Saturday, April 01, 2006

One More C-Section Post

The journal Obstetrics and Gynecology has an editorial on c-sections in the April issue, entitled, "Can a 29% Cesarean Delivery Rate Possibly Be Justified?" by USCD Professor of Reproductive Medicine Dr. Robert Resnik. Free full-text is not available, but here are a few samples of Resnik's commentary:

"The abandonment of vaginal breech delivery, concerns about operative vaginal delivery and shoulder dystocia, and waning enthusiasm for VBAC all contributed to the unprecedented change in obstetric practice. Obstetricians were justifiably unwilling to challenge the zero-tolerance legal environment and public expectation for a perfect outcome every time, and cesarean delivery seemed to be the answer."

"Moreover, although difficult operative vaginal deliveries may be associated with fetal intracranial trauma, the procedure and complications are rare, reliable long-term follow-up data are hard to find, and most children do not sustain permanent injury. The same may be said for shoulder dystocia; it has been estimated that several hundred cesarean deliveries would be required to prevent one case of persistent brachial plexus injury."

"What about the maternal benefits of cesarean delivery? There is little argument that vaginal delivery is associated with a higher frequency of subsequent stress urinary incontinence and uterine and vaginal prolapse. However, it is also clear that nulliparous women and those who have had only cesarean delivery may also be symptomatic, suggesting that the aging process, pregnancy per se, genetic factors, and just walking upright for more than 50 years are significant contributors to the problem. Also, although prevalence figures vary widely, some studies suggest that the risk of symptomatic pelvic floor dysfunction occurs in less than 50% of parous women and that only 11% of women require surgery."

"What about the maternal benefits of cesarean delivery? There is little argument that vaginal delivery is associated with a higher frequency of subsequent stress urinary incontinence and uterine and vaginal prolapse. However, it is also clear that nulliparous women [Note: nulliparous=women who have not had children] and those who have had only cesarean delivery may also be symptomatic, suggesting that the aging process, pregnancy per se, genetic factors, and just walking upright for more than 50 years are significant contributors to the problem. Also, although prevalence figures vary widely, some studies suggest that the risk of symptomatic pelvic floor dysfunction occurs in less than 50% of parous women and that only 11% of women require surgery."

Based on this commentary and responses to the NIH conference, it seems that there is much disagreement over appropriate use of c-section, and confusing or absent evidence regarding the topic. Why so much confusion over a major abdominal procedure? Resnik hits some of the high points - fear of malpractice, changing attitudes, expectations of perfect/easy deliveries every time. In the meantime, women are left with little recourse but to work closely with their birth attendants, try to understand the factors affecting their individual births, and to insist on an evidence-based rationale for their care. It's confusing out there - good luck.

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MeSH Tags: Cesarean Section/trends OR /utilization; Surgical Procedures, Elective

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