Elective cesarean sections are too risky, WHO study says

By Katherine Harmon

Despite medical advances and increasing access to improved obstetric care across the globe, surgical childbirths are still more risky for both mother and baby, according to an ongoing international survey by the World Health Organization (WHO).

A new report from the survey, which was published online today in the medical journal The Lancet, found that in Asia—in both developed and developing nations—cesarean section births only reduced risks of major complications for mother and child if they were medically recommended. Elected surgical deliveries, on the other hand, put both at greater risk.

"Cesarean section should be done only when there is a medical indication to improve the outcome for the mother or the baby," the authors of the report concluded. Common reasons for a recommendation for cesarean delivery included a previous cesarean section, cephalopelvic disproportion (when the baby's head cannot fit through the mother's pelvic opening) and fetal distress.

In the nine countries studied (Cambodia, China, India, Japan, Nepal, the Philippines, Sri Lanka, Thailand and Vietnam), more than a quarter of the 107,950 births analyzed (27.3 percent) were C-sections, and in China, which had the highest rate of operations, nearly half (46.2 percent) of the births in the survey were cesarean. With these surgeries comes increased risk of maternal death, infant death, admission into an intensive care unit, blood transfusion, hysterectomy or internal iliac artery ligation (to control bleeding in the pelvis) compared to spontaneous vaginal delivery, according to the report.

But these risks have not necessarily been absorbed into popular, or even medical culture. The rates of cesarean section procedures are on the rise in many countries across the globe, the authors report, and in some countries they "have reached epidemic proportions." Among the nations studied, China had the highest rate of cesarean sections that were performed without medical indication—11.7 percent; the overall rate for the facilities studied had a rate of 1.9 percent.

Most cesarean sections (15.8 percent of births) were begun during labor, as opposed to before it starts. But these later procedures—both elected (0.5 percent) and medically required (15.3 percent)—also carry the most risks for adverse outcomes, the authors found.

In a commentary accompanying the report, Yap-Seng Chong of the National University of Medicine in Singapore and Kenneth Y C Kwek of the KK Women's and Children's Hospital also in Singapore call the results "surprising and chilling." The findings, they say "should help us to prioritize our strategies to reduce unnecessary interventions in childbirth," they wrote. "There is little wrong with medical interventions when indicated, but for those who are still inclined to consider caesarean delivery a harmless option, they need to take a cold hard look at the evidence against unnecessary cesarean section."

The investigators were able to analyze some 96 percent of the births reported in the 122 hospitals that participated in the survey over two to three months between 2007 and 2008. Facilities were located in the capital city of each country and two randomly chosen regions. To qualify for the survey, hospitals had to be delivering at least 1,000 babies a year and performing cesarean surgeries, so as the authors noted, "the results therefore cannot be generalized to smaller facilities" or to the countries overall.

Despite the increased risks associated with cesarean deliveries, no mothers or babies in the study died after an elected cesarean before hospital release. The most dangerous form of childbirth proved to be vaginal operative delivery, which includes using forceps or a vacuum to assist in delivery and is more rare, occurring in just 3.2 percent of the births analyzed.

The findings confirm a previous WHO report published in 2006 in The Lancet, analyzing the rates and safety of various childbirth approaches in Latin America, where the investigators found that "increasing rates of cesarean section do not necessarily lead to improved outcomes and could be associated with harm." Taking the two reports together, the authors concluded, lends "strong multiregional support for the recommendation of avoiding unnecessary cesarean sections."

Surgical childbirth also requires more resources than a natural vaginal delivery, the authors note. Especially in countries where money, medical practitioners or proper equipment is more limited, unnecessary cesarean sections can drain resources away from those cases in which it can improve the chances of a healthy mother and baby.

http://www.scientificamerican.com/blog/post.cfm?id=elective-cesarean-sections-are-too-2010-01-11

5 Reasons to Avoid Induction

The Risk of Inducing Labor

By Robin Elise Weiss, LCCE, About.com

The induction of labor can be done for many reasons, including many valid medical reasons. However, the rise in the rate of social inductions, or elective inductions is on the rise. As the induction rate rises there are more babies and mothers placed at risk for certain complications. Here are five risks of induction that you may not know about:

1. Increased risk of abnormal fetal heart rate, shoulder dystocia and other problems with the baby in labor.
Labor induction is done by intervening in the body's natural process, typically with powerful drugs to bring on contractions or devices that are used to break the water before labor starts. Both of these types of induction can cause the baby to react in a manner that is called fetal distress as seen by fetal monitoring.

The nature of induction like contractions may also be more forceful than natural labor. This can cause your baby to assume or stay in an unfavorable position for labor making labor longer and more painful for the mother. It can also increase the need for other interventions as well.

2. Increased risk of your baby being admitted to the neonatal intensive care unit (NICU).
Babies who are born via induction have not yet sent signals to the mother to start labor. This means that they simply aren't yet ready to be born. This risk is worth it if the baby or mother's lives are in danger, but simply to take this risk for elective reasons may not be well advised.

When a baby is in the intensive care unit there is less ability for you to be with your baby or to hold your baby. Breastfeeding usually gets off to a rocky start as well. This can usually be avoided by giving birth when your body and baby say it is time.

3. Increased risk of forceps or vacuum extraction used for birth.
When labor is induced babies tend to stay in unfavorable positions, the use of epidural anesthesia is increased and therefore the need to assist the baby's birth via the use of forceps and vacuum extraction is also increased.

4. Increased risk of cesarean section.
Sometimes labor inductions don't take, but it's too late to send you home, the baby must be born. The most common cause of this is that the bags of waters has been broken, either naturally or via an amniotomy. Since the risk of infection is greater, your baby will need to be born via c-section.

A cesarean in an induced labor is also more likely for reasons of malpresentation (posterior, etc.) as well as fetal distress.

5. Increased risks to the baby of prematurity and jaundice.
Induction can be done before your baby is ready to be born, because your due date is off or because your baby simply needed more time in the womb to grow and mature their lungs. Your baby may also be more likely to suffer from jaundice at or near birth because of the induction. This can lead to other medical treatments as well as stays in the hospital for your baby.

Being born even a week or two early can result in your baby being a near term or late preterm infant. This means that your baby is likely to have more trouble breathing, eating and maintaining temperature.

CDC Says Cesarean Triples Neonatal Death Risk

by Misha Sanfranski
While the increased risks of cesarean section to neonatal and maternal health have long been known, an even more grim issue came to light in a study released in the September, 2006 issue of Birth Journal. The CDC conducted research on cesarean section and neonatal mortality, expecting to
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find that the neonatal mortality rate (defined as death within the first 28 days of life) following cesarean section correlated directly with medical complications of the mother and baby. What they found, instead, was that regardless of risk factors, babies born by cesarean section face a risk of death nearly three times that of vaginally born babies.

MacDorman, et al. analyzed national birth and death data for 5,762,037 live infants and 11,897 neonatal deaths, for the years 1998-2001. The purpose of the study was to examine the neonatal outcomes of primary cesarean delivery in women who had no other known complications or medical risk factors. The logical result of this examination would seem to be comparable neonatal mortality rates among cesarean and vaginally born infants. In fact, what the results show is that cesarean independently raises the risk of neonatal death by almost three-fold - .62 per 1000 deaths among vaginal births versus 1.77 per 1000 infant deaths among cesarean babies.

Even more astounding than the simple fact that cesarean section raises the risk of infant death - regardless of the reason the cesarean was performed - is that even when the researchers adjusted for sociodemographic, medical and congenital factors, and removed infants with APGARs under 4, the risk of death was only reduced "moderately". A stark difference in the death rates between cesarean born infants and vaginally born infants remained even with no medical explanation.

We aren't talking about babies dying from the few, rare complications that can arise in childbirth. We're talking about healthy, low-risk mothers electing for a primary cesarean section with no medical indication resulting in a nearly three times higher rate of death than those who have a vaginal birth.

According to Marian MacDorman, the CDC's study leader, "These findings should be of concern for clinicians and policymakers who are observing the rapid growth in the number of primary Caesareans to mothers without a medical indication."

While the findings of this research on cesarean and neonatal mortality were reported by major media outlets upon its release, publicity for the issue quickly waned. It is evident that care providers and mothers have continued to discount the disturbing results of the CDC study on neonatal
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mortality and cesarean, as the rate of surgical delivery has continued to climb to a record-breaking high of 31.8% in 2007, up from 31.1% in 2006.

The World Health Organization recommends no more than a 10% cesarean rate in developed countries, based upon research indicating more harm than good to both mothers and babies when the cesarean rate tops 15%. Until mothers and obstetricians start taking the risks of elective cesarean section seriously, we will likely continue to see tragic consequences of the interference of surgery in childbirth.

References:

MacDorman MF, Declercq E, Menacker F, Malloy MH.

Division of Vital Statistics, NationalCenter for Health Statistics, Centers for Disease Control and Prevention,

Hyattsville, Maryland20782, USA. Birth. 2006 Sep;33(3):175-82.

The Real Risk of C-Section - Medscape Interview

Editor's Note:

Cesarean section (c-section) is the most commonly performed surgery in the United States. The frequency of surgical birth has increased from 4% in 1965 to about 33% today, despite World Health Organization (WHO) recommendations that a 5% to 10% rate is optimal and that a rate greater than 15% does more harm than good.^[1-3]

Reasons for this increase have been discussed profusely:

• The surgical focus of obstetrics and the need to train residents;
• The low priority and few practical skills for supporting women's abilities to labor and give birth naturally;
• A rigid view of the duration of normal labor; and
• A low threshold of definition for 'labor dystocia' (the justification for up to 60% of cesarean births^[4]).

Surgical birth is also a 'side effect' of interventions associated with actively managed labor: induction, artificial rupture of membranes, labor medications, and fetal monitoring.^[5,6] Policies against vaginal birth after cesarean (VBAC) and, increasingly, unsupported 'supply-side' justifications such as "baby seems large," also drive the trend toward cesareans. A recent report by the Lamaze Institute associates surgical birth with obstetricians' personalities -- specifically their anxiety levels.^[7-9]

The risks for birth by surgery have also come under discussion. Maternal risks include a higher overall death rate, rehospitalization for wound complications and infection, placenta accreta and percreta (both with 7% mortality rate), placenta previa, uterine rupture with subsequent pregnancy, and preterm birth, with its own set of risks and complications for the newborn.^[10-15]

Pamela K. Spry, BSN, MS, CNM, PhD, the President of Lamaze International, a leading childbirth-advocacy group, spoke with us about the risks for birth by scalpel.

Medscape: Childbirth methods are often trend-driven. In the 1960s and 1970s, there was a big push for natural childbirth. What has driven women away from that method since then?

Dr. Spry: In the 1960s, women were rebelling against twilight sleep -- childbirth under heavy narcotics that required being strapped down to the delivery table. There was also the push for fathers to be in the delivery room, which wasn't allowed, and certainly not during heavily sedated birth. Now we have a widespread availability of local and regional methods of pain relief that let women be awake and aware, share the birth with their families, and basically rely on technology to assist them at birth. I think this drive has been somewhat alleviated, but there is still a push for natural childbirth. This is the reason women are still seeking classes, making birth plans, and choosing home birth and birthing centers.

"Natural childbirth" can mean different things to different people. For Lamaze, it means a birth that's allowed to happen on its own without the use of unnecessary medical interventions, to provide women the safest and healthiest birth possible.

Medscape: Are rates of surgical delivery being driven up by women or clinicians? Is this the age of Blackberry birth -- scheduling everything ahead of time?^[16]

Dr. Spry: Actually, there are 2 parts to this question. One is, what has driven up the rate of repeat cesareans, and that answer is easy: there has been a big decrease in the availability of choosing to labor and deliver vaginally (VBAC) after having 1 or 2 previous cesarean births, causing a huge increase in the rate of surgical delivery [for repeat cesareans]. Compared with the early 1990s when VBACs were encouraged and acceptable, many hospitals, insurance companies, and clinicians now refuse to allow women to try laboring after a previous c-section because of perceived medical and legal risks.

The second part of the question is whether women or clinicians are responsible for the increase in the primary c-section rate, and I think that's more difficult to answer. In a study of more than 1500 women, we tried to determine just that. The research results indicated that only 1 woman in the study actually reported that she requested a cesarean, which leaves the decision for the vast majority of cesarean deliveries up to clinicians. So understanding when cesareans are medically necessary, as well as the risks involved, is important in achieving a safe and healthy birth.

Although it might be convenient, babies who are born before they are ready are at increased risk for major medical problems.

Medscape: Could fear be the reason for women agreeing to surgical birth? Are women enduring pain differently than in previous decades? Is the surgical scenario easier to contemplate than the unknowns of a natural labor and delivery?

Dr. Spry: Exactly. I think all of that has to do with the fact that our culture actually breeds fear around childbirth. We've got TV shows, popular culture, and horror stories from friends and families; women are taught to expect a negative experience and incredible pain. Lamaze is focused on trying to help women get the facts, know what to expect, and help take the fear out of the process. But the unknown parts, such as labor, its duration, birth, and even the unknown of when labor will start, makes it more appealing for some women to schedule a cesarean.

Medscape: The culture of hospital obstetrics seems designed for interventions, with cesarean procedures bringing in more money than natural delivery. Do you think hospital financial incentives are a reason for the rise in cesareans? Or would the costs for longer hospital stays with cesarean procedures balance out the revenues from them?^[17]

Dr. Spry: I think that sometimes financial concerns, convenience, or concerns over lawsuits do rule medical decision-making around childbirth. When women have a good understanding of what constitutes quality care, they are in a better position to ask for it from their care providers. Interestingly enough, I just returned from our nurse-midwifery convention in Seattle, and I heard a speaker address this very thing: reducing the cesarean rate. Among his suggestions was the provocative notion that providers should be reimbursed the highest rate for labor and vaginal birth after cesarean, followed by labor and vaginal birth, and the lowest reimbursement for scheduled, elective cesarean delivery. That way, providers would be compensated for their actual time involved in the process, and scheduled c-sections would have the lowest reimbursement. He thought that would make a difference.

Medscape: What are the main risks these days with c-sections? Are these risks underplayed by obstetricians, and, if so, why?

Dr. Spry: Many of them were covered in the introduction. Any time we schedule a surgery or an induction, we are assuming that we know the baby's due date. Anything that's scheduled before a woman's estimated due date could result in a baby being born before it's ready. [And iatrogenic prematurity is a reality with any scheduled birth -- that is, due dates may have been calculated wrong and inadvertently, babies are born before they are actually term.] We're getting more research looking at the near-term preemie. We find that they have breathing and developmental problems and that the risk for death is increased. Certainly, cesarean delivery increases the risk for the baby being injured from the incision. Surgery also carries risks for women, such as blood loss, clotting, infections, severe pain, and adverse anesthesia-related events. This is something that we haven't focused on, and I'm not certain that informed consent includes this information -- that there are complications during future pregnancies and that it does risk future children. There is an increased risk for stillbirth with a second or third c-section, as well as placental problems like percreta and accreta (abnormal growth and attachment of the placenta into the uterus), increasing the risk for hemorrhage. Women may experience dire complications as a result -- bladder injury, hysterectomy, and maternal death. I don't know that I would describe these risks as "underplayed" by obstetricians, but rather that women are not prepared to ask the right questions that lead to informed decision-making.

It would be interesting to read the informed-consent documents for cesarean deliveries, and see what risks are included.

Medscape: A story in The New York Times recently reported that women who have c-sections seem to have fewer children. That story provoked over 200 comments, from women who have had all of their children by planned cesarean to women who had had births at home. A strong fear-driven contingent regarded childbirth as fraught with pain and danger, and that anyone who risked giving birth outside of a hospital was committing child abuse. Can you discuss any evidence comparing the risks to mothers and children between in-hospital and at-home births?^[18]

Dr. Spry: A number of studies have looked at this. Some of the criticism of these studies has been that hospitals end up with higher-risk women, so it's an unfair comparison. But there are studies of low-risk women who had a planned home birth with a qualified birth attendant, compared with low-risk women who chose hospital births; the outcomes for home birth were better or as good as outcomes for women who birthed in hospitals.

Each study limits what kind of comparisons are made, but certainly women with previous surgical uterine scars, medical complications, or breech babies are all considered high-risk.

Medscape: The recovery period after any birth, from time immemorial known as the "lying-in" period, used to last several weeks after a birth. Now, even after surgical birth, women are up and around within a few days. Postpartum depression is another health consideration that has been much in the news lately. Do you think we have lost something with this shortened period of rest and recovery?^[19]

Dr. Spry: I do. Studies have shown that it's better for mothers and babies to stay together after birth. Experts agree that unless a medical reason exists, healthy mothers and babies should not be separated following birth. Interrupting, delaying, or limiting the time that a mother and her baby spend together may have a harmful effect on their relationship and on breast-feeding. Babies stay warm, cry less, and have a better start on breast-feeding if moms and babies are together.

[As for the question about depression], women with postpartum depression do experience difficulty bonding with their babies. But this could be a result of depression rather than the cause, so it's really hard to answer [whether a shortened period of recovery is related to causing postpartum depression]. Most people get 6 weeks off of work, but even in those 6 weeks, women are still running around [trying to take care of other children, do chores, and manage the household]. I don't know whether we, as a culture, discourage mothers and babies to be together in the postpartum period by no longer posting signs on the doors that say "Don't knock, baby sleeping!" I'm just not aware of any comparative studies on how different postpartum protocols correlate with postpartum depression.

Medscape: There's a marked trend toward inducing delivery -- vaginally or surgically -- before 40 weeks, with mounting evidence that this is risky business. Where is this coming from?^[20,21]

Dr. Spry: This increased induction rate has occurred for several reasons: the desire on the part of the women or the providers to arrange a convenient time for delivery. Again, it's a scheduling issue. Concerns about postmaturity, or a post-dates baby, with a fear of adverse outcome and litigation may have contributed to this. But despite the large number of women experiencing induction, one-half of the women who responded to the "Listening to Mothers" study said that they felt that labor should not be interfered with unless it's medically necessary. Eleven percent of the mothers also said that they had experienced some pressure from their care providers to have an induction. Lamaze gives this information to women to help them select their place of birth and communicate with their healthcare provider. These tools can assist women in having a safe and healthy birth.

Medscape: Even truly full-term infants born by cesarean end up in intensive care more frequently than their vaginally born peers. Is this because such infants born by cesarean are high-risk to begin with, or is the procedure itself responsible for this?

Dr. Spry: I think that it's both. I definitely think that some medically indicated surgical deliveries do end up with babies that were higher-risk to begin with. But if you compare low-risk babies that are born by cesarean with vaginal-birth babies, vaginal-birth babies do better. There is an increased likelihood of babies born surgically having problems with fluid in the lungs and less ability to clear it. So actually going through the birth canal seems to be better for the baby.

Medscape: In 2005, surgical birth was the most common Medicaid-billed procedure, performed on women who are most likely at risk for the poorest aftercare, complications, and support. Why is this population at highest risk for c-section?^[21]

Dr. Spry: I don't think this statistic indicates that the Medicaid population is at highest risk if they were compared to the insured population. I think that a large part of the Medicaid population consists of pregnant women, because this is a time when they can get coverage. So Medicaid often ends at the 6-week postpartum exam. A childbearing woman would be more likely to be covered under Medicaid than a woman in her forties who needed gallbladder surgery.

There have been a couple of studies that looked at the cesarean delivery rate of women with private insurance delivering in private hospitals, and found that privately insured women had a higher surgical risk than the Medicaid population. The rate in New York was 30% for private vs 21% for Medicaid, if the Medicaid women delivered in a public hospital (a teaching hospital). So what has happened is that we've had somewhat of a shift of Medicaid patients moving into the private sector; they've shifted their deliveries from teaching hospitals to private institutions, and this has increased their probability for cesareans.

A study from Kaiser in California showed that this increased risk persists even after adjusting for patient demographics and clinical factors. The risk was associated not so much with Medicaid, but with delivering in a private institution. Teaching hospitals tend to follow evidence-based practice, and encourage women to deliver vaginally.

Medscape: What's your perspective on recent reports about the rate of repeat cesareans jumping from 65% to 90% between 1997 and 2006?^[22]

Dr. Spry: Again, I think it's litigation fear. There have been more and more restrictions placed on women who want to have VBACs. Some insurance companies won't cover clinicians or hospitals [if they provide a trial of labor after cesarean; and] there are certainly clinicians who won't do VBACs. Women are finding it more and more difficult to seek and have a vaginal birth after a prior cesarean.

I just went to a conference where I talked to a number of women whose previous experience was with c-section, but who wanted a vaginal birth. Some of them chose home birth for their next pregnancies because it was their only option.

Medscape: As the concept of birth transitions from a physical, sexual, and societal passage to a billable surgical procedure, placing women in a more passive role, how is the overall well-being of women affected?

Dr. Spry: Within the maternity system, there's a distinct drive toward convenience: predictable process of labor and birth, maximized reimbursement, and limited liability. All of these factors can lead any care provider to make decisions that aren't necessarily based on the mother's and baby's needs. Women's decisions are affected as well, because without maximum reimbursement, they can't select a place of birth that they can't afford. I think it's critical for every birthing woman to recognize the realities of the environment and be prepared to advocate for herself, taking a more active role in her birth. This is something that Lamaze focuses on.

Studies have been done where a woman has experienced a kind of birth that she didn't want, and she felt that she had no control over it. Penny Simkin just gave an excellent talk on the risk of posttraumatic stress syndrome resulting from a birth in which a woman felt not in control, who felt decisions were made for her and were imposed on her. I think that sense of control is really important to the mental health and to the feeling of being competent and OK after birth.

Medscape: Obstetrics is a surgical specialty. So far, the significant numbers of women now practicing in the field have done little to change the surgical view of birthing women. Do you think there will be a tipping point away from the surgical approach to birth among obstetricians?

Dr. Spry: Sometimes it takes us years to figure out what we've been doing wrong; this is an alarming aspect of surgery, and few women are aware of the poor state of maternity care that we have in the United States. Many women assume that because they're birthing in the United States, they're getting quality care. Research and outcome studies suggest that this isn't necessarily the case, but I don't think our population knows that yet. We're seeing an increased number of maternal deaths. We haven't seen an increase in maternal deaths in this country for a long time. [An example of a delay in recognizing risk of accepted treatment is, that] in the 1950s, 1960s, and 1970s, we gave diethylstilbestrol to women to prevent miscarriage. It wasn't until the next generation, and even after the next generation -- 30 years -- that we got rid of that practice. So I think change will come. And I think that we need to continue to perform research, monitor maternal morbidity, and look at these statistics, and then we'll see a shift.

The other issue is that really adverse, terrible events are rare; maternal deaths are rare, even though they are increasing. So an obstetrician having a personal experience of a maternal death is infrequent.

Essential skills are being lost in obstetrics -- for example, breech deliveries or twins. However, they are preserved in the world of midwifery.

I hope that we get the message across that women want and need a positive birthing experience, and that they will choose a birth team that will support that goal. We would like for everybody to have a safe and healthy birth.

Cesarean vs, VBAC - a dramatic difference

This is such a touching video and eye opening video. Most people do not realize the force needed to get a baby out during a cesarean section - in the second birth, a vacuum is used as well as manual force. It is 16 minutes long, but worth the time.

Cesarean vs. VBAC: A Dramatic Difference from Alexandra Orchard on Vimeo.

C-section Births Cause Genetic Changes That Could Increase Odds For Developing Diseases In Later Life

Swedish researchers have discovered that babies born by Caesarean section experience changes to the DNA pool in their white blood cells, which could be connected to altered stress levels during this method of delivery, according to the July issue of Acta Paediatrica.

It is thought that these genetic changes, which differ from normal vaginal deliveries, could explain why people delivered by C-section are more susceptible to immunological diseases such as diabetes and asthma in later life, when those genetic changes combine with environmental triggers.

Blood was sampled from the umbilical cords of 37 newborn infants just after delivery and then three to five days after the birth. It was analysed to see the degree of DNA-methylation in the white blood cells - a vital part of the immune system.

This showed that the 16 babies born by C-section exhibited higher DNA-methylation rates immediately after delivery than the 21 born by vaginal delivery. Three to five days after birth, DNA-methylation levels had dropped in infants delivered by C-section so that there were no longer significant differences between the two groups.

“Delivery by C-section has been associated with increased allergy, diabetes and leukaemia risks” says Professor Mikael Norman, who specialises in paediatrics at the Karolinska Institutet in Stockholm, Sweden. “Although the underlying cause is unknown, our theory is that altered birth conditions could cause a genetic imprint in the immune cells that could play a role later in life.

“That is why we were keen to look at DNA-methylation, which is an important biological mechanism in which the DNA is chemically modified to activate or shut down genes in response to changes in the external environment

. As the diseases that tend to be more common in people delivered by C-section are connected with the immune system, we decided to focus our research on early DNA changes to the white blood cells.”

The authors point out that the reason why DNA-methylation is higher after C-section deliveries is still unclear and further research is needed.

“Animal studies have shown that negative stress around birth affects methylation of the genes and therefore it is reasonable to believe that the differences in DNA-methylation that we found in human infants are linked to differences in birth stress.

“We know that the stress of being born is fundamentally different after planned C-section compared to normal vaginal delivery. When babies are delivered by C-section, they are unprepared for the birth and can become more stressed after delivery than before. This is different to a normal vaginal delivery, where the stress gradually builds up before the actual birth, helping the baby to start breathing and quickly adapt to the new environment outside the womb.”

The authors point out that the surgical procedure itself may play a role in DNA-methylation and that factors other than the delivery method need to be explored in more detail.

“In our study, neonatal DNA-methylation did not correlate to the age of the mother, length of labour, birth weight and neonatal CPR levels - proteins that provide a key marker for inflammation” says Professor Norman. “However, although there was no relation between DNA-methylation and these factors, larger studies are needed to clarify these issues.”

Professor Norman states that the Karolinska study clearly shows that gene-environment interaction through DNA-methylation is more dynamic around birth than previously known.

“The full significance of higher DNA-methylation levels after C-section is not yet understood, but it may have important clinical implications” he says.

“C-section delivery is rapidly increasing worldwide and is currently the most common surgical procedure among women of child-bearing age. Until recently, the long-term consequences of this mode of delivery had not been studied. However, reports that link C-section deliveries with increased risk for different diseases in later life are now emerging. Our results provide the first pieces of evidence that early ‘epigenetic’ programming of the immune system may have a role to play.”

The authors feel that their discovery could make a significant contribution to the ongoing debate about the health issues around C-section deliveries.

“Although we do not know yet how specific gene expression is affected after C-section deliveries, or to what extent these genetic differences related to the mode of delivery are long-lasting, we believe that our findings open up a new area of important clinical research” concludes lead author Titus Schlinzig, a research fellow at the Karolinska Institutet.

Canadian docs to stop automatic C-sections for breech babies

Unfortunately here in St. George, there are no providers at the hospital that will do a planned vaginal breech birth. Hopefully, the US will take notice of Canada's new stance on breech birth and follow.
Vaginal breech birth is possible and surgical birth should not be the only choice. Your best chance for a vaginal breech birth, if you find yourself in that position, is a homebirth midwife. Do your research.
___________________________________________________________________

By Sharon Kirkey, Canwest News Service

In a major shift in medical practice and another assault on Canada's rising cesarean section rate, Canada's delivery doctors are being told to stop automatically scheduling C-sections for breech babies and attempt a normal delivery instead — something significant numbers of obstetricians aren't trained to do.

New guidelines issued Wednesday by the Society of Obstetricians and Gynaecologists of Canada say women carrying babies in the breech, or bottom-first, position should be given the right to choose to attempt a traditional delivery when possible.

The society says that women in Canada want the choice, and that some women with breech babies are delivering at home "because they knew if they went to hospital A, B or C it would not be offered," says Dr. Andre Lalonde, executive vice-president of the obstetricians' group and an adjunct professor of obstetrics and gynecology at McGill University and the University of Ottawa.

Lalonde says the group is working aggressively to ensure future specialists are trained in breech vaginal deliveries and is organizing courses across Canada for practising doctors to refresh their training.

"Paramount is the safe birth of the child," he said.

Most babies are positioned in the head-down position when labour starts. With breech babies, the feet or buttocks come out first during birth.

Breech babies account for about three to four per cent of all pregnancies in Canada, or about 11,000 to 14,500 pregnancies each year.

"Breech pregnancies are almost always delivered using a cesarean section, to the point where the practice has become somewhat automatic," Dr. Robert Gagnon, a principal author of the new guidelines and chair of The Society of Obstetricians and Gynaecologists of Canada's maternal fetal medicine committee, said.

"What we've found is that, in some cases, vaginal breech birth is a safe option and obstetricians should be able to offer women the choice to attempt a traditional delivery."

An international, Canadian-led study reported in 2000 that the safest way for breech babies to enter the world was via C-section. The study of more than 2,000 women found babies of mothers in the cesarean group were three to four times less likely to die, or have serious problems in the first six weeks of life, compared to those in the vaginal birth group (1.6 per cent versus 5.0 per cent).

The study had widespread influence worldwide. Many doctors stopped doing vaginal deliveries for breech babies, and many medical schools stopped training doctors in how to do them.

But the doctor who led the study said the risks, while different, were never huge. "The risks were still quite low," says Dr. Mary Hannah, a professor in the department of obstetrics and gynecology at the University of Toronto and Sunnybrook Health Sciences Centre.

More recent studies, including a study of more than 8,000 French and Belgian women carrying breech babies, found no significant differences in risks to babies whether they were born vaginally or via C-section.

Hannah says that a planned vaginal delivery of breech babies can be a safe and reasonable option. But, she said, most women she knows "will still want the option that is possibly safer, and that will be a planned cesarean section."

The main concern has always been delivery of the head — that the body will deliver, but that the baby's head will get caught.

"You can push the baby all the way back up into the uterus and do a cesarean section. But that's very traumatic," Hannah says. "And by the time that you are able to do that the baby may have suffered severe hypoxia," or lack of oxygen.

The new guidelines say that many breech deliveries will still require a C-section, and that a vaginal birth is not recommended for a "footling" breech, where the baby is positioned feet-first, with one or both feet pointing directly down toward the birthing canal.

Vaginal breech births also aren't recommended if the woman's pelvis is narrow or small, if the umbilical cord is likely to become entangled or compressed during delivery, or for babies that are too big (weighing more than 4,000 grams, or 8.8 pounds) or too small (less than 2,500 grams, or 5.5 pounds).

Breech deliveries are one of the main reason for C-sections, "and, if you do one (C-section), you increase the risk for another" in future pregnancies, Lalonde says. Repeat C-sections account for 30 to 40 per cent of all cesareans.

Is the Cord Around the Baby's Neck Really Dangerous?

May 19, 2008 by Misha Safranski

As a confirmed birth junkie, I have heard over and over again birth stories where the baby was born by cesarean for either fetal distress or failure to descend, and the difficulties are blamed on "the cord was around the baby's neck". Is this condition - scientifically termed "nuchal
cord" - actually dangerous? A new study backs up previous research showing that nuchal cord is not the threat it's perceived to be.

A study published this year in the Journal of Perinatal Medicine showed there were no statistically significant differences in outcomes of post-term pregnancies involving a nuchal cord verses no nuchal cord. Drs. Ghosh and Gudmundsson performed color ultrasound on 202 women with post-term pregnancies. Nuchal cords were detected in 69 of the women. There were no significant differences in Apgar scores, umbilical cord anomalies, cesarean section, perinatal death or admission of the baby to the NICU (neonatal intensive care unit).

These findings confirm what has been found in most of the past research on nuchal cord outcomes. A 2006 study from the Archives of Obstetrics and Gynecology was on a much larger scale, looking at the outcomes of 166,318 deliveries during a 15 year study period, 24,392 of which had a documented nuchal cord at birth. The authors, Sheiner et. Al, conclude: "Nuchal cord is not associated with adverse perinatal outcome. Thus, labor induction in such cases is probably unnecessary."
The interesting thing about the Sheiner study is that despite the equivalent outcomes among nuchal cord babies and those without the cord wrapped around the neck, there were higher rates of labor induction and non-reassuring fetal heart tones during labor among the nuchal cord cases.

These two factors are most likely related. We know without a doubt that induction of labor can cause fetal distress. The fact that there were higher induction rates in the nuchal cord group could very well explain the higher rate of transient fetal distress. Induction is nearly always accompanied by AROM (artificial rupture of membranes), which can cause undue pressure on the cord, which can in turn result in blips in the hearttones. Regardless of the cause, the outcomes were still good.

Finally, we look at yet another study which demonstrated that nuchal cord does not result in worse outcomes. In a 2005 study looking at the effects of nuchal cord on birthweight and immediate neonatal outcomes, Mastrobattista, et. Al examined the outcomes of 4426 babies, 775 of whom had a nuchal cord. They found that there were no significant differences between the two groups in birthweight, non-reassuring fetal hearttones, Apgar scores below 7, or operative vaginal deliveries. The cesarean rate was actually highest among the women whose babies did not have a nuchal cord.

The most important thing to keep in mind is that unborn babies do not breathe through their mouth and neck - they receive oxygen through the umbilical cord. This is why it normally doesn't matter if the cord is around the neck (unless the cord is being compressed too much, which is fairly rare). The baby cannot "choke to death" before she/he is born. What we can conclude from the overwhelming majority of data is that nuchal cord - or "cord around the neck" - is not pathological; that is to say, it's not an abnormality. It is a normal condition of the umbilical cord and typically causes no problems with the delivery, even though doctors frequently try to convince parents otherwise.

References:
J Perinat Med. 2008;36(2):142-4. Nuchal cord in post-term pregnancy - relationship to suspected intrapartum fetal distress indicating operative intervention. Ghosh GS, Gudmundsson S. Department of Obstetrics and Gynecology, Malmö University Hospital, Malmö, Sweden.

Arch Gynecol Obstet. 2006 May;274(2):81-3. Epub 2005 Dec 23. Nuchal cord is not associated with adverse perinatal outcome. Sheiner E, Abramowicz JS, Levy A, Silberstein T, Mazor M, Hershkovitz R. Department of Obstetrics and Gynecology, Soroka University Medical Center, Ben Gurion University of the Negev, Beer-Sheva, Israel. sheiner@bgu.ac.il

Neonatal Outcomes May Be Better With Vaginal Birth After Cesarean Delivery

News Author: Laurie Barclay, MD
CME Author: Charles Vega, MD, FAAFP

June 3, 2009 — Neonates born after elective subsequent cesarean delivery have significantly higher rates of respiratory morbidity and neonatal intensive care unit (NICU) admission and longer length of hospital stay vs those with vaginal birth after cesarean (VBAC), according to the results of a retrospective cohort study reported in the June issue of Obstetrics & Gynecology.

"Controversy remains on whether a trial of labor or an elective repeat cesarean delivery is preferable for a woman with a history of cesarean delivery," write Beena D. Kamath, MD, MPH, from the University of Colorado School of Medicine in Denver, and colleagues. "Historically, concerns regarding the increased risk of uterine rupture and perinatal asphyxia in trial of labor after cesarean compared with planned repeat cesarean have swayed obstetricians away from recommending a trial of labor after cesarean delivery; however, the absolute risk of perinatal asphyxia remains small."

The goals of this study were to compare the outcomes of neonates born by elective subsequent cesarean delivery vs VBAC in women with 1 previous cesarean delivery and to compare the cost differences between these procedures. The study cohort consisted of 672 women with 1 previous cesarean delivery and a singleton pregnancy at or after 37 weeks of gestation. Participants were categorized based on their intention to have an elective subsequent cesarean delivery or a VBAC, whether successful or failed. The main endpoints of the study were NICU admission and measures of respiratory morbidity.

Compared with the VBAC group, neonates born by cesarean delivery had higher NICU admission rates (9.3% vs 4.9%; P = .025). Rates of oxygen supplementation were also higher in the subsequent cesarean group for delivery room resuscitation (41.5% vs 23.2%; P < .01) and after NICU admission (5.8% vs 2.4%; P < .028). The rates of delivery room resuscitation with oxygen were lowest in neonates born by VBAC and highest in neonates delivered after failed VBAC.

Although the costs of elective subsequent cesarean delivery were significantly higher vs VBAC, the highest costs for the total birth experience were for failed VBAC, considering both delivery and NICU use.

"In comparison with vaginal birth after cesarean, neonates born after elective repeat cesarean delivery have significantly higher rates of respiratory morbidity and NICU-admission and longer length of hospital stay," the study authors write.

Limitations of this study include relatively short postpartum follow-up of the mothers to determine the additional costs of postsurgical complications and insufficient data to allow estimation of costs other than those for hospital care.

"Given the increasing rates of primary cesarean delivery and the concomitant decrease in VBACs, once a woman has had a primary cesarean delivery, we must consider the risks that this places on her subsequent deliveries and subsequent neonates," the study authors conclude. "Indeed, this argues for greater selectivity in performing a cesarean delivery in the first place, and certainly a greater need for counseling before a primary elective cesarean delivery. As investigators continue to search for ways to make cesarean delivery safer, we may be better served by exploring other means for reducing overall cesarean delivery rates and recognizing our own preoccupation with the individual that will be our patient, whether it be mother or neonate."

The study authors have disclosed no relevant financial relationships.

Obstet Gynecol. 2009;113:1231-1238.

Clinical Context

The rate of cesarean delivery has reached an all-time high in the United States, and the current study provides an overview of the epidemiology of cesarean delivery. In 2006, 31.1% of all deliveries were via cesarean, and this rate was fueled by an increase in the rate of primary cesarean delivery by 60% between 1996 and 2005.

Women with a primary cesarean delivery have a greater than 90% chance of having another cesarean delivery. Overall, more than half of cesarean deliveries are performed electively, before the onset of labor.

The current study examines neonatal outcomes in women with a history of primary cesarean delivery, with the primary variable being VBAC vs subsequent elective cesarean delivery.

Study Highlights

• The study was a retrospective review of cases at 1 Colorado hospital between 2005 and 2008.
• Researchers focused on women with a history of 1 previous cesarean delivery who were pregnant with a singleton pregnancy at 37 weeks or more of gestation. 51% of these women had planned an elective subsequent cesarean delivery, and 49% had planned for VBAC.
• The primary outcome of the study was admission to the NICU. Researchers conducted a multivariate regression analysis to account for the effects of maternal demographic and disease factors as well as birth factors on the study outcome. Other outcomes included the need for neonatal resuscitation and the cost of care.
• 672 women were included in the analysis. The mean maternal age was 29 years, and approximately half of women were of Hispanic origin.
• 35.6% of the study cohort had a planned elective cesarean delivery without labor, 15.5% had an elective cesarean delivery after the onset of labor, 36.3% of women had a successful VBAC, and 12.6% had a failed VBAC requiring cesarean delivery.
• Older women and women with higher educational achievement were more likely to have an elective subsequent cesarean delivery.
• 9.3% of neonates delivered by elective subsequent cesarean delivery required admission to the NICU vs only 4.9% of neonates delivered by intended VBAC. The adjusted odds ratios for NICU admission in neonates delivered with elective subsequent cesarean delivery without and with labor vs successful VBAC delivery were 2.93 and 2.26, respectively.
• Infants in the cesarean group were more likely to require blow-by oxygen and continuous positive airway pressure after delivery vs infants delivered by VBAC, and they also had higher rates of NICU admission for hypoglycemia.
• Conversely, infants delivered by VBAC were more likely to require bag mask ventilation and endotracheal intubation after delivery.
• Infants delivered via cesarean after a failed VBAC had rates of NICU admission similar to rates of admission in the elective subsequent cesarean delivery group. However, infants delivered after failed VBAC required the most resuscitation efforts after delivery.
• Factors associated with failed VBAC included chorioamnionitis and induction of labor.
• Neonates delivered at 37 weeks of gestation required more resuscitation efforts vs more mature neonates.
• Successful VBAC was associated with the shortest hospital stay and the lowest overall cost of care. Although failed VBAC was associated with the highest cost of care from all groups, planned VBAC still cost less than planned elective subsequent cesarean delivery overall.

Clinical Implications

• The rate of cesarean deliveries in the United States was 31.1% in 2006, and an increase in the rate of primary cesarean deliveries was primarily responsible for this high rate. In addition, women with a primary cesarean delivery have a greater than 90% chance of having another cesarean delivery, and more than half of all cesarean deliveries are performed electively, before the onset of labor.
• The current study finds that the rate of NICU admission is higher in infants delivered via elective subsequent cesarean delivery vs VBAC. Overall, elective subsequent cesarean delivery was estimated to be a more costly strategy.

Caesarean sections linked to future birth risks

by Ginger Rough - Mar. 31, 2009 12:00 AM
The Arizona Republic

Flagstaff mom Jody Borrero was only five weeks along in her pregnancy when doctors told her something had gone awry.

An ultrasound confirmed her placenta had implanted itself at the bottom of her uterus, across her cervix. What's worse, it also had attached itself too deeply, perforating the uterine wall and invading her bladder.

Borrero's physicians at St. Joseph's Hospital and medical center kept her stable for as long as they could. But on Feb. 2, they were forced to deliver Ethan Jr. nearly four months early.

He's still struggling to survive, and his 28-year-old mother, who hemorrhaged during the delivery, can no longer bear children.

Borrero's conditions, called placenta previa and placenta accreta, are both still relatively rare.

But physicians say they're turning up in more women, and medical experts believe the trend is tied to record numbers of moms-to-be delivering their children via Caesarean section.

C-sections, in which a baby is delivered via an incision made through the abdominal wall, leave a scar on the uterus. It now appears that scar is a key risk factor for the complication in subsequent pregnancies, physicians say.

Many women are unaware of the danger, however.

"I wanted to have four children, so after the first one was born by Caesarean, I knew I was going to have lots of C-sections," Borrero said. "I thought it would be fine. It wasn't. It's devastating."

Rise in C-sections

In the mid-1990s, roughly 1 in 5 babies were born via Caesarean section. But over the past decade, the rate of C-section births has jumped more than 50 percent.

Statistics released earlier this month by the U.S. Centers for Disease Control and Prevention showed that nearly 32 percent of babies born in 2007 were through Caesarean delivery.

That's a new record, and the 11th straight year of increase.

Doctors say that in many cases, C-sections are medically necessary, even life-saving.

A woman may be unable to deliver vaginally, for example, if the baby is breech, meaning its feet or bottom has entered the birth canal first. In some instances, labor stops or the baby is simply too big to pass through the birth canal.

But C-sections also have increased in popularity simply because mothers see them as less painful or more convenient than a vaginal birth. They can be scheduled around work and home events. There is no prolonged labor.

Physicians say they fear that women who choose C-sections for these elective reasons may not realize that they are still putting their bodies through major trauma and could be setting themselves up for problems in future pregnancies.

"We tend to think about the immediate circumstance," said Dr. Marlin Mills, medical director of perinatal services with Banner Desert Medical Center. "But it's important to think about the consequences down the line, especially if you want to have a big family."

Future complications

Tracy Alexander, 31, had no reason to suspect that her most recent pregnancy would be any different than her first six. Her last delivery, via Caesarean, had been smooth.

But early in her second trimester, the Queen Creek mother got the bad news. Like Borrero, she had developed placenta accreta, a complication generally characterized by an improper attachment of the placenta to the uterine wall.

And like Borrero, hers was the most severe form of accreta, known as placenta percreta. It went through the uterus and intertwined with her other organs, including the bladder.

Alexander, who had started bleeding lightly at six weeks, eventually contracted an infection in her uterus. Her son Samuel was born at Banner Desert in Mesa 16 weeks early, on Jan. 24. He, too, remains in intensive care.

Doctors aren't sure exactly why Borrero and Alexander developed placenta accreta. But they believe it has something to do with their previous C-sections.

"We think that whenever the uterus has a scar on it . . . for some reason, that scar increases the chance that you have this," said Dr. Linda Chambliss, director of maternal-fetal medicine at St. Joseph's Hospital and Medical Center.

Studies and textbooks suggest that the risk of developing an accreta is as high as 40 percent in women who have had two previous Caesareans; that jumps to 60 percent with three C-sections, their physicians said.

And while Valley hospitals can't say exactly how many women they are seeing with the complication, those that traditionally deliver the most babies say it's a trend they're watching.

Earlier this year, St. Joseph's saw three women with the condition in one week, Chambliss said.

"In the 1950s, the incidence was something like 1 in 30,000 women," Mills said, adding that newer studies, conducted within the last decade, suggest that the rate has climbed to as high as 1 in 2,500 or even 1 in 500.

"So there is definitely an increase in occurrence," he said. "And in women with C-sections, that's where we've really seen an explosion."

New protocols

The uptick in accretas, and the emergency deliveries they cause, has prompted several Valley hospitals, including St. Joseph's in Phoenix and Banner Desert in Mesa, to establish new protocols.

Chief among them: creating on-call teams of surgeons and specialists to lend their expertise during the emergency surgery.

At Banner Desert, for example, the team draws in not only obstetricians but urologists, general surgeons and vascular surgeons. Patients with severe placenta accretas frequently need a total hysterectomy and, in many cases, subsequent surgeries to repair damage to the urinary tract and other organs.

Excessive bleeding is also a common problem. At St. Joseph's, a protocol allows the hospital to notify the blood bank of a "catastrophic situation," Chambliss said, giving the patient the highest priority for blood products.

Last year, one woman needed more than 100 units, roughly the equivalent of 100 pints, of blood. The average human body typically holds 10 pints.

Hospitals also are encouraging more pre-natal counseling of C-section risks, particularly if a woman is interested in having multiple children. They say it is possible for a woman who has delivered her first baby via Caesarean to give birth vaginally the second time.

Physicians have historically shied away from the option because it was thought to carry risks of uterine rupture. But those dangers now are believed to be very small in many patients.

In fact, the American Pregnancy Association suggests that as many as 90 percent of women who have had a Caesarean are candidates to later give birth vaginally.

"The real complications from vaginal births after C-sections are minuscule," said Dr. Mike Foley, a specialist in maternal-fetal medicine and chief medical officer at Scottsdale Healthcare . "Women shouldn't make a snap decision to have a C-section just because they've had one previously."

Most importantly, Borrero said, women need to educate themselves before they decide on an elective Caesarean.

"Women say they are too scared of the pain (of a vaginal delivery)," she said. "But I could lose my baby.

"I can't imagine anything more painful than that."

ICAN State by State VBAC Hospital Policy Summary

The information collected here was collected to identify VBAC policies in individual hospitals. We wanted to identify those hospitals that have official bans against VBAC in place. In some ways, these were the simplest calls. It is unlikely that we are mistaken about these hospitals. The more difficult hospitals were those with de facto bans in place. This is defined as a hospital that indicates there is no official policy against VBAC but in reality there are no doctors who will agree to attend one, or the restrictions on a VBAC are so extreme as to make it very unlikely a VBAC would be achieved. Our callers asked a series of questions to try to accurately identify hospitals where there is no official ban but there is no option for VBAC. Obviously, this is a “softer number”, because we were dependent on more subjective information to make this determination. It is important to acknowledge this when using these numbers, especially when giving them to a reporter. If you have time, it would be worth calling these hospitals yourself and seeing what responses you get. You can find the contact information on the VBAC Hospital Policy Database.

It is also very important to understand that even the hospitals that do “allow” VBAC, and that were able to give us names of physicians who are known to support VBAC, very few of these hospitals actually do very many VBACs. We would estimate that no more than 10% of the hospitals we called were truly “VBAC supportive”, based on the comments of the people we talked to. Making sure you emphasize this point is crucial in presenting the VBAC access crisis accurately – the number of official bans is truly only the tip of the iceberg.

I’ve also included the state cesarean rate and VBAC rate data for each state. These numbers are from the National Vital Statistics Report. Births: Final Data for 2006. A couple of comments on these numbers: the cesarean rate is defined as the percentage of births that end in a cesarean. However, some states only report “low risk” cesareans in this rate – in other words, cesareans of breech or multiples are NOT included in this number. Unfortunately, I don’t have a good list of which states do this, we just know it does happen. Obviously, the states are not eager to let us know if they report this way. VBAC rate is defined as the percentage of women with a previous cesarean who then have a subsequent vaginal birth. The percentage is NOT that of total births (unlike the cesarean rate) but a percentage of ONLY the women with a previous cesarean who had a birth that year. So, if you wanted to find out the VBAC rate relative to the total number of births, you’d need to divide the total number of VBACs by the total number of births. Needless to say, that number is going to be very small.

Alabama:
51 total hospitals
8 Official Bans (16%)
6 de facto
33.4% c/s rate
5.2% VBAC rate

Alaska:
17 total hospitals
5 Official Bans (29%)
2 de facto
23% c/s rate
17.7% VBAC rate

Arizona:
27 total hospitals
9 Official Bans (33%)
4 de facto
26.5% c/s rate
5.5% VBAC rate

Arkansas:
43 total hospitals
16 Official Bans (37%)
9 de facto
33.2% c/s rate
4.6% VBAC rate

California:
251 total hospitals
96 Official Bans (38%)
17 de facto
31.3% c/s rate
5.2% VBAC rate

Colorado:
56 total hospitals
24 Official bans (43%)
3 de facto bans
25.3% c/s rate
10.2% VBAC rate

Connecticut:
28 total hospitals
1 Official ban (4%)
2 de facto bans
34.1% c/s rate
6.2% VBAC rate

District of Columbia:
5 total hospitals
0 Official bans (0%)
0 de facto bans
30.6% c/s rate 2006
6.4% VBAC rate

Delaware:
5 total hospitals
2 official bans (40%)
0 de facto bans
30.7% c/s rate
9.8% VBAC rate

Florida:
101 total hospitals
25 Official bans (25%)
31 de facto bans
36.1% c/s rate
5.4% VBAC rate

Georgia:
78 total hospitals
12 official bans (15%)
16 de facto bans
31.3% c/s rate
4.7% VBAC rate

Hawaii:
12 total hospitals
6 official bans (50%)
1 de facto bans
25.6% c/s rate
11.0% VBAC rate

Idaho:
26 total hospitals
14 official bans (54%)
1 de facto ban
22.8% c/s rate
17.5% VBAC rate

Illinois:
111 total hospitals
19 official bans (17%)
5 de facto bans
29.6% c/s rate
8.0% VBAC rate

Indiana:
97 total hospitals
26 official bans (27%)
16 de facto bans
29% c/s rate
5.8% VBAC rate

Iowa:
70 total hospitals
45 official bans (64%)
8 de facto bans
27.7% c/s rate
7.9% VBAC rate

Kansas:
67 total hospitals
31 official bans (46%)
13 de facto bans
29.3% c/s rate
10.6% VBAC rate

Kentucky:
30 total hospitals
6 banned (20%)
3 de facto bans
34.5% c/s rate
6.1% VBAC rate

Louisiana:
50 total hospitals
5 official bans (10%)
12 de facto bans
35.4% c/s rate
2.5% VBAC rate

Maine:
27 total hospitals
15 official bans (56%)
5 de facto bans
29.9% c/s rate
5.5% VBAC rate

Massachusetts:
49 total hospitals
13 official bans (27%)
5 de facto bans
33.2% c/s rate
8.2% VBAC rate

Maryland:
34 total hospitals
3 official bans (9%)
0 de facto bans
32.2% c/s rate
8.7% VBAC rate

Michigan:
93 total hospitals
29 official bans (31%)
5 de facto bans
29.8% c/s rate
7.8% VBAC rate

Minnesota:
96 total hospitals
30 official bans (31%)
25 de facto bans
25.4% c/s rate
9.7% VBAC rate

Mississippi:
38 total hospitals
8 official bans (21%)
6 de facto bans
35.4% c/s rate
3.1% VBAC rate

Missouri:
66 total hospitals
16 official bans (24%)
11 de facto bans
30.2% c/s rate
7.3% VBAC rate

Montana:
26 total hospitals
12 official bans (46%)
2 de facto bans
28% c/s rate
10.2% VBAC rate

Nebraska:
58 total hospitals
28 official bans (48%)
14 de facto bans
28.8% c/s rate
9.7% VBAC rate

Nevada:
18 total hospitals
8 official bans (44%)
5 de facto bans
32.3 % c/s rate
4.4% VBAC rate

New Hampshire:
22 total hospitals
6 official bans (27%)
3 de facto bans
29.9% c/s rate
13.4% VBAC rate

New Jersey:
48 total hospitals
5 official bans (10%)
6 de facto bans
37.4% c/s rate
8.8% VBAC rate

New Mexico:
23 total hospitals
12 official bans (52%)
3 de facto bans
23.3% c/s rate
12.0% VBAC rate

New York:
141 total hospitals
24 official bans (16%)
15 de facto bans
32.6% c/s rate
9.8% VBAC rate (excludes NYC)
13.1% VBAC rate, NYC

North Carolina:
67 total hospitals
17 official bans (25%)
9 de facto bans
29.9% c/s rate
7.7% VBAC rate

North Dakota:
11 total hospitals
5 official bans (45%)
1 de facto ban
27.8% c/s rate
14.1% VBAC rate

Ohio:

112 total hospitals
37 official bans (33%)
8 de facto bans
29.3% c/s rate
12.6% VBAC rate

Oklahoma:
60 total hospitals
28 official bans (47%)
19 de facto bans
33.3% c/s rate
2.6% VBAC rate

Oregon:
54 total hospitals
23 official bans (42%)
9 de facto bans
28.2% c/s rate
9.3% VBAC rate

Pennsylvania:
97 total hospitals
6 official bans (6%)
17 de facto bans
29.7% c/s rate
13.8% VBAC rate

Puerto Rico:
24 total hospitals
0 official bans (0%)
12 de facto bans
48.3% c/s rate
7.5% VBAC rate

Rhode Island:
7 total hospitals
3 official bans (43%)
0 de facto bans
31.1% c/s rate
8.4% VBAC rate

South Carolina:
46 total hospitals
13 official bans (28%)
7 de facto bans
32.9% c/s rate
10.2% VBAC rate

South Dakota:
21 total hospitals
2 official bans (10%)
2 de facto bans
27% c/s rate
16.1% VBAC rate

Tennessee:
60 total hospitals
13 official bans (22%)
6 de facto bans
32.4 % c/s rate
11.3% VBAC rate

Texas:
138 total hospitals
20 official bans (14%)
24 de facto bans
33.2% c/s rate
9.4% VBAC rate

Utah:
36 total hospitals
9 official bans (25%)
7 de facto bans
21.5% c/s rate
18.7% VBAC rate

Virginia:
53 total hospitals
8 official bans (15%)
6 de facto bans
32.4% c/s rate
5.4% VBAC rate

Vermont:
12 total hospitals
3 official bans (25%)
0 de facto bans
26% c/s rate
20.9% VBAC rate

Washington:
68 total hospitals
28 official bans (41%)
2 de facto bans
28.4% c/s rate
12.4% VBAC rate

West Virginia:
23 total hospitals
9 official bans (39%)
2 de facto bans
35.2% c/s rate
4.9% VBAC rate

Wisconsin:
72 total hospitals
19 official bans (26%)
6 de facto bans
24.6% c/s rate
12.1% VBAC rate

Wyoming:
21 total hospitals
13 official bans (62%)
3 de facto bans
26.3% c/s rate
8.5% VBAC rate

Breech Vaginal Birth is NOT an Emergency

This blog was written by a blogger friend. It was so good, I asked if she would mind me posting it here. Thanks Emily (http://jeremyscorner-grifter.blogspot.com) for letting me share this with my readers!

In my continuing crusade to shoot down OB myths, this week I am tackling breech vaginal birth. This post has taken a lot longer to write than I thought it would. At first I thought I was having trouble with the amount of information available about it, but that isn't the problem. The problem is that I can't really understand why breech vaginal birth is considered an emergency in the first place. Sure, I know that there are risks associated with breech vaginal birth, but I just can't shake the idea that babies are born breech all over the world with little fanfare or issue. Nevertheless, obstetricians continue to look for more and more excuses to avoid the topic entirely by just cutting the babies out. So, in the interest of being thorough, here is some food for thought.

According to this article, "Vaginal breech deliveries were previously the norm until 1959 when it was proposed that all breech presentations should be delivered abdominally to reduce perinatal morbidity and mortality." Typical of obstetric mentality, instead of looking at the cause of morbidity and mortality in the first place, they chose to focus on the correlative factor instead - that many babies who presented breech had a high rate of injury or death. But as far as I know, no one thought to ask if medications, managed, or instrumental delivery could have contributed to those injuries or deaths.

Fast forward to today, and more than 90% of all breech births in the U.S. are delivered by c-section. This has happened largely because of a study that was done in 2000 by Hannah, et al, that shows a higher rate of perinatal morbidity and mortality associated with breech vaginal birth, as compared to planned c-section. Consequently, the American College of Obstetrics and Gynecology (ACOG) has systematically condemned breech vaginal birth, and it is no longer offered as a choice to women today. Henci Goer does a good job here of explaining why the conclusions of that 2000 study are not valid.

However, the ACOG has a history of picking and choosing those studies that support its own position. They also prefer to ignore any studies not done in the United States, as those studies are often contrary to American obstetric practics. For example:

A study out of Sweden in 2003 in the European Journal of Obstetrics & Gynecology and Reproductive Biology showed no difference between elective cesarean vs. planned vaginal birth for term breech deliveries.

Another study actually published with the American Journal of Obstetrics and Gynecology in 2006 examined planned breech delivery in France and Belgium, and found no discernable difference in outcome with more than 8,000 breech patients studied.

A different study from France in 2002 and published in European Journal of Obstetrics & Gynecology and Reproductive Biology looked at more than 500 patients and found no difference in outcome.

The International Journal of Gynecology & Obstetrics published a study in 2004 from the United Emirates which found no clear difference in breech vaginal vs. cesarean, but did find more maternal morbidity associated with cesarean section.

The Malaysian Journal of Medical Sciences, published a study in 2007, which concluded, "Most of the perinatal mortality was due to IUD, congenital abnormality and prematurity and there
were no perinatal death related to mode of delivery or due to birth trauma."

and there have been other studies to support these findings.

Danell Swim writes in her article, A Breech of Trust,

So I ask you, what are the United States hospitals doing wrong for their vaginal breech deliveries?

It is NOT that cesarean section is safer for breech deliveries in this nation, it is that vaginal breech is more dangerous in this country. US hospital policy and procedure are killing more breech babies than their European counterparts.

And to remedy the situation, it’s been recommended that nearly all babies in a breech presentation be delivered via cesarean section. This is despite the study published with the American Journal of Obstetrics and Gynecology that discovered that France and Belgium are able to safely deliver them vaginally, and safely.

So rather than teach our doctors how to safely deliver a breech baby, the ACOG's answer to the breech problem is to simply take them by c-section at term.

This article describes how best to safely deliver a breech baby. Included in the highlighted points are:

• Spontaneous onset anytime after about the 37th week.
• No augmentation if labour is slow or there is poor progress - caesarean section.
• Mother encouraged to assume positions of choice during the first stage.
• Fetal heart listened to frequently with a Pinard stethoscope or a hand held Doppler Sonic aid using ultrasound.
• Food and drink encouraged, but remembering that women in strong progressing labour rarely want to eat.
• Membranes not ruptured artificially.
• Vaginal examinations restricted to avoid accidental rupturing of the membranes.
• If, and when spontaneous rupture occurs conduct a vaginal examination as soon as possible.
• Second stage by maternal propulsion and spontaneous expulsive efforts guided by the attendant if judged appropriate.
• Mother encouraged to be in an all-fours position.
• No routine episiotomy.
• Third stage without chemical or mechanical assistance, usually managed according to woman's wishes.

Of that list, tell me how many of those are likely to occur in a medically managed birth in a US hospital today?

The most dangerous aspect of this trend is that American health care providers are losing, or have completely lost, the art of safely delivering breech babies. While some doctors may envision a 100% c-section rate for breech births, that will never be possible. The World Health Organization (WHO), in this publication about planned c-section for breech says,

It will be impossible to deliver all term breech pregnancies by caesarean section. The systematic review showed that 9% of women with breech presentation still have a vaginal breech delivery because the mother may insist on vaginal delivery, breech labour may be precipitate, or special situations such as the second fetus in twins. It is therefore imperative to continue providing expertise in vaginal breech delivery to all the intrapartum care providers.

This atmosphere of fear and foreboding surrounding breech births is leading women to choose dangerous options to avoid having a breech baby at all costs. The current recommendation is to attempt an external cephalic version (ECV), in which the care provider attempts to turn the baby from the outside into a head-down position. But ECV is not without risks. According to this publication:

The largest review which included 44 studies and 7377 patients found the most common complication of ECV to be transient fetal heart rate abnormalities (5.7%). The risk of placental abruption, emergency cesarean section, vaginal bleeding, and perinatal mortality were less than 1 percent combined. Because of the risk of alloimmunization, Rhogam is recommended for non-sensitised Rh negative women following ECV. There currently is not enough evidence from randomized controlled trials to assess complications of ECV.

In addition, in order to perform an ECV, tocolytics such as terbutaline, and epidural anesthesia are sometimes used. The risks of epidural anesthesia are well-documented. Risks of terbutaline to the baby include fetal tachycardia, hyperinsulinemia, hyperglycemia, myocardial and septal hypertrophy, myocardial ischemia. Terbutaline not only does not have FDA approval but the FDA disapproves of its use as a tocolytic.

ECV is only successful 50-60% of the time (various sources). When ECV is unsuccessful, the only other option is to schedule a planned c-section for some arbitrary date. The problem with this is that breech babies can and do turn, up to, and even during labor. So planning a c-section may be taking a baby even before it is ready to be born, and without giving it a chance to get itself into a favorable position.

It is clear to me that breech birth, while carrying some risk, is not unreasonably dangerous in itself. The danger lies in breech birth in a highly managed hospital setting. For this reason, I would suggest that if a woman plans to birth in the hospital in the U.S, and her baby is breech, she should plan to have c-section. In fact, if a woman is planning a hospital birth and her baby is breech, she probably won't have a choice about it. If she does not want to have a c-section, she should stay home. But she should know a c-section for breech is not necessary! In fact, I don't even believe any undue concern should be attributed to breech presentation, especially if one has a midwife who is experienced and skilled in delivering breech babies.

If you find yourself pregnant, approaching term, and your baby is breech, please try these suggestions for gently encouraging your baby to turn. If you want to avoid unnecessary surgery, start now looking for a midwife who is experienced in breech delivery. Don't schedule a c-section - allow baby all the time it needs to turn itself. You can visit spinningbabies.com to learn how to tell whether your baby is head-down.

LDS-Church funded study shows majority of pregnant women need more vitamin D

Heather May
Salt Lake Tribune
Posted: 02/26/2009 04:47:02 PM MST

An LDS Church-backed study has found a majority of pregnant women don't get enough vitamin D, which means their fetuses are deficient, too. The vitamin is critical for fetal growth, and a lack of it could put them at future risk for a host of diseases, including cancer, diabetes and multiple sclerosis.

Results from the South Carolina-based study could eventually help lead to new recommendations on how much vitamin D pregnant women should take -- and perhaps the development of new multivitamins to meet the need.

Physician Carol Wagner, who will discuss her preliminary findings Friday in Salt Lake City, called the widespread vitamin deficiency an "epidemic." She found 85 percent of study participants had insufficient or deficient levels of the vitamin, which is critical to bone growth, calcium absorption and immunity. She said it's one of the few studies that tracked deficiency levels during pregnancy.

"When you see something like this that's so pervasive, you have to do something about it," she said in an interview Thursday.

Vitamin D deficiency has long been linked to the bone disease rickets. Inadequate amounts have also been shown to increase the risk of osteoporosis, cardiovascular disease, diabetes, autoimmune diseases and colon, prostate and breast cancers.

Wagner's study was funded with $335,000 from the Thrasher Research Fund, which supports research to prevent and treat children's diseases. It is administered by The Church of Jesus Christ of Latter-day Saints.

Typical prenatal vitamins contain 400 international units of the supplement, which has been shown to have little effect on maternal levels. Wagner, a professor at Medical University of South Carolina, is studying whether 2,000 units or 4,000 units is better at reducing pregnancy complications and boosting levels of vitamin D in infants.

Wagner has extensively studied the deficiency in women and children: She was the lead author of 2008 American Academy of Pediatrics' guidelines that say all children and infants, including those breastfed, should have 400 units.

And in a separate study, Wagner is studying whether breastfeeding women should take 6,000 units.

"Babies are born with low levels of vitamin D because their only source is the mother," Wagner said. "If she's deficient, her milk will be deficient [and] the baby will be deficient."

Diet contributes just 10 percent of a person's vitamin D levels. Sun exposure is the main source -- up to 15 minutes of full-body exposure during the summer generates up to 20,000 units for the fair-skinned. Using sunscreen prevents skin cancer but also blocks vitamin D production.

People with darker skin pigmentation typically have lower levels of vitamin D because they need even more sun exposure.

Wagner's study backed that. After screening 500 underserved pregnant women in Eau Claire, S.C., Wagner found vitamin D deficiency varied by ethnicity and race. About 94 percent of black, 78 percent of Latino and 68 percent of white women had insufficient or deficient levels.

The Institute of Medicine is reviewing vitamin D studies and may revise guidelines that recommend 200 units a day for most adults and no more than 2,000 units.

Studies link maternity leave with fewer C-sections and increased breastfeeding

Studies link maternity leave with fewer C-sections and increased breastfeeding
Berkeley -- Two new studies led by researchers at the University of California, Berkeley, suggest that taking maternity leave before and after the birth of a baby is a good investment in terms of health benefits for both mothers and newborns.
One study found that women who started their leave in the last month of pregnancy were less likely to have cesarean deliveries, while another found that new mothers were more likely to establish breastfeeding the longer they delayed their return to work.
Both papers were part of the Juggling Work and Life During Pregnancy study, funded by the Maternal and Child Health Bureau of the U.S. Health Resources and Services Administration and led by Sylvia Guendelman, professor of maternal and child health at UC Berkeley's School of Public Health. The research takes a rare look into whether taking maternity leave can affect health outcomes in the United States.
"In the public health field, we'd like to decrease the rate of C-sections (cesarean deliveries) and increase the rate of breastfeeding," said Guendelman. "C-sections are really a costly procedure, leading to extended hospital stays and increased risks of complications from surgery, as well as longer recovery times for the mother. For babies, it is known that breastfeeding protects them from infection and may decrease the risk of SIDS (Sudden Infant Death Syndrome), allergies and obesity. What we're trying to say here is that taking maternity leave may make good health sense, as well as good economic sense."
The study on the use of antenatal leave - time off before delivery with the expectation of returning to the employer after giving birth - and the rate of C-sections is the first examination of birth outcomes in U.S. working women, the researchers said. It will appear in the January/February print edition of the journal Women's Health Issues.
The researchers analyzed data from 447 women who worked full-time in the Southern California counties of Imperial, Orange and San Diego, comparing those who took leave after the 35th week of pregnancy with those who worked throughout the pregnancy to delivery. Only women who gave birth to single babies with no congenital abnormalities were included in the analysis. They adjusted for sociodemographic factors such as income, age and type of occupation, as well as for various health measures such as high blood pressure, body mass index, amount of self-reported stress and average number of hours of sleep at night.
Using a combination of post-delivery telephone interviews and prenatal and birth records, the researchers found that women who took leave before they gave birth were almost four times less likely to have a primary C-section as women who worked through to delivery.
The study authors pointed out that the United States falls behind most industrialized countries in its support for job-protected paid maternity leave. The federal Family and Medical Leave Act provides for only unpaid leave of up to 12 weeks surrounding the birth or adoption of a child.
The bulk of studies on leave-taking and health outcomes from other countries suggest that taking leave prior to birth can be beneficial. The authors point to a macroanalysis of 17 countries in Europe that linked failure to take such leave with low birthweight and infant mortality. Rates of pre-term delivery were lower among female factory workers in France if the women took antenatal leave, and a study conducted in several industrialized countries found that paid leave, but not unpaid leave, significantly decreased low birthweight rates.
According to the U.S. Census, among working women who had their first birth between 2001 and 2003, only 28 percent took leave from their jobs before giving birth while an additional 22 percent quit their jobs. Twenty-six percent of women took no leave before birth.
"We don't have a culture in the United States of taking rest before the birth of a child because there is an assumption that the real work comes after the baby is born," said Guendelman. "People forget that mothers need restoration before delivery. In other cultures, including Latino and Asian societies, women are really expected to rest in preparation for this major life event."
The authors added that financial need may also deter women from taking leave in the last month of pregnancy. Only five states - California, Hawaii, New Jersey, New York, Rhode Island - and the territory of Puerto Rico offer some form of paid pregnancy leave, and none offer full replacement of the woman's salary.
The study on maternity leave and breastfeeding is in the January issue of the journal Pediatrics. Using data from 770 full-time working mothers in Southern California, researchers assessed whether maternity leave predicted breastfeeding establishment, defined in this study as breastfeeding for at least 30 days after delivery. Phone interviews were conducted 4.5 months, on average, after delivery.
In this study, women who had returned to work by the time of the interview took on average 10.3 weeks of maternity leave. Overall, 82 percent of mothers established breastfeeding within the first month after their babies were born. Among women who established breastfeeding, 65 percent were still breastfeeding at the time of the interview.
Researchers found that women who took less than six weeks of maternity leave had a four-fold greater risk of failure to establish breastfeeding compared with women who were still on maternity leave at the time of the interview. Women who took six to 12 weeks of maternity leave had a two-fold greater risk of failing to establish breastfeeding.
Having a managerial position or a job with autonomy and a flexible work schedule was linked with longer breastfeeding duration in the study. After 30 days, managers had a 40 percent lower chance of stopping breastfeeding, while those with an inflexible work schedule had a 50 percent higher chance of stopping.
Overall, the study found that returning to work within 12 weeks of delivery had a greater impact on breastfeeding establishment for women in non-managerial positions, with inflexible jobs or who reported high psychosocial distress, including serious arguments with a spouse or partner and unusual money problems.
"The findings suggest that if a woman postpones her return to work, she'll increase her chances of breastfeeding success, especially if she's got a job where she's on the clock and has less discretion with her time," said Guendelman. "Also, women who are in jobs where they have more authority may feel more empowered with how they use their time."
The American Academy of Pediatrics (AAP) recommends that babies be breastfed for at least the first year of life, and exclusively so for the first four to six months.
According to the AAP, increased breastfeeding has the potential for decreasing annual health costs in the U.S. by $3.6 billion and decreasing parental employee absenteeism, the environmental burden for disposal of formula cans and bottles, and energy demands for production and transport of formula.
The study authors noted that just having maternity leave benefits offered by an employer was not helpful in breastfeeding establishment unless the leave was actually used, indicating the importance of encouraging the use of maternity leave and making it economically feasible to take it.
"These new studies suggest that making it feasible for more working mothers to take maternity leave both before and after birth is a smart investment," said Guendelman.

http://www.eurekalert.org/pub_releases/2009-01/uoc--slm122308.php