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:

The Politics of Cesarean Surgery ~
What obstetricians are saying to each other about Cesarean Surgery

---

Elective C-section Revisited by Dr. Elaine Waetjen;
Ob.Gyn.News; August 1, 2002, Vol 36, No 15;

Maternal-Choice Cesarean – Safer than Normal Birth? Excerpt ~ Transcript of Diane Sawyer interview of ACOG president Dr Ben Harer on Good Morning g American June 2000

Prophylactic Cesarean Section at Term? Drs Feldman & Friedman
New England Journal of Medicine1985, 312:1264-1276,

Elective Cesarean Section: An Acceptable Alternative to Vaginal Delivery?  
Dr Peter Bernstein, MD, MPH; Medscape Ob/Gyn &Women’s Health, posted 9/16/02  

Violence Against Women in Health Care Institutions: an emerging problem
British Medical Journal /The Lancet, May 11, 2002  

Shoulder Dystocia Rate Constant Despite Risk Factors – Mediolegal Implications
 Parity, C-Section, Birth Wt / Ob.Gyn.News, May 15, 2003, Vol 38, No 10;

 Experts Say Cesarean Section Rates are Headed ‘Sky-High”;  
Ob.Gyn.News, April 1, 2002, Vol 37

 Experts Say Guideline Out of Step with Trend Toward Elective C-Section
Ob.Gyn.News Dec 1, 2002, Vol 37, No 23;

 Offering C-Section “On Demand” Can Be Ethical: ACOG Doctors ‘ethically justified’ in performing procedure  /  Ob.Gyn.News Dec 1, 2003, Vol 38, No 23;  

---

Elective C-section Revisited by Dr. Elaine Waetjen; Ob.Gyn.News; August 1, 2002, Vol 36, No 15;  

The prophylactic use of elective cesarean section to prevent pelvic organ prolapse and urinary incontinence is gaining increased attention. Dr Benson Harer, Jr, past president of the American College of Obstetricians and Gyncologists, stated publicly last year that women should have the right to choose a cesarean delivery. 

 

....why shouldn't we offer prophylactic C-section to prevent this problem later in life?

 

The answer is that the evidence does not support this approach. Preventive strategies should cause no more harm than the disease or problem that they are tying to prevent. Ideally, they should incorporate some kind of screening to identify people at risk. They should be cost effective and based on very good evidence of benefit. Elective C-section to preserve pelvic floor function fails on all there measure. 

 

“Cesarean surgery causes more maternal morbidity and mortality than vaginal birth. In the short term, C-Section doubles or triples the risk of maternal death, triples the risk for infection, hemorrhage and hysterectomy, increase the risk of serious blood clots 2 to 5 times and causes surgical injury in about 1% of operations.
 

In the long term, cesarean section increases the mother’s risk of a placenta previa, accreta or percreta, uterine rupture, surgical injury, spontaneous abortions and ectopic pregnancies while decreasing fecundity.

 

Babies delivered by cesarean have a higher risk of lung disorders and operative lacerations.” Cesarean babies also suffer triple the rate of asthma as adults. (*Cesarean Birth Associated with Adult Asthma -- ObGynNews, 6/15/01, Vol  36, N0. 12)  

 

…would have to do 23 C-sections to prevent one such surgery [for organ prolapse or incontinence) later in life. So instead of offering elective cesarean in an attempt to prevent future prolaspe or incontinence, we should be examining what we can do in our management of vaginal deliveries to protect pelvic floor function”.

---

The Maternal Choice Cesarean – ACOG’s the ‘ideal’ standard of care?

A very short excerpt from a segment on “Good Morning America” (Jun 2000) promoting the “maternal choice” cesarean by obstetrician Ben Harer, MD, then president of the American College of Gynecologists:

Diane SAWYER  … 

One in five now have cesarean sections but you say cesareans are safer and in fact better, and that in the future, women should be able to choose and in fact that maybe they should be routine.

Dr. Ben HARER:     

For the baby, the risks are far higher for vaginal delivery than for an elective cesarean section at term. 

For the mother, the immediate risks for a cesarean section are a little higher, but the longer term risks of pelvic dysfunction, … incontinence, pelvic dysfunction--those risks are higher for vaginal birth and over the long time I think that the risks balance out, that there really is no big difference.

Prophylactic Cesarean Section at Term? by George B. Feldman, MD, Jennie A. Feldman, MD; 
NEJM, May 1985,  

[The Doctors Feldman & Friedman make the “case” for Cesarean on demand and promote the idea that a 100% scheduled or “prophylactic” cesarean become the norm for all women. This drastic idea is seen as a preemptive strike to protect the baby from the “dangers” normal labor and birth and would change the professional focus of doctors to determining when fetal lung maturity was achieved so that the CS could be scheduled before (gasp!) the mother went into spontaneous labor and (gulp!) gave birth naturally!] 

The Doctors Feldman & Friedmen make a statistical case for cesarean surgery as “saving” babies with only a little “excess” or “extra maternal mortality” and opin that the “low cost of excess maternal mortality” may be a price worth paying. Here is a short excerpt:

p. 1266 ….the number of extra women dying as a result of a complete shift to prophylactic cesarean section at term would be 5.3 per 100,000….  This may be the proper moment to recall that the number of fetuses expected to suffer a disaster after reaching lung maturity is between 1 in 50 to 1 in 500. … if it could save even a fraction of the babies at risk, these calculations would seem to raise the possibility that a shift toward prophylactic cesarean section at term might save a substantial number of potentially healthy infants at a relatively low cost of excess maternal mortality.

We probably would not vary our procedures if the cost of saving the baby’s life were the loss of the mother’s. But what if it were a question of 2 babies saved per mother lost, or 5 or 10 or (as our calculations roughly suggest) as many as 36 or 360? ….  Is there some ratio of fetal gain to maternal loss that would unequivocally justify a wider application of this procedure? 

p. 1267….is it tenable for us to continue to fail to inform patients explicitly of the very real risks associated with the passive anticipation of vaginal delivery* after fetal lung maturity has been reached?  If a patient considers the procedure and decides against it, must she then be required to sign a consent form for the attempted vaginal delivery? 

Elective Cesarean Section: An Acceptable Alternative to Vaginal Delivery?
Dr Peter Bernstein, MD, MPH; 

Medscape Ob/Gyn & Women’s Health, posted 9/16/02  // Peter S. Bernstein, MD MPH, Associate Professor of Clinical Obstetrics & Gynecology and Women's Health, Dept of Obstetrics and Gynecology, Albert Einstein College of Medicine / Montefiore Medical Center, and Medical Director, Obstetrics & Gynecology , Comprehensive Family Care Center / Montefiore Medical Group, Bronx, New York 

Excerpt --> One argument often cited in favor of elective cesarean delivery is prevention of pelvic floor damage, which can occur with vaginal delivery. Stress urinary incontinence, pelvic organ prolapse, and anal incontinence have been associated with vaginal delivery. 

But these adverse side effects may be more the result of how current obstetrics manages the second stage of labor. Use of episiotomy and forceps has been demonstrated to be associated with anal incontinence in numerous studies. 

Perhaps also vaginal delivery in the dorsal lithotomy position with encouragement from birth attendants to shorten the second stage with the Valsalva maneuver [prolonged breath-holding], as is commonly practiced in developed countries, contributes significantly to the problem. 

Nonetheless, the  prevention of pelvic floor injury by routine elective cesarean delivery is not an appropriate solution. Rather, more research into the management of the second stage of labor is clearly necessary. Moreover, cesarean delivery does not guarantee protection against pelvic floor dysfunction, given the reports of similar rates of urinary incontinence in nulliparous woman as in parous women [2]

A potentially more persuasive argument in favor of elective cesarean delivery is based on the potential for fetal risks before and during vaginal delivery, including intrapartum death, intrapartum acquired hypoxic ischemic encephalopathy, and stillbirth at term before the onset of labor. What is not clear, however, is how many cesareans would have to be performed to avert these disastrous event and what the cost would be in terms of maternal morbidity and mortality in order to prevent a single untoward fetal outcome. 

To suggest that performing an elective cesarean delivery in a low-risk patient will avert intrapartum fetal injury is very misleading. These outcomes are rate, even in higher-risk women. Indeed, they are so rate in women without any identifiable risk factors that an absurd number of cesarean deliveries would need to be performed to avert even one of these poor outcomes. Thus, resorting to cesarean delivery would not be appropriate standard procedure.

Although cesarean delivery has clearly become safer over the past 50 years with advances in antibiotics, anesthesia and thromboprophylaxis, it is still not without risks. Woman undergoing cesarean delivery have greater blood loss and risk of damage to internal organs. The mortality risk of under going an elective cesarean delivery with no emergency present has recently been reported as almost 3 times the risk of vaginal delivery. [3] In addition, risks to the fetus associated with cesarean delivery range from lacerations [a cut in the baby's face or head when the surgeon makes the incision into the uterus] to respiratory distress syndrome and transient tachypnea of the newborn. Although these are typically manageable, their cost will be multiplied many times over if more elective cesareans are performed. 

One of the most significant risks of cesarean delivery is the need for a subsequent cesarean delivery.  ...  A repeat cesarean delivery carries significantly more risk in terms of placenta previa, placenta accreta, uterine rupture, injury to internal organs during surgery excessive blood loss, need for hysterectomy and maternal death. These risks rise with each subsequent repeat cesarean delivery. Risk of [placenta] accreta and previa increases with each subsequent cesarean delivery, reaching a risk of > 60% in women with 4 or more cesarean deliveries. [4] In addition, the incidence of emergency peripartum hysterectomy for abnormal placentation seems to be rising as a result of the increase rates of cesarean delivery.  

A move toward routine elective cesarean delivery may also have significant costs in terms of lost opportunities for bonding between mother and newborn. A woman who has had a cesarean may be less able to care for her child and may have a more difficult time breastfeeding .....  Although this impact may be small for the individual patient, again, its costs multiplied over a large population may be great, based on the accumulating evidence for the benefits of successful long-term breastfeeding. 

Arguments made by proponents of elective cesarean that it should only be provided to women who intend to have only 1 or 2 children fall flat, given that the rates of unintended pregnancy in the US approach 50%. And what of the woman who changes her mind 10 years later and chooses to have another child after having had 2 prior cesareans?  

There may be no legal liability to the physician who performed the patient's first cesarean section when the patient winds up with a hysterectomy or worse, but that does not clear that physician of responsibility for performing a surgical procedure of unclear benefit upon a patient's request. 

Some argue that, from an ethical point of view, allowing a patient to choose to deliver by cesarean is not substantially different from allowing her to choose to undergo cosmetic surgery. But cesarean is very different. The benefits of elective cesarean relative to vaginal delivery are not established and the risks are substantial, especially given the potential for future repeat cesareans. 

That women are seeking elective cesarean deliveries is probably more significant in that it indicates the failure of modern medicine and society at large in the sense that women may fear the experience of labor and birth attendants may fear the legal risks of allowing appropriate women to have a trial of labor. Modern management of labor should be reassessed to address the concerns raised by proponents of elective cesarean delivery. If elective cesarean becomes an acceptable alternative, we may never be able to undo the practice. 

Peter S. Bernstein, MD MPH, Asssociate Professor of Clinical Obstetrics & Gynecology and Women's Health, Dept of Obstetrics and Gynecology, Albert Einstein College of Medicine/Montefiore Medical Center, and Medical Director, Obstetrics & Gynecology , Comprehensive Family Care Center/Montefiore Medical Group, Bronx, New York 

Excerpt --> Violence Against Women in Health Care Institutions: an emerging problem ~  British Medical Journal /The Lancet, May 11, 2002  

Other important forms of violence against women occur in reproductive health services and deserve more discussion than is possible in a short article. 

These forms include excessive or inappropriate medical treatments in childbirth, such as doctors doing caesarean sections for reasons related to their social or work schedules or financial incentives or adhering to obstetric practices that are known to be unpleasant, sometimes harmful, and not evidence based, including shaving pubic hair, giving enemas, routine episiotomy, routine induction of labour and preventing women having companions in labour. 

Shoulder Dystocia Rate Constant Despite Risk Factors – Mediolegal Implications Parity, C-Section, Birth Wt / Ob.Gyn.News, May 15, 2003, Vol 38, No 10;  

Shoulder dystocia appears to occur at a constant rate, despite increased cesarean sections and variations in other risk factors, Dr. Michael Lucas reported at the annual meeting of the Society for Gynecologic Investigation. 

“It seems counterintuitive,” said Dr. Lucas of the University of Texas, Houston, in an interview. “There's this notion that if we manipulate the risk factors we should see a lower rate of shoulder dystocia, but that does not appear to be the case.” 

His study of more than 12,650 births in two Houston hospitals showed a similar rate of shoulder dystocia, despite differences in the risk factors of parity, birth weight, cesarean delivery, and operative vaginal delivery between the two hospital populations. The findings could have implications in the defense of shoulder dystocia cases. 

“The argument has always been that there are risk factors for shoulder dystocia, which the physician should have acted on,” he said. “Our data suggest this is not true. It may at least be argued that we can take a population with a much different rate of risk factors and have virtually the same rate of shoulder dystocia. This is important clinically, because it supports the notion that our options and our ability to avoid trauma with this complication are limited.” 

Dr. Lucas researched the obstetric databases of an urban public hospital and a community teaching hospital ... The community hospital had twice the rate of cesarean deliveries, fewer multiparous mothers, a lower operative vaginal delivery rate, and smaller babies, factors usually associated with lower rates of shoulder dystocia. 

Still, both hospitals had virtually the same incidence of shoulder dystocia: 1.1% and 1.3% of vaginal births at the public and community hospital, respectively...The community hospital had a higher cesarean delivery rate than the public hospital (30% vs. 14%) and more babies weighing less than 4,000 g (59% vs. 41%). 

Babies with shoulder dystocia tended to be smaller (3,844 g vs. 4,117 g) at the community hospital .. The operative vaginal delivery rate was higher at the public hospital than at the community hospital (11% vs. 8.5%). 

... the high cesarean delivery rate, lower rate of multiparity, and lower birth weight at the community hospital were not associated with a reduced rate of shoulder dystocia. 

“It seems intuitive to say if you avoid a vaginal delivery you can lessen the rate of shoulder dystocia, but this doesn't appear to hold water,” Dr. Lucas said. 

Experts say Cesarean Section Rates Are Headed ‘Sky-High’ – Fewer VBACs cited as one factor [ACOG ‘no vaginal breech’ policy] Ob.Gyn.News, April 1, 2002, Vol 37

Cesarean section rates are headed up, up and away.  

According to the CDC, the VBAC rate …dropped from 28% in 1996 to 20% in 2000.  “I suspect that the cesarean section rate is probably going to double by the next generation,”  “speakers cited multiple contributing factors --  the American College of Obstetrics and Gynecologists’ recent recommendation that vaginal birth after cesarean section (VBAC) be attempted only if physicians are “immediately available” to provide emergency care.”   “That’s already having a chilling effect.”

“the recent ACOG practice bulletin recommending against planned vaginal delivery of singleton breech presentations will cause a bump in C-section rates.  …three quarters of such cases are already managed by planned C-section. A bigger contributor … the patient choice issue, with a growing number of women opting for C-section to avoid perineal dysfunction after vaginal delivery..” 

There is no mistaking ACOG’s intent …VBAC be restricted to setting where physicians are ‘immediately available’ ….”I don’t think ‘immediately’ means your in your office 6 blocks away or you’re at home. I think it means your backside is in the hospital.” Denver ob.gyn in private practice, said that the ‘immediately available’ criterion has put physicians like him in a bind.

“the real issue now is whether you’re willing to have an obstetrics practice where you’re going to devote a person to staying in the hospital all the time. If you don’t have a [medical] resident staff to help you, and you’re a practitioner who’s totally in control of your patients all the time and responsible to them, I’m going to predict for you – as I can now see happening in Denver --- that the C-section rate is going to go sky-high,” he said.

Rural obstetricians cited another problem: Even though many of them would like to offer their patients VBAC, they typically can’t get an anesthesiologist or nurse anesthetist to stay in the hospital. And this precludes VBAC because of the now-unacceptable medicolegal risk.   

[Note the risk to the mother is the same as it has always been -- which is to say low for spontaneous labor. However,  the focus of this concern is not the mother’s risk at the time of the labor or future pregnancies to her and her next baby as a direct result of a medically unnecessary repeat cesarean but instead on the physician’s malpractice risk defined as ‘now’ unacceptably high as a direct result of legal standard created by ACOG]  

The recent change in practice regarding singleton breech....

… cited a highly publicized study by the Term Breech trial Collaborative Group as its basis …. led to ACOG’s recommendation in December against planned vaginal delivery. 

The study has flaws rendering it vulnerable to criticism  [editor's note: some of the 'breech’ deaths in the vaginal breech cohort were of unrelated causes, such as SIDS death]  

None the less, the speaker agreed that once it was published, the fate of planned vaginal delivery of … breech was sealed. There had already been increasing concern among ob.gyn leaders regarding younger American’s obstetrician’ lack of experience with the procedure  

“People have been doing cesarean deliveries for breeches because they wanted to avoid medicolegal issues  This study was the icing on the cake. It was what everyone was waiting for,” 

Today, a highly motivated woman seeking vaginal breech delivery may with difficulty be able to find an obstetrician experienced in the procedure and willing to take the medicolegal risk. “I guarantee that in another generation they’re not going to be able to find anyone to do it,” Dr Gibbs said. (28)  

---

Experts Say Guideline Out of Step with Trend Toward Elective C-Section, Ob.Gyn.News Dec 1, 2002, Vol 37, No 23;  

Practice guideline discouraging scheduled elective cesarean section are out of step with increasingly liberal attitudes toward the procedure on the part of rank-and-file ob.gyns, panelists asserted at the 12th International Pelvic Reconstructive and Vaginal Surgery Conference. 

Many ob.gyns are persuaded that elective C-section protects a woman's pelvic floor and thereby prevents future problems with incontinence and prolapse. And they believe that large numbers of patients would opt for the procedure if fully informed about the risks and benefits of cesarean section and vaginal delivery. 

I'm all in favor of the C-section. ... I personally think a woman has a right to decide how she wants her baby delivered. And I feel like more and more of my colleagues are saying the same thing," said Dr. Sebastian Faro, professor of ob.gyn at the University of Texas...

Woman can choose to have a breast implant, so why can't they choose to have a C-section if they don't ant to go through the process of labor, Its their body," argued Dr Figueiredo Netto, an ob.gyn at Londrina (Brazil) State University. 

He cited the Brazilian experience as evidence suggesting C-section prevents pelvic floor injury. The vast majority of private practice patients routinely opt for cesarean section; in some obstetricians' practice, the rate is 90%. In Brazil, we've been studying the outcomes of purely elective cesarean section with pathology versus labor. So far, I've been convinced that c-section is not all that much more morbid. 

---

 Offering C-Section “On Demand” Can Be Ethical: ACOG Doctors ‘ethically justified’ in performing procedure
 /  Ob.Gyn.News Dec 1, 2003, Vol 38, No 23;  

A physician who believes elective cesarean delivery is in the best interest of the mother and her fetus is ethically justified in performing the procedure, according to a committee opinion issued last month by the American College of Obstetricians and Gynecologists. 

This is critically important. Now we have an ACOG opinion saying it is ethical to perform an elective cesarean,"  Dr Ben Harer, a past president of the college... 

This decision is ... complicated by the lack of data on the risks and benefits of cesarean vs. vaginal delivery, the committee said. 

Doctors are not obligated to initiate discussion on the relative risk of cesarean compared with vaginal delivery with every pregnant patient, given the lack of good comparative data ....

Still, the document could open the door for an even greater increase in the rate of elective cesarean deliveries, which is not necessarily a negative development as long as the patients are selected appropriately, according to Dr Harar, who is medical director of the Riverside County Regional Medical Center in Moreno Valley, California. 

The committee opinion may in part reflect the fact that obstetricians currently emphasize the short-term benefits of vaginal delivery and downplay its potential long-term complication such as vaginal prolapse and incontinence, ....

"The overall rate of complication from attempting vaginal delivery, particularly when both short and long-term complications are considered, is significantly higher than the rate seen in elective cesarean section said Dr. Bost, who supports elective cesarean in appropriate cases. "

"Just because the decision for attempting vaginal delivery is separated from the complications it produces by 10-20 years doesn't mean it should be discussed now," he said.