of the American College of Obstetricians and Gynecologists. 


In a chart review of 35,031 babies born at the Hartford (Conn.) Hospital over a 10-year period, Dr. Wax identified 18 neonates with severe respiratory distress syndrome (RDS)—7 of whom were electively delivered.  "Of those, one baby had a mature amniocentesis, although it did have immature lungs, so in our minds this was an unpreventable case of RDS. However, the RDS in the other six babies could have been avoided had their caregivers performed the proper tests for determining fetal lung maturity," he said. 

In 37-week babies, there's an almost 39-times-higher frequency of severe RDS, compared to term babies. And at 38 weeks, the risk of RDS is 13-fold higher than at term," he said. 

But given the relative rarity of RDS, the problem of increased RDS rates in electively delivered babies may not be evident to many physicians. ... But when we take aggregate population-based data, it's a significant problem and a significant health hazard," he said. {citation missing}

“In 37 week babies, there’s almost a 39 times higher frequency of sever RDS, compared to term babies….at 38 weeks the risk of RDS is 13-fold higher than at term” …a frequency of 1 in 1,000 deliveries at 38 weeks or 3 in 1000 at 37 weeks [or one of every 333]. (8)  


Higher Rates of Respiratory Distress Seen with Cesarean;  Ob.Gyn.News, Dec 1, 2001, Vol 36, No 23;

Sever preeclampsia (toximia of pregnancy with high blood pressure) accounts for nearly 2/3 of all Cesarean deliveries but the procedure offers no inherent benefits to patients with this condition. 

In the study, mothers and infants who were delivered vaginally had a significantly lower incidence of respiratory distress. Other outcomes were either equal … or worse for those in the C-section group …the incidence of pulmonary compromise was 3 times higher in women in the C-section group, with rates of 26% vs 8%, respectively. 

The difference was nearly as high among neonates: More than half –52%-- …delivered by C-section had respiratory distress syndrome, compared to 18% who were delivered vaginally.  


Asthma Associated With Planned Cesarean  ObGynNews; May 15 2003 • Volume 38 • Number 10

Babies delivered by planned cesarean section are significantly more likely to require hospitalization for asthma during childhood than babies born vaginally, Dr. Gordon Smith reported at the annual meeting of the Society for Gynecologic Investigation. 

Dr. Smith's retrospective cohort study examined the medical histories of 173,319 children born at term in Scottish hospitals between 1992 and 1995. 

The association between planned cesarean section and childhood asthma hospitalizations was strongest for infants who developed neonatal respiratory complications after birth;
these children had a 75%-80% increase in the risk of hospital admissions for asthma over the first 5 years of life, according to Dr. Smith.

“We've known for a long time that there is an association between cesarean section and short-term respiratory morbidity, but we really didn't think that was reflected in increased risks over the long term,Dr. Smith of Cambridge (England) University, said in an interview. “Apparently, however, it is,” he added.

He believes the increased incidence of asthma among these children is related to
an inflammatory process in the lungs at the time of birth, which leads to conditioning of bronchial smooth muscle toward a hyperresponsive, proinflammatory phenotype.

The risk was higher during the first year of life (1.75 as likely) and dropped to baseline by 5 years or older, according to Dr. Smith.

Infants delivered by planned cesarean section who also developed neonatal respiratory morbidity (transient tachypnea or respiratory distress syndrome) were 1.8 times more likely to require hospitalization for asthma during childhood.


Cesarean Birth Associated with Adult Asthma, Ob.Gyn.News Jun 15, 2001, Vol 36, No 12  

“Birth by Cesarean section may lead to asthma in adulthood”  The babies in the C-section group had more than a 3 times greater risks for having asthma in adult hood, compared to those in the vaginal delivery group.”