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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