Monday, November 28, 2016

External Version for Breech After Prior Cesarean


An External Cephalic Version (ECV, or turning the baby manually to a head-down position) is one option open to people whose babies are breech. However, if you have had a prior cesarean, you may be told that this is not an option for you.

The evidence does not support excluding those with a prior cesarean from an External Cephalic Version. It's time for obstetric societies to update their guidelines about this, and it's time for more providers to routinely offer ECV.

Background

The main benefit of External Cephalic Version is that it is often successful in getting the baby head-down, and a head-down birth is usually less risky than a breech birth.

Although many breech babies can be born vaginally just fine (especially those that meet certain criteria and/or are attended with alternate positioning), there are some increased risks to be aware of.

As a result, many care providers these days strongly prefer a cesarean or even schedule one automatically with a breech baby. Because some areas do not "allow" Vaginal Birth After Cesarean (VBAC), this can mean that all future babies must also be born by cesarean.

Therefore, getting the baby head-down via an External Cephalic Version can help prevent not just the first cesarean, but many automatic repeat cesareans and the serious complications that can happen with them.

Of course, like everything, ECV has both benefits and risks. The risks of ECV include premature labor, placental abruption (placenta detaching too early), hemorrhage, or fetal distress. Although real, these risks are relatively rare, usually less than 1%.

Obviously, sometimes ECV is also contraindicated. Most clinicians agree that ECV should not be attempted in the presence of pre-existing fetal distress, placenta previa, placental abruption, premature rupture of membranes, and certain uterine malformations. Low amniotic fluid levels may also be a relative contraindication.

A good review of the benefits and risks of ECV can be found here. Basically, ECV is able to turn babies head-down most of the time without many complications, and thus prevents many cesareans that would otherwise happen. This is important because cesarean rates are so high; ECV is quite an effective way to reduce the number of cesareans and probably many cases of resulting abnormal placental attachment.

Astonishingly, though, research shows that ECV is not used that much in many areas, despite its relative success rate and potential for lowering the cesarean rate.

Often, doctors don't even tell people that ECV is an option. They just schedule a cesarean and discourage people from exploring other options. One study from New Zealand estimated that only 26% of eligible patients with breech presentations were referred for ECV.

The situation is even worse if you have had a prior cesarean. For those with a scarred uterus, it's even harder to get an ECV because doctors have been taught that it's too dangerous.

The Controversy

People whose babies are breech and have a history of a prior cesarean are often told that ECV is simply not a choice for them because manipulation done during an ECV might make the uterus rupture along the scar from the prior cesarean.

The problem is that there is no actual proof that this is a substantial risk. No study has found this to be a problem, but just the mere fear of the possibility has led to its denial for this group. Currently, you can still find recommendations online that list prior cesarean (or any prior uterine surgery) as a contraindication to even attempting an ECV.

However, a policy of no External Cephalic Version for people with a prior cesarean is not supported by research.

There are a number of studies, including some very recent studies, that suggest that people with a prior cesarean SHOULD have the option to have an External Version if they want it.

The latest study (Weill 2016) had 158 women in the study group and found no increase in complications in the group with a prior cesarean. The success rate of ECV in this group was good (117/158, or 74%), and only 12 of these patients ended up with a cesarean during labor. That means that using ECV in the prior cesarean group prevented 105 automatic repeat cesareans. The authors summarized their findings this way:
ECV may be successfully performed in patients with a previous caesarean delivery. It is associated with a high success rate, and is not associated with an increase in complications.
Similarly, another recent study (Burgos 2014) found no increased rate of complications in the group with a prior cesarean. The authors concluded:
Uterine scar should not be considered a contraindication and ECV should be offered to women with previous caesarean section with breech presentation at term.
Another study (Abenhaim 2009) also found no increase in complications in those with a prior cesarean who had an ECV. The authors stated:
Concern about procedural success in women with a previous cesarean section is unwarranted and should not deter attempting an external cephalic version.
However, both RCOG (Royal College of Obstetricians and Gynaecologists) and ACOG (American College of Obstetricians and Gynecologists) still hesitate to endorse ECV after prior cesarean. They say that there is not enough research to prove that it is safe. They point out that many of the studies on ECV and prior cesarean are fairly small, which limits their power.

That is a fair point. It's true that most studies have been relatively small and we don't have a huge pool of data to pull from, but taken together the results are quite encouraging.

One older review (Sela 2008) did a search of previous studies to pool the results. They found a total of 124 patients who had an ECV after prior cesarean. They added 42 patients from their own database. Adding in the 36 from the Abenhaim 2009 study, 70 from the Burgos 2014 study, and 158 from the Weill 2016 study, you get a total of 430 patients who have been documented to have an ECV after prior cesarean ─ all without any poor outcomes.

What this means is that there isn't ANY evidence to prove that ECV is unsafe in those with a prior cesarean. While the data pool is still somewhat limited, so far ALL of it supports ECV after prior cesarean.

Yet ACOG's recently revised 2016 guideline on ECV states, "Having had a previous cesarean delivery is not linked with lower rate of success; however, whether it magnifies risk for uterine rupture is not known." They cite only two studies from 1991 and 1998 and state, "Larger studies would be needed to establish the risk of uterine rupture." This ignores all the recent studies on ECV. This cavalier omission will continue to lead many care providers to continue to deny ECV to those with prior cesareans.

Although more research is needed, the bottom line is that the accumulating evidence certainly suggests that an ECV after a prior cesarean is not unduly risky and is a reasonable choice that should be offered to those who want it. 

A more reasonable view of the evidence has led the SOGC (the Canadian version of RCOG and ACOG) to state:
External cephalic version is not contraindicated in women with a previous Caesarean birth.
It's time for ACOG and RCOG to recognize that they are basing their guidelines more on fear than on the latest evidence and update their guidelines accordingly. Bravo to the Canadians for leading the way on this issue.

More research should be done ─ an excellent question is WHY hasn't more been done by now? My best guess is that it reflects the exaggerated fears of the care providers rather than a reasoned response. But given the absence of poor outcomes up till now, research on this topic should be expanded and in the meantime, ECV should be available to those with a prior cesarean.

In addition, it is time for more care providers to offer ECV as an option across the board. This is a sadly underused procedure that could certainly greatly impact cesarean rates and maternal morbidity, both by preventing the first cesarean and lowering the rate of automatic repeat cesareans that follow.


References

External Cephalic Version After Prior Cesarean

Aust N Z J Obstet Gynaecol. 2016 Sep 14. doi: 10.1111/ajo.12527. [Epub ahead of print] The efficacy and safety of external cephalic version after a previous caesarean delivery. Weill Y, Pollack RN. PMID: 27624629
BACKGROUND: External cephalic version (ECV) in the presence of a uterine scar is still considered a relative contraindication despite encouraging studies of the efficacy and safety of this procedure. We present our experience with this patient population, which is the largest cohort published to date. AIMS: To evaluate the efficacy and safety of ECV in the setting of a prior caesarean delivery. MATERIALS AND METHODS: A total of 158 patients with a fetus presenting as breech, who had an unscarred uterus, had an ECV performed. Similarly, 158 patients with a fetus presenting as breech, and who had undergone a prior caesarean delivery also underwent an ECV. Outcomes were compared. RESULTS: ECV was successfully performed in 136/158 (86.1%) patients in the control group. Of these patients, 6/136 (4.4%) delivered by caesarean delivery. In the study group, 117/158 (74.1%) patients had a successful ECV performed. Of these patients, 12/117 (10.3%) delivered by caesarean delivery. There were no significant complications in either of the groups. CONCLUSIONS: ECV may be successfully performed in patients with a previous caesarean delivery. It is associated with a high success rate, and is not associated with an increase in complications.
BJOG. 2014 Jan;121(2):230-5; discussion 235. doi: 10.1111/1471-0528.12487. Epub 2013 Nov 19. Is external cephalic version at term contraindicated in previous caesarean section? A prospective comparative cohort study. Burgos J, Cobos P, Rodríguez L, Osuna C, Centeno MM, Martínez-Astorquiza T, Fernández-Llebrez L. PMID: 24245964
OBJECTIVE: To determine if external cephalic version (ECV) can be performed with safety and efficacy in women with previous caesarean section. DESIGN: Prospective comparative cohort study. SETTING: Cruces University Hospital (Spain). POPULATION: Single pregnancy with breech presentation at term. METHODS: We compared 70 ECV performed in women with previous caesarean section with 387 ECV performed in multiparous women (March 2002 to June 2012). MAIN OUTCOME MEASURES: Success rate, complications of the ECV and caesarean section rate. RESULTS: The success rate of ECV in women after previous caesarean section was 67.1% versus 66.1% in multiparous women (P = 0.87). The logistic regression analysis confirmed this result (odds ratio 0.93, 95% CI 0.52-1.68; P = 0.82) adjusted by the variables associated with success of ECV. There were no complications in the previous caesarean section cohort. The vaginal delivery rate in the previous caesarean section cohort was 52.8% versus 74.9% in the multiparous cohort (P < 0.01). There were no cases of uterine rupture. CONCLUSION: Based on our data, we conclude that complications are uncommon with ECV in women with previous caesarean section, with a success rate comparable to that of multiparous women. Uterine scar should not be considered a contraindication and ECV should be offered to women with previous caesarean section with breech presentation at term.
J Perinat Med. 2009;37(2):156-60. doi: 10.1515/JPM.2009.006. External cephalic version among women with a previous cesarean delivery: report on 36 cases and review of the literature. Abenhaim HA1, Varin J, Boucher M. PMID: 19021458
AIMS: Whether or not women with a previous cesarean section should be considered for an external cephalic version remains unclear. In our study, we sought to examine the relationship between a history of previous cesarean section and outcomes of external cephalic version for pregnancies at 36 completed weeks of gestation or more. METHODS: Data on obstetrical history and on external cephalic version outcomes was obtained from the C.H.U. Sainte-Justine External Cephalic Version Database. Baseline clinical characteristics were compared among women with and without a history of previous cesarean section. We used logistic regression analysis to evaluate the effect of previous cesarean section on success of external cephalic version while adjusting for parity, maternal body mass index, gestational age, estimated fetal weight, and amniotic fluid index. RESULTS: Over a 15-year period, 1425 external cephalic versions were attempted of which 36 (2.5%) were performed on women with a previous cesarean section. Although women with a history of previous cesarean section were more likely to be older and para >2 (38.93% vs. 15.0%), there were no difference in gestational age, estimated fetal weight, and amniotic fluid index. Women with a prior cesarean section had a success rate similar to women without [50.0% vs. 51.6%, adjusted OR: 1.31 (0.48-3.59)]. CONCLUSION: Women with a previous cesarean section who undergo an external cephalic version have similar success rates than do women without. Concern about procedural success in women with a previous cesarean section is unwarranted and should not deter attempting an external cephalic version. 
Eur J Obstet Gynecol Reprod Biol. 2009 Feb;142(2):111-4. doi: 10.1016/j.ejogrb.2008.08.012. Epub 2008 Nov 18. Safety and efficacy of external cephalic version for women with a previous cesarean delivery. Sela HY, Fiegenberg T, Ben-Meir A, Elchalal U, Ezra Y. PMID: 19019528
OBJECTIVE: To evaluate the success and morbidity rates for attempted external cephalic version (ECV) in patients with one previous cesarean delivery (CD) and a breech-presenting fetus at term. STUDY DESIGN: This is a retrospective study of outcomes of ECV at our institution for all women with one previous CD and a breech-presenting fetus at term between January 1997 and June 2005. A literature review was also performed as a Medline search (1966-2006). RESULTS: ECV was attempted for 42 women with a breech-presenting fetus and previous CD. The success rate of ECV was 74.0%, and 84% of women with successful ECV delivered vaginally. All fetal and maternal outcomes were favorable. Only four Medline reports met our inclusion criteria, representing a total of 124 patients and a mean ECV success rate of 76.6%. Thus we assessed 166 cases of attempted ECV and find an average ECV success rate of 76.5% and favorable fetal and maternal outcomes. CONCLUSIONS: Women with a breech-presenting fetus at term and previous CD, who desire a trial of labor, should be counseled regarding the accumulating evidence about the efficacy and apparently safety of this procedure and may be offered an ECV attempt.
Eur J Obstet Gynecol Reprod Biol. 1998 Oct;81(1):65-8. External cephalic version after previous cesarean section: a series of 38 cases. de Meeus JB1, Ellia F, Magnin G. PMID: 9846717
OBJECTIVE: To determine if external cephalic version (ECV) is a reasonable alternative to repeat cesarean section in case of breech presentation. STUDY DESIGN: Retrospective study of 38 women with one previous cesarean section and a breech presentation after 36 weeks of gestational age who have had at least one experience of ECV. Statistics used the Fisher's test with significance when P<0.05. RESULTS: Version attempts were successful in 25 of the 38 women (65.8%). Seventy-six percent of the successful version women went on to have vaginal birth after cesarean section. A total of 19 successful vaginal deliveries occurred (50%). Success rate of ECV was lowered when breech was the indication of the previous cesarean section. The vaginal delivery rate was increased after successful ECV in patients previously vaginally delivered, but this difference did not reached significance (P=0.057). No maternal or neonatal complications occurred. CONCLUSION: ECV is acceptable and effective in women with a prior low transverse uterine scar, when safety criteria are observed.
Int J Gynaecol Obstet. 1994 Apr;45(1):17-20. External cephalic version after previous cesarean section--a clinical dilemma. Schachter M, Kogan S, Blickstein I. PMID: 7913053
OBJECTIVES: To describe our limited experience with external cephalic version from breech to vertex presentation at term, with the use of ritodrine tocolysis, in women who had undergone a previous cesarean delivery. METHODS: Eleven parturients after previous cesarean delivery underwent external version after 36 gestational weeks, utilizing tocolysis with ritodrine, after excluding cases of low-lying placenta, severe oligohydramnion or ruptured membranes. Patients were then followed until delivery and scar examination was carried out after vaginal delivery, or at re-cesarean section, according to mode of delivery. RESULTS: All 11 attempted versions were successful. Six patients subsequently delivered vaginally and five by re-cesareansection. None of the uterine scars showed any signs of dehiscence. Three of the five infants delivered by re-cesarean section weighed over 4000 g, whereas all of the vaginally-delivered infants weighed under 3500 g. CONCLUSIONS: External cephalic version to vertex presentation after previous cesarean section was successful in all 11 carefully selected patients. No untoward effects were noted, and no signs of scar dehiscence were found. The safety and efficacy of this procedure after previous cesarean delivery should be examined further.
Am J Obstet Gynecol. 1991 Aug;165(2):370-2. External cephalic version after previous cesarean section. Flamm BL, Fried MW, Lonky NM, Giles WS. PMID: 1872341
Approximately 100,000 cesarean sections are performed each year in the United States because of breech presentation. Numerous studies have shown that external cephalic version can eliminate the need for many of these operations. However, because of the fear of uterine rupture, these studies have generally excluded patients who have undergone previous cesarean section. To evaluate the validity of this exclusion policy, we studied patients with one or more previous cesarean sections and breach presentations near term. Version attempts were successful in 82% of 56 patients who had undergone a previous cesarean section. Sixty-five percent of the successful version patients went on to have vaginal birth after cesarean section. There were no serious maternal or fetal complications associated with the version attempts. We conclude that external cephalic version is a reasonable option in patients with prior low transverse cesarean section.

Sunday, November 13, 2016

Stop Blaming Women for Cesarean Rates


For many years, the cesarean rate rose, virtually unchecked. When this was questioned, care providers resorted to the old mantra of blaming the women.

At first they said that the cesarean rate was rising because women wanted cesareans to avoid the pain and bother of labor, or for the sake of convenience. The Brits called this being "too posh to push," implying that women were selfish, lazy, and couldn't be bothered to go through labor.

In the U.S., doctors implied that women wanted cesareans for the sake of convenience; they implied the increase in cesareans was simply in response to demands from women themselves.

Of course, there are a few women request elective cesareans, but those women are rare, probably around 1-3%. By and large the cesarean rate was NOT being driven by mother request or because women couldn't be bothered to labor.

When data came out questioning this, doctors started blaming women instead. 

They said the cesarean rate was rising because women were too old, were waiting too long to have babies, were too fat, or were too sick. Numerous articles said that was what was REALLY driving the increase in cesareans. Here is a quote from one Canadian article:
Doctors said several factors are driving the push for surgical births, from fear of pain during childbirth and the convenience factor to the growing proportion of expectant mothers who are obese.
Ugh. I've been arguing against the "women are too fat" argument for years. Fat women have had plenty of babies in the past and the cesarean rate for them then was far lower than it is now. In some studies it was no different than that of average-sized women.

It's not women's size that is directly driving the cesarean rate. Instead what seems to have changed is providers' practice patterns around handling the pregnancies of fat women.

One German study really zeroed in on this by showing that the cesarean rate for obese women had drastically risen over a 12-year period. In the study, the cesarean rate for "morbidly obese" women (BMI over 40) increased from 26.9% in 1990 to 55.2% in 2012. Basically, it doubled.

Critics would argue that the cesarean rate has increased in all groups over time, which is correct. However, it has not increased equally over all groups, suggesting that something about the management of certain groups has changed.

For example, the rate has increased MOST in the women with the highest BMIs. In the German study, the cesarean rate increased 15.3% in the "normal" BMI group, whereas it increased 28.3% in the "morbidly obese" group.

This strongly suggests that it is not obesity itself that is driving the increase, but the way that obese pregnancies are being managed. Obese women are subjected to more interventions, more exaggeration of fear around their pregnancies, and a lowering of the surgical threshold for a cesarean.

But it's not just about blaming obesity. Women are being blamed across the board for higher cesarean rates in order to deflect criticism from how births are being managed these days.

I have written about this topic of mother-blaming for cesarean rates many times. That's why I was delighted recently to see this mother-blaming thoroughly debunked in an article from Australia. (The article is not new; it is from 2012, but I only recently saw it.) It was written by maternity care professionals there. Sadly, they were mostly addressing the cesarean rate in Australia, although they did reference the rates in the U.S. Wish more U.S. providers had the guts to chime in on this issue.

But at least the Australian authors said out loud what few in the obstetric world have been willing to admit until recently ─ that the increase in cesareans has largely been driven by provider practice, not by differences in women themselves.

Here is a quote from the authors (my emphasis):
When we’re not using the “too posh to push” or “asking for it” explanation for rising caesarean rates, health professionals resort to the “too old, too sick and too fat” mantra to explain away our responsibility for the rise. In other words, women are giving birth at older ages, they have more health complications and are increasingly overweight. 
All of this is true on one level – women are older and more likely to be overweight and this all increases the chance of complications – but caesareans are rising among all groups, regardless of age, risk factors and weight...
It’s time to abandon the “too old, too fat, too sick and asking for it” mantra and stop blaming women for the high rates of caesarean births. 
Instead, we need to address the real problem: we health providers are too often scared, impatient and inadequately informed to give women a real choice.
About time someone in the profession is saying what consumers have been saying for years! Yet many in the medical world are still scapegoating women for high cesarean rates.

It is not a matter of a rising tide of high-risk mothers driving up the cesarean rate, but rather a deep and increasing trend towards more intervention and a lower surgical threshold in ALL groups. As Henci Goer and CNM Amy Romano note in their book, "Optimal Care in Childbirth":
U.S. cesarean rates have increased sharply at every maternal age, in every ethnic group, and for every demographic or medical risk factor.
By blaming mothers, caregivers avoid taking responsibility for their own actions which have pushed up the cesarean rate. 

The induction and "pushed birth" epidemic, the over-intervention in normal labors, the lack of support for vaginal breech birth, the virtual abandonment of VBAC, the loss of skills in manually turning poorly-positioned babies, the lack of patience during labor, the increasingly narrow definition of "normal," the fear around lawsuits, and the lowering of surgical thresholds have all been caregiver-driven reasons for the rise in the cesarean rate.

The conversation needs to stop being about mother-blaming. It should be about caregivers taking responsibility for the patterns of management that have driven up cesarean rates over the years. Providers have conveniently managed to deflect this for years by blaming women instead of turning a critical eye to their own practices, but this must end.

Changing demographics may play a small role and women do have a responsibility to be proactive in their health habits to minimize the risk for complications, but providers need to acknowledge that the way they manage births has been a very significant factor in the tremendous rise in the cesarean rate.

It's time to stop scapegoating women for the high cesarean rate, and it's time for caregivers to take responsibility for their own contributions to the high cesarean rate.


References

Am J Public Health. 2006 May;96(5):867-72. Epub 2006 Mar 29. Maternal risk profiles and the primary cesarean rate in the United States, 1991-2002. Declercq E, Menacker F, Macdorman M. PMID: 16571712
OBJECTIVES: We examined factors contributing to shifts in primary cesarean rates in the United States between 1991 and 2002. METHODS: US national birth certificate data were used to assess changes in primary cesarean rates stratified according to maternal age, parity, and race/ethnicity. Trends in the occurrence of medical risk factors or complications of labor or delivery listed on birth certificates and the corresponding primary cesarean rates for such conditions were examined. RESULTS: More than half (53%) of the recent increase in overall cesarean rates resulted from rising primary cesarean rates. There was a steady decrease in the primary cesarean rate from 1991 to 1996, followed by a rapid increase from 1996 to 2002. In 2002, more than one fourth of first-time mothers delivered their infants via cesarean. Changing primary cesarean rates were not related to general shifts in mothers' medical risk profiles. However, rates for virtually every condition listed on birth certificates shifted in the same pattern as with the overall rates. CONCLUSIONS: Our results showed that shifts in primary cesarean rates during the study period were not related to shifts in maternal risk profiles.
PLoS Med. 2014 Oct 21;11(10):e1001745. doi: 10.1371/journal.pmed.1001745. eCollection 2014. Maternal clinical diagnoses and hospital variation in the risk of cesarean delivery: analyses of a National US Hospital Discharge Database. Kozhimannil KB1, Arcaya MC2, Subramanian SV2. PMID: 25333943
BACKGROUND: Cesarean delivery is the most common inpatient surgery in the United States, where 1.3 million cesarean sections occur annually, and rates vary widely by hospital. Identifying sources of variation in cesarean use is crucial to improving the consistency and quality of obstetric care. We used hospital discharge records to examine the extent to which variability in the likelihood of cesarean section across US hospitals was attributable to individual women's clinical diagnoses. METHODS AND FINDINGS: Using data from the 2009 and 2010 Nationwide Inpatient Sample from the Healthcare Cost and Utilization Project--a 20% sample of US hospitals--we analyzed data for 1,475,457 births in 1,373 hospitals. We fitted multilevel logistic regression models (patients nested in hospitals). The outcome was cesarean (versus vaginal) delivery. Covariates included diagnosis of diabetes in pregnancy, hypertension in pregnancy, hemorrhage during pregnancy or placental complications, fetal distress, and fetal disproportion or obstructed labor; maternal age, race/ethnicity, and insurance status; and hospital size and location/teaching status. The cesarean section prevalence was 22.0% (95% confidence interval 22.0% to 22.1%) among women with no prior cesareans. In unadjusted models, the between-hospital variation in the individual risk of primary cesarean section was 0.14 (95% credible interval 0.12 to 0.15). The difference in the probability of having a cesarean delivery between hospitals was 25 percentage points. Hospital variability did not decrease after adjusting for patient diagnoses, socio-demographics, and hospital characteristics (0.16 [95% credible interval 0.14 to 0.18]). A limitation is that these data, while nationally representative, did not contain information on parity or gestational age. CONCLUSIONS: Variability across hospitals in the individual risk of cesarean section is not decreased by accounting for differences in maternal diagnoses. These findings highlight the need for more comprehensive or linked data including parity and gestational age as well as examination of other factors-such as hospital policies, practices, and culture--in determining cesarean section use. 
J Perinat Med. 2014 Jun 10. Impact of maternal body mass index on the cesarean delivery rate in Germany from 1990 to 2012. Kyvernitakis I, Köhler C, Schmidt S, Misselwitz B, Großmann J, Hadji P, Kalder M. PMID: 24914711
ABSTRACT AIMS: Maternal obesity is a risk factor for cesarean delivery (CD). The aim of this analysis was to determine the association between early-pregnancy body mass index (BMI) and the rate of CD over the past two decades. METHODS: We retrospectively analyzed data from the perinatal quality registry of singleton deliveries in the state of Hesse in Germany from 1990 to 2012. We divided the patients into groups according to the WHO criteria for BMI: underweight (<18.5), normal weight (18.5-<25), overweight (25-<30), obese class I (30-<35), obese class II (35-<40), and obese class III (≥40). RESULTS: The analysis included 1,092,311 patients with available data regarding maternal BMI and mode of delivery. The CD rates for underweight (<18.5), normal weight (18.5-<25), overweight (25-<30), obese class I (30-<35), obese class II (35-<40), and obese class III (≥40) women increased from 14.4%, 16.1%, 19.5%, 22.3%, 25%, and 26.9% in the year 1990 to 27.9%, 31.4%, 38.8%, 45.1%, 50.2%, and 55.2% in the year 2012, respectively (P<0.001). CONCLUSION: Maternal BMI in early pregnancy is linearly associated with the incidence of CD. We found a disproportionate increase of CD in morbidly obese women compared with the CD incidence in the reference BMI population over the past two decades.
J Obstet Gynaecol Can. 2011 May;33(5):443-8. Higher caesarean section rates in women with higher body mass index: are we managing labour differently? Abenhaim HA, Benjamin A. PMID: 21639963
BACKGROUND: Higher body mass index has been associated with an increased risk of Caesarean section. The effect of differences in labour management on this association has not yet been evaluated. METHODS: We conducted a cohort study using data from the McGill Obstetrics and Neonatal Database for deliveries taking place during a 10-year period. Women's BMI at delivery was categorized as normal (20 to 24.9), overweight (25 to 29.9), obese (30 to 39.9), or morbidly obese (≥ 40). We evaluated the effect of the management of labour on the need for Caesarean section using unconditional logistic regression models. RESULTS: Data were available for 11 922 women, of whom 2289 women had normal weight, 5663 were overweight, 3730 were obese, and 240 were morbidly obese. After adjustment for known confounding variables, increased BMI category was associated with an overall increase in the use of oxytocin and in the use of epidural analgesia, and with a decrease in use of forceps and vacuum extraction among second stage deliveries. Higher BMI was also found to be associated with earlier decisions to perform a Caesarean section in the second stage of labour. When adjusted for these differences in the management of labour, the increasing rate of Caesarean section observed with increasing BMI category was markedly attenuated (P < 0.001). CONCLUSION: Women with an increased BMI are managed differently in labour than women of normal weight. This difference in management in part explains the increased rate of Caesarean section observed with higher BMI.

Monday, October 31, 2016

Exercise During Pregnancy May Cut Labor Length in Women of Size

Image from Stocky Bodies Image Bank
Here is the abstract of a recent study that found that exercise during pregnancy might be useful in reducing how long a high-BMI woman spends in labor.

In the study, women of size who were active during pregnancy had shorter labors (13.4 hours vs. 19.2 hours) than those who were more sedentary.

The effect seemed particularly strong for women who had given birth before (multips). "Obese" multips who were active in pregnancy had labors of about 6.2 hours, vs. 16.7 hours for obese multips who were not active in pregnancy.

The difference in cesarean rates between those who were active in pregnancy and those who were not did not rise to statistical significance in this study, but as we wrote about recently, other research has suggested that exercise in pregnancy might reduce the risk for cesareans as well.

One caution is that this study was small, so that limits the conclusions from it. Perhaps there were simply not enough participants to show a significant difference in cesareans. On the other hand, its relatively small size might also have magnified the effect on labor length. So there is that caveat.

And of course, this finding is only a correlation. There are plenty of people who exercise religiously and end up with long labors and/or cesareans, and some people who don't exercise at all and have easy short labors and births. Exercising is no guarantee of anything, but it does seem likely to reduce the odds of problems. For example, some research suggests that regular exercise during pregnancy might reduce the risk for gestational diabetes in obese women.

Potentially reducing labor length is just one more reason for women of size to exercise during pregnancy. It's a low-tech intervention that is very unlikely to harm (barring the rare contraindications to exercise in pregnancy) and seems likely to be helpful.

If exercising is something you already do, good work! Keep it up. Regularity of exercise is more important in pregnancy than its intensity. You don't have to run marathons to benefit. Just get out and move most days of the week.

If exercise is something you can improve on, get started. Choose a form of exercise that you enjoy. Walking, swimming, dancing, prenatal yoga, riding an exercise bike, and water aerobics are all forms of exercise that are very friendly to pregnant women of size. And remember, any amount you do is better than none.

You'll feel better for having exercised, trust me (I definitely felt better in my pregnancies when I exercised). And maybe it will pay off with a shorter labor, fewer complications, or less chance of a cesarean too.


Reference

J Sports Med Phys Fitness. 2015 Nov 12. [Epub ahead of print] Impact of physical activity during pregnancy on obstetric outcomes in obese women. Tinius R1, Cahill AG, Cade WT. PMID: 26564274
AIM: Maternal obesity is associated with complications and adverse outcomes during the labor and delivery process. In pregnant women with a healthy body weight, maternal physical activity during pregnancy is associated with better obstetric outcomes; however, the effect of maternal physical activity during pregnancy on obstetric outcomes in obese women is not known. The purpose of the study was to determine the influence of self-reported physical activity levels on obstetric outcomes in pregnant obese women. METHODS: A retrospective chart review was performed on 48 active obese women and 48 inactive obese women (N=96) who received prenatal care and delivered at the medical center during the past five years. Obstetric and neonatal outcomes were compared between the active and inactive groups. RESULTS: Obese women who were active during pregnancy spent less total time in labor (13.4 hours vs. 19.2 hours, p=0.048) and were less likely to request an epidural (92% vs. 100%, p=0.04). When stratified by parity, active multiparous women spent significantly less total time in labor compared to inactive multiparous (6.2 hours vs. 16.7 hours, p=0.018). There were no statistical differences between groups in rates of cesarean deliveries or neonatal outcomes. CONCLUSION: Maternal physical activity during pregnancy appears to improve obstetric outcomes in obese women, and this improvement may be more pronounced among multiparous women. Our finding is of particular importance as pregnant obese women are at higher risk for adverse and delivery outcomes.

Monday, October 24, 2016

Exercise During Pregnancy May Cut Cesarean Risk

Image from World Obesity Federation Image Bank*
I'm a big fan of being proactive in pregnancy. I think eating healthfully, getting enough sleep, avoiding stress when possible, and getting regular exercise strongly benefit pregnant women of all sizes. Now there is new research suggesting it may also lower the risk for cesarean.

However, keep in mind that there are plenty of women who don't do these things and still have a vaginal birth. And there are plenty of women who do everything "right" and still end up with a cesarean. There's certainly not a one-to-one relationship between exercise and cesareans. But being as proactive as possible in your health habits during pregnancy may lessen the risk for complications or for an unplanned cesarean.

Personally, in my first pregnancy I didn't exercise that much. I had quite a bit of bleeding and spotting at first and was told not to do much, plus we had a major move in the middle of it all which meant that most of my non-work time was spent on packing and unpacking from the move. I felt pretty out of shape by the end of pregnancy.

In my second and third pregnancies, I exercised quite a bit. I wasn't running marathons or anything, but I did walk regularly, and added in swimming, water aerobics, and prenatal yoga as my schedule allowed. If all else failed, I ran the stairs in my house. I felt SO much better and had way more stamina.

In my fourth pregnancy, I was taking care of my seriously ill mother as well as my three young children. It was hard to find time to sleep, let alone exercise, but I did still manage to walk some. I fit in swimming or stairs where I could but I didn't get nearly as much exercise as the second and third pregnancies. By the end, I felt the difference.

Here is the abstract for a recent study that supports the idea that regular exercise in pregnancy might cut the risk for cesarean. 

For me, exercise didn't make much difference in which pregnancies ended in cesarean, but it sure did make a difference in how I felt by the end of pregnancy! And I think it helped me lower my risk for complications like blood pressure issues etc., which I never got despite being "morbidly obese" and a much older mom.

So I'm a major fan of getting regular exercise in pregnancy. It doesn't have to mean running a marathon, but simply doing regular movement of some sort seems to be a common-sense thing to do. And if it lowers your risk for cesarean somewhat, all the better.

However, exercise programs are often pushed mainly for "obese" women. Frankly, ALL pregnant women should be encouraged to get more exercise, not just women of size. High-BMI women may benefit the most from it, but women of all sizes benefit from regular exercise.

As long as you don't have any medical contraindications, exercise is just a common-sense thing to do in pregnancy.


*Isn't it telling that I couldn't find a good positive picture of a pregnant woman of size exercising? Many of us do it, so why aren't there many good pictures of that? The very few pictures I did find were problematic for various reasons. Most images in articles about exercise for heavier pregnant women actually showed pregnant women of average size, or the images were patronizing and stigmatizing. Please, if you have a good picture of yourself pregnant and exercising, I'd appreciate it if you shared it with me for use in the future. 


Reference

Am J Obstet Gynecol. 2016 Aug 23. pii: S0002-9378(16)30579-8. doi: 10.1016/j.ajog.2016.08.014. [Epub ahead of print] Exercise during pregnancy and risk of cesarean delivery in nulliparous women: a large population-based cohort study. Owe KM1, Nystad W2, Stigum H2, Vangen S3, Bø K4. PMID: 27555317
...OBJECTIVE: The purpose of this study was to investigate the association between exercise during pregnancy and cesarean delivery, both acute and elective, in nulliparous women. STUDY DESIGN: We conducted a population-based cohort study that involved 39,187 nulliparous women with a singleton pregnancy who were enrolled in the Norwegian Mother and Child Cohort Study between 2000 and 2009. All women answered 2 questionnaires in pregnancy weeks 17 and 30. Acute and elective cesarean delivery data were obtained from the Medical Birth Registry of Norway. Information on exercise frequency and type was assessed prospectively by questionnaires in pregnancy weeks 17 and 30...RESULTS: The total cesarean delivery rate was 15.4% (n=6030), of which 77.8% (n=4689) was acute cesarean delivery. Exercise during pregnancy was associated with a reduced risk of cesarean delivery, particularly for acute cesarean delivery...The largest risk reduction was observed for acute cesarean delivery among women who exercised >5 times weekly during weeks 17 (-2.2%) and 30 (-3.6%) compared with nonexercisers (test for trend, P<.001). Reporting high impact exercises in weeks 17 and 30 was associated with the greatest reduction in risk of acute cesarean delivery (-3.0% and -3.4%, respectively). CONCLUSION: Compared with nonexercisers, regular exercise and high-impact exercises during pregnancy are associated with reduced risk of having an acute cesarean delivery in first-time mothers.

Saturday, October 15, 2016

Placenta Accreta Rates Reflect High Cesarean Rates and VBAC Bans


October is Accreta Awareness Month. The International Cesarean Awareness Network (ICAN) is featuring Accreta Awareness as part of its focus this month, and is promoting the importance of donating blood in order to help women who experience accretas.

Placenta Accreta is a condition in which the placenta attaches too deeply to the uterine wall, or actually grows into the uterine wall. Occasionally it even grows through the uterine wall and into adjoining tissues. This means the placenta can't separate during birth. It causes massive bleeding, and frequently requires a hysterectomy in order to control the bleeding. Placenta Accreta has about a 7% maternal mortality rate and is one of the most serious obstetric situations a woman can face.

You can read more about Placenta Accreta in my series about it here:

  • Part One: What Is Accreta?
  • Part Two: Life-Threatening Complication of Prior Cesarean
  • Part Three: Risks to Mother and Baby
  • Part Four: Diagnosis, Treatment, and a Cautionary Story

Accretas have several different risk factors, including maternal age, parity, smoking, infection, pregnancy after fertility treatment, and prior uterine procedures such as D&C or fibroid removal.

However, the strongest risk factor for accretas is a history of prior cesarean sections. The discovery of placenta previa (a low-lying placenta) in a woman with a history of prior cesareans is particularly predictive of an accreta.

In addition, the risk for accreta rises strongly as the number of prior cesareans increases. Silver 2006 found the following risk for accreta by number of prior cesareans:

  • First cesarean:                  0.24%
  • Second cesarean:             0.31%
  • Third cesarean:                0.57%
  • Fourth cesarean:              2.13%
  • Fifth cesarean:                 2.33%
  • Sixth or more cesarean:   6.74%

A recent large Nordic study found:
The risk of AIP [abnormally invasive placenta] increased seven-fold after one prior caesarean section (CS) to 56-fold after three or more CS.
Accretas are associated with poor outcomes, but very high-order repeat cesareans are particularly associated with poor outcomes.

Many accretas occur in women who have a cesarean in their first pregnancy and are automatically scheduled for repeat cesareans thereafter. Women who have larger families are particularly impacted. Yet many of these women say that they were never counseled about the risk of accreta with repeat cesareans. This is wrong. Informed consent should include discussions of all the risks of both VBAC and repeat cesareans.

Alarmingly, the incidence of placenta accreta cases seems to be on the rise. As noted by ACOG in the graphic above, this is likely in response to the rising cesarean rates. This reflects an increase in both primary cesareans and routine repeat cesareans as a result of de facto VBAC bans.

The increase in accretas is not just a U.S. phenomenon. A recent study from Hong Kong, where there is a high underlying cesarean rate, demonstrates that the rate of accreta increased over time as the cesarean rate increased. The authors note:
The overall rate of morbidly adherent placenta...increased from 0.17/1000 births in 1999-2003 to 0.79/1000 births in 2009-2013.
For such a rare condition, that's a significant increase. A similar result was found in an Italian region with a strong increase in cesarean rates over the years. Researchers found that:
The incidence increased from 0.12% during the 1970s, to 0.31% during the 2000s. During the same period, cesarean section rates increased from 17 to 64%. Prior cesarean section was the only risk factor showing a significant concomitant rise. Our results reinforce cesarean section as the most significant predisposing condition for placenta accreta.
One recent analysis concluded:
The incidence of placenta accreta has increased 13-fold since the early 1900s and directly correlates with the increasing cesarean delivery rate.
Alarmingly, the increase in accreta rates also seems to parallel the rise in maternal mortality rates over time. There are many other factors that play into the maternal mortality rate, mind, but the high cesarean rate and resulting accretas is one major piece of the puzzle.

If we hope to reduce the number of women impacted by accretas, we must reduce the cesarean rate. The authors of the recent Nordic study pointed this out, saying:
Our findings indicate that a lower CS rate in the population may be the most effective way to lower the incidence of AIP [Abnormally Invasive Placenta]. 
This means not only reducing the number of women who have first cesareans but also the number of women who have automatic repeat cesareans. In order to do that, we must increase access to VBACs. Far too many women have difficulty finding providers who will support them in labor after cesarean. Many hospitals have outright VBAC bans.

Of course, it's only fair to note that most women who have higher-order cesareans will not experience an accreta. However, accreta is such a serious and life-threatening condition that even relatively small incidences carry a huge burden of complications, cost, and potential loss of life. That's why it is vital that women have balanced risk counseling after a prior cesarean and real access to VBAC if they want it.

There are many birth stories online of women who have experienced accretas. It's important to emphasize that many of them have good outcomes, but also important to point out that many of them have challenging outcomes, and some of them have even had tragic outcomes.

This is the bottom line. Real women have died because of accretas, leaving their children motherless. Others have lost their uterus to hysterectomy or their babies to prematurity. Although I have not personally known anyone who died from accreta, I have known several women who have had very close near-misses due to accreta. Nearly all lost their uteri as a result of their accreta, and some lost their babies as well.

This is the real consequence of a too-high cesarean rate. This is why it's so important to avoid non-indicated cesareans and improve VBAC access. 

*If you can, give blood to help support women who have been affected by accreta. 


References

Support Groups


Accreta Studies

Semin Perinatol. 2012 Oct;36(5):315-23. doi: 10.1053/j.semperi.2012.04.013. Implications of the first cesarean: perinatal and future reproductive health and subsequent cesareans, placentation issues, uterine rupture risk, morbidity, and mortality. Silver RM. PMID: 23009962
Rates of cesarean delivery have substantially increased worldwide during the past 30 years. Indeed, almost one-third of deliveries in the United States are cesareans. Most cesareans are safe, and major complications are uncommon. However, there is a "concealed" downside to cesarean deliveries. There are rare but life-threatening morbidities that may occur, which are often overlooked because most cesareans go well. In addition, subsequent pregnancies are fraught with an increased risk of both maternal and fetal complications. The worst of these are associated with placental problems such as previa, abruption, and accreta. The risk dramatically worsens in patients with multiple repeat cesarean deliveries. This article will summarize and highlight the implications of the rising cesarean rate on maternal and fetal morbidity and mortality.
Hong Kong Med J. 2015 Dec;21(6):511-7. doi: 10.12809/hkmj154599. Epub 2015 Nov 6. Rising incidence of morbidly adherent placenta and its association with previous caesarean section: a 15-year analysis in a tertiary hospital in Hong Kong. Cheng KK1, Lee MM1. PMID: 26554269
OBJECTIVES: To identify the incidence of morbidly adherent placenta in the context of a rising caesarean delivery rate within a single institution in the past 15 years, and to determine the contribution of morbidly adherent placenta to the incidence of massive postpartum haemorrhage requiring hysterectomy. SETTING: A regional obstetric unit in Hong Kong. PATIENTS: Patients with a morbidly adherent placenta with or without previous caesarean section scar from 1999 to 2013. RESULTS: A total of 39 patients with morbidly adherent placenta were identified during 1999 to 2013. The overall rate of morbidly adherent placenta was 0.48/1000 births, which increased from 0.17/1000 births in 1999-2003 to 0.79/1000 births in 2009-2013. The rate of morbidly adherent placenta with previous caesarean section scar and unscarred uterus also increased significantly. Previous caesarean section (odds ratio=24) and co-existing placenta praevia (odds ratio=585) remained the major risk factors for morbidly adherent placenta. With an increasing rate of morbidly adherent placenta, more patients had haemorrhage with a consequent increased need for peripartum hysterectomy. No significant difference in the hysterectomy rate of morbidly adherent placenta in caesarean scarred uterus (19/25) compared with unscarred uterus (8/14) was noted. This may have been due to increased detection of placenta praevia by ultrasound and awareness of possible adherent placenta in the scarred uterus, as well as more invasive interventions applied to conserve the uterus. CONCLUSION: Presence of a caesarean section scar remained the main risk factor for morbidly adherent placenta. Application of caesarean section should be minimised, especially in those who wish to pursue another future pregnancy, to prevent the subsequent morbidity consequent to a morbidly adherent placenta, in particular, massive postpartum haemorrhage and hysterectomy.
Acta Obstet Gynecol Scand. 2013 Apr;92(4):457-60. doi: 10.1111/aogs.12080. Placenta accreta: incidence and risk factors in an area with a particularly high rate of cesarean section. Morlando M, Sarno L, Napolitano R, Capone A, Tessitore G, Maruotti GM, Martinelli P. PMID: 23347183
...The aim of this study was to investigate the change in the incidence of placenta accreta and associated risk factors along four decades, from the 1970s to 2000s, in a tertiary south Italian center. We analyzed all cases of placenta accreta in a sample triennium for each decade. The incidence increased from 0.12% during the 1970s, to 0.31% during the 2000s. During the same period, cesarean section rates increased from 17 to 64%. Prior cesarean section was the only risk factor showing a significant concomitant rise. Our results reinforce cesarean section as the most significant predisposing condition for placenta accreta.
Obstet Gynecol. 2015 Sep;126(3):654-68. doi: 10.1097/AOG.0000000000001005. Abnormal Placentation: Placenta Previa, Vasa Previa, and Placenta Accreta. Silver RM1. PMID: 26244528
Placental disorders such as placenta previa, placenta accreta, and vasa previa are all associated with vaginal bleeding in the second half of pregnancy. They are also important causes of serious fetal and maternal morbidity and even mortality. Moreover, the rates of previa and accreta are increasing, probably as a result of increasing rates of cesarean delivery, maternal age, and assisted reproductive technology....
BJOG. 2016 Jul;123(8):1348-55. doi: 10.1111/1471-0528.13547. Epub 2015 Jul 29. Abnormally invasive placenta-prevalence, risk factors and antenatal suspicion: results from a large population-based pregnancy cohort study in the Nordic countries. Thurn L, Lindqvist PG, Jakobsson M, Colmorn LB, Klungsoyr K, Bjarnadóttir RI, Tapper AM, Børdahl PE, Gottvall K, Petersen KB,Krebs L, Gissler M, Langhoff-Roos J, Källen K. PMID: 26227006
OBJECTIVE: The objective was to investigate prevalence, estimate risk factors, and antenatal suspicion of abnormally invasive placenta (AIP) associated with laparotomy in women in the Nordic countries. DESIGN: Population-based cohort study. SETTING AND POPULATION: A 3-year Nordic collaboration among obstetricians to identify and report on uterine rupture, peripartum hysterectomy, excessive blood loss, and AIP from 2009 to 2012 The Nordic Obstetric Surveillance Study (NOSS). METHODS: In the NOSS study, clinicians reported AIP cases from maternity wards and the data were validated against National health registries. MAIN OUTCOME MEASURES: Prevalence, risk factors, antenatal suspicion, birth complications, and risk estimations using aggregated national data. RESULTS: A total of 205 cases of AIP in association with laparotomy were identified, representing 3.4 per 10 000 deliveries. The single most important risk factor, which was reported in 49% of all cases of AIP, was placenta praevia. The risk of AIP increased seven-fold after one prior caesarean section (CS) to 56-fold after three or more CS. Prior postpartum haemorrhage was associated with six-fold increased risk of AIP (95% confidence interval 3.7-10.9). Approximately 70% of all cases were not diagnosed antepartum. Of these, 39% had prior CS and 33% had placenta praevia. CONCLUSION: Our findings indicate that a lower CS rate in the population may be the most effective way to lower the incidence of AIP. Focused ultrasound assessment of women at high risk will likely strengthen antenatal suspicion. Prior PPH is a novel risk factor associated with an increased prevalence of AIP.
Am J Obstet Gynecol. 2015 Sep;213(3):384.e1-11. doi: 10.1016/j.ajog.2015.05.002. Epub 2015 May 5. Morbidity associated with cesarean delivery in the United States: is placenta accreta an increasingly important contributor? Creanga AA, Bateman BT, Butwick AJ, Raleigh L, Maeda A, Kuklina E, Callaghan WM. PMID: 25957019
OBJECTIVE: The purpose of this study was to examine cesarean delivery morbidity and its predictors in the United States. STUDY DESIGN: We used 2000-2011 Nationwide Inpatient Sample data to identify cesarean deliveries and records with 12 potential cesarean delivery complications, including placenta accreta. We estimated cesarean delivery morbidity rates and rate changes from 2000-2011, and fitted Poisson regression models to assess the relative incidence of morbidity among repeat vs primary cesarean deliveries and explore its predictors. RESULTS: From 2000-2011, 76 in 1000 cesarean deliveries (97 in 1000 primary and 48 in 1000 repeat cesarean deliveries) were accompanied by ≥1 of 12 complications. The unadjusted composite cesarean delivery morbidity rate increased by 3.6% only among women with a primary cesarean delivery (P < .001); the unadjusted rate of placenta accreta increased by 30.8% only among women with a repeat cesarean deliveries (P = .025). The adjusted rate of overall composite cesarean delivery morbidity decreased by 1% annually from 2000-2011 (P < .001). Compared with women with a primary cesarean delivery, those women who underwent a repeat cesarean delivery were one-half as likely (incidence rate ratio, 0.50; 95% CI, 0.49-0.50) to experience a complication, but 2.13 (95% CI, 1.98-2.29) times more likely to have a placenta accreta diagnosis. Both cesarean delivery morbidity and placenta accreta were positively associated with age >30 years, non-Hispanic black race/ethnicity, the presence of a chronic medical condition, and delivery in urban, teaching, or larger hospitals. CONCLUSION: Overall, cesarean delivery morbidity declined modestly from 2000-2011, but placenta accreta became an increasingly important contributor to repeat cesarean delivery morbidity. Clinicians should maintain a high index of suspicion for abnormal placentation and make adequate preparations for patients who need cesarean deliveries.
BJOG. 2013 Jan;120(1):85-91. doi: 10.1111/1471-0528.12010. Epub 2012 Oct 24. Multiple repeat caesarean section in the UK: incidence and consequences to mother and child. A national, prospective, cohort study. Cook JR1, Jarvis S, Knight M, Dhanjal MK. PMID: 23095012
OBJECTIVE: To estimate the incidence of multiple repeat caesarean section (MRCS) (five or more) in the UK and to describe the outcomes for women and their babies relative to women having fewer repeat caesarean sections. DESIGN: A national population-based prospective cohort study using the UK Obstetric Surveillance System (UKOSS). SETTING: All UK hospitals with consultant-led maternity units. POPULATION: Ninety-four women having their fifth or greater MRCS between January 2009 and December 2009, and 175 comparison women having their second to fourth caesarean section. METHODS: Prospective cohort and comparison identification through the UKOSS monthly mailing system. MAIN OUTCOME MEASURES: Incidence, maternal and neonatal complications. Relative risk, unadjusted (OR) and adjusted (aOR) odds ratio estimates. RESULTS: The estimated UK incidence of MRCS was 1.20 per 10 000 maternities [95% confidence interval (CI), 0.97-1.47]. Women with MRCS had significantly more major obstetric haemorrhages (>1500 ml) (aOR, 18.6; 95% CI, 3.89-88.8), visceral damage (aOR, 17.6; 95% CI, 1.85-167.1) and critical care admissions (aOR, 15.5; 95% CI, 3.16-76.0), than women with lower order repeat caesarean sections. These risks were greatest in the 18% of women with MRCS who also had placenta praevia or accreta. Neonates of mothers having MRCS were significantly more likely to be born prior to 37 weeks of gestation (OR, 6.15; 95% CI, 2.56-15.78) and therefore had higher rates of complications and admissions. CONCLUSIONS: MRCS is associated with greater maternal and neonatal morbidity than fewer caesarean sections. The associated maternal morbidity is largely secondary to placenta praevia and accreta, whereas higher rates of preterm delivery are most likely a response to antepartum haemorrhage.
Obstet Gynecol. 2011 Sep;118(3):687-90. doi: 10.1097/AOG.0b013e318227b8d9. The rising cesarean delivery rate in America: what are the consequences? Blanchette H1. PMID: 21860302
Cesarean delivery is now the most common operation in the United States, and it has increased dramatically from 5.8% in 1970 to 32.3% in 2008. This rise has not resulted in significant improvement in neonatal morbidity or maternal health. Three recent studies of elective repeat cesarean deliveries performed before 39 completed weeks of gestation have demonstrated increased respiratory and other adverse neonatal outcomes. Maternal mortality in the United States has increased from 10 per 100,000 to 14 per 100,000 from 1998 to 2004. Contributing to this in an increasing incidence of placenta accreta associated with multiple uterine scars requiring the need for emergency cesarean hysterectomy, blood transfusion, and maternal mortality due to obstetric hemorrhage. To reverse the trend of the rising cesarean delivery rate, obstetricians must reduce the primary rate and avoid the performance of a uterine incision unless absolutely necessary for fetal or maternal indications. For women with one previous low transverse cesarean delivery, obstetricians should promote a trial of labor after previous cesarean delivery in those women who desire three or more children.

Sunday, October 2, 2016

Staples vs. Sutures During Cesareans in High BMI Women


Women of size have higher rates of cesareans in many studies. Many of them are probably preventable but the fact remains that high-BMI women have a high rate of cesareans.

One of the problems with this is that "obese" women are at increased risk for infection and wound complications after a cesarean, and this leads to a great deal of morbidity and healthcare costs.

What can be done to improve outcomes? Past research has strongly suggested that closing the subcutaneous fat layer and avoiding a surgical drain reduces the rates of infection in high-BMI women. Higher doses of antibiotics also seem to be helpful, though the best dosage is still being debated. Using low transverse incisions instead of vertical incisions whenever possible probably also lowers the risk for complications.

Now, new studies seem to suggest that taking the time to suture the wound closed may result in less infection than using staples to close the wound. 

Doctors don't always like to do this because suturing takes longer. And suturing a woman with a lot of abdominal fat is more challenging as well. So most often, staples are used to close a cesarean, especially in women of size. But is this a good idea?

Mackeen 2015 performed a meta-analysis of studies and found that using sutures cut the risk for wound complications in half compared to staples. This risk reduction persisted even when data was stratified by obesity levels.

Zaki 2016 studied sutures vs. staples specifically in obese women. They found:
Women with staples had higher wound complications compared with sutures (22.0% versus 9.7%) with a 2.27 unadjusted relative risk (RR) (95% confidence interval (CI), 1.7 to 3.0) and 1.78 adjusted RR (95% CI, 1.27 to 2.49) after controlling for confounders in the final analysis, including vertical skin incisions. 
Further studies done specifically on high-BMI women should be done to confirm these findings, but the findings so far seem pretty clear. Using a subcuticular suture to close the incision seems to lessen the risk for wound complications compared to staples.

This is important news because research shows that as BMI increases, doctors are less inclined to use sutures. 

In other words, without intending to, doctors may actually be unnecessarily increasing the risk for wound complications after cesarean in women of size.

Conclusion

I'm glad to see that more research is FINALLY being done on how to lessen the rate of complications in women of size who undergo a cesarean.

For years, doctors simply made assumptions about what they thought would improve cesarean outcomes in obese women ─ but they didn't test their assumptions. Once they started testing the assumptions, they found a few surprises.

Doctors have traditionally been more inclined to use vertical incisions in high-BMI women. They did this because they thought that vertical incisions would lessen the risk for infection by avoiding the area underneath the belly (pannus). They were wrong; most research shows that vertical incisions actually increase the risk for wound complications in obese women.

They thought surgical drains would allow fluids to exit and thereby decrease the chances for wound separations and infections. Yet some research seems to suggest that surgical drains actually increase the risk for problems.

They assumed that the standard antibiotic dosage for all women was sufficient for high-BMI women too. Yet research shows that standard dosages probably do not provide adequate coverage to prevent infections.

When a cesarean is truly needed, it's a wonderful and life-saving thing to have available. Although cesareans carry more risks for obese women, there are important things that doctors can do to improve outcomes in high-BMI women when a cesarean is truly necessary. This list may now include suturing instead of using staples to close the wound, even if it takes slightly longer to accomplish.

However, let's not lose sight of the fact that the most important step that doctors can take to improve outcomes in obese women is to only do cesareans when they are truly needed. 


References

J Perinatol. 2016 Oct;36(10):819-22. doi: 10.1038/jp.2016.89. Epub 2016 Jun 2. Wound complications in obese women after cesarean: a comparison of staples versus subcuticular suture. Zaki MN, Truong M, Pyra M, Kominiarek MA, Irwin T. PMID: 27253895
OBJECTIVE: To compare wound complications between staples versus subcuticular suture for skin closure in obese women (body mass index (BMI)⩾30 kg m(-2)) after cesarean delivery (CD). STUDY DESIGN: We conducted a retrospective cohort study to compare wound complications between staples and subcuticular suture closure in women, with a prepregnancy BMI⩾30 kg m(-2) after CD between 2006 and 2011 at an inner-city teaching hospital. Wound complication was defined as a composite of wound disruption (hematoma or seroma) or infection diagnosed up to 6 weeks postpartum. Variables collected include age, parity, prior CDs, prior abdominal surgeries, incision type, chorioamnionitis, maternal comorbidities (hypertension, diabetes) and gestational age. RESULTS: Of the 1147 women included in the study, women with staple closure were older and had higher BMIs (40.6±9.3 versus 36.1±5.4) and were more likely to be multiparous, have a prior CD, diabetes and hypertension compared with women with subcuticular suture. The overall occurrence of wound complications was 15.5% (178/1147). Women with staples had higher wound complications compared with sutures (22.0% versus 9.7%) with a 2.27 unadjusted relative risk (RR) (95% confidence interval (CI), 1.7 to 3.0) and 1.78 adjusted RR (95% CI, 1.27 to 2.49) after controlling for confounders in the final analysis, including vertical skin incisions. CONCLUSIONS: In obese women, skin closure with staples at the time of CD is associated with a higher rate of wound complications compared with subcuticular suture. Skin closure with subcuticular suture over staples should be considered in obese women undergoing a CD regardless of skin incision type.
Am J Obstet Gynecol. 2015 May;212(5):621.e1-10. doi: 10.1016/j.ajog.2014.12.020. Epub 2014 Dec 19. Suture versus staples for skin closure after cesarean: a metaanalysis. Mackeen AD, Schuster M, Berghella V. PMID: 25530592
OBJECTIVE: We sought to perform a metaanalysis to synthesize randomized clinical trials of cesarean skin closure by subcuticular absorbable suture vs metal staples for the outcomes of wound complications, pain perception, patient satisfaction, cosmesis, and operating time...RESULTS: Twelve randomized trials with data for the primary outcome on 3112 women were identified. Women whose incisions were closed with suture were significantly less likely to have wound complications than those closed with staples (risk ratio, 0.49; 95% confidence interval [CI], 0.28-0.87). This difference remained significant even when wound complications were stratified by obesity. The decrease in wound complications was largely due to the lower incidence of wound separations in those closed with suture (risk ratio, 0.29; 95% CI, 0.20-0.43), as there were no significant differences in infection, hematoma, seroma, or readmission. There were also no significant differences in pain perception, patient satisfaction, and cosmetic assessments between the groups. Operating time was approximately 7 minutes longer in those closed with suture (95% CI, 3.10-11.31). CONCLUSION: For patients undergoing cesarean, closure of the transverse skin incision with suture significantly decreases wound morbidity, specifically wound separation, without significant differences in pain, patient satisfaction, or cosmesis. Suture placement does take 7 minutes longer than staples.
Am J Perinatol. 2014 Apr;31(4):299-304. doi: 10.1055/s-0033-1348402. Epub 2013 Jun 13. Maternal obesity and risk of postcesarean wound complications. Conner SN, Verticchio JC, Tuuli MG, Odibo AO, Macones GA, Cahill AG. PMID: 23765707
OBJECTIVE: To estimate the effect of increasing severity of obesity on postcesarean wound complications and surgical characteristics. STUDY DESIGN: We performed a retrospective cohort study of consecutive cesarean deliveries at a tertiary care facility from 2004 to 2008. Four comparison groups were defined by body mass index (BMI; kg/cm2): < 30 (n = 728), 30 to 39.9 (n = 1,087), 40 to 49.9 (n = 428), or ≥ 50 (n = 201). The primary outcome was wound complication, defined as wound disruption or infection within 6 weeks postoperatively. Surgical characteristics were compared between groups including administration of preoperative antibiotics, type of skin incision, estimated blood loss (EBL), operative time, and type of skin closure. RESULTS: Of the 2,444 women with complete follow-up data, 266 (10.9%) developed a wound complication. Compared with nonobese women (6.6%), increasing BMI was associated with an increased risk of wound complications: BMI 30.0 to 39.9, 9.2%, adjusted odds ratio (aOR) 1.4 (95% confidence interval [CI] 0.99 to 2.0); BMI 40.0 to 49.9, 16.8%, aOR 2.6 (95% CI 1.7 to 3.8); BMI ≥ 50, 22.9%, aOR 3.0 (95% CI 1.9 to 4.9). Increasing BMI was also associated with increased rates of midline vertical incision, longer operative time, higher EBL, and lower rates of subcuticular skin closure. CONCLUSION: A dose-response relationship exists between increasing BMI and risk of postcesarean wound complications. Increasing obesity also significantly influences operative outcomes.
Decreasing Cesarean Wound Complications in Obese Women

Best Pract Res Clin Obstet Gynaecol. 2015 Apr;29(3):406-14. doi: 10.1016/j.bpobgyn.2014.08.009. Epub 2014 Oct 16. Obesity and the challenges of caesarean delivery: prevention and management of wound complications. Ayres-de-Campos D1. PMID: 25457856
Caesarean section in obese patients is associated with an increased risk of surgical wound complications, including haematoma, seroma, abscess and dehiscence. This review focusses on the available strategies to decrease wound complications in this population, and on the clinical management of these situations. Appropriate dose of prophylactic antibiotics, closure of the subcutaneous tissue, and avoidance of subcutaneous drains reduce the incidence of wound complications associated with caesarean section in obese patients. For treatment of superficial wound infection associated with dehiscence, there are data from general surgery patients to suggest that the use of vacuum-assisted devices leads to faster healing and that surgical reclosure is preferable to healing by secondary intention, when there are no signs of ongoing infection. There is a need for stronger evidence regarding the prevention and management of wound complications for caesarean section in obese women.
  

Sunday, September 25, 2016

Routine Planned Cesareans in Older Mothers Do More Harm Than Good


Many care providers push strongly for elective (planned) cesareans in older moms. However, a recent study challenges the wisdom of this common practice.

This extremely large study confirms that planned cesareans as a routine intervention for older moms is a bad idea. It increased their risk for infection, hysterectomy, kidney failure, cardiac arrest, and death.

This is an issue close to my heart as I was an "AMA" (Advanced Maternal Age, or 35 or older) mom for three of my four pregnancies.

In many practices, a woman like me ─ an older "morbidly obese" mother with a prior cesarean ─ would have faced intense pressure for a planned cesarean. I was fortunate to have care providers that didn't pressure me to have a cesarean just because of my age or weight. (Then again, I purposely chose providers who utilized a more low-intervention model.)

But the pressure for a planned cesarean can be quite strong on older mothers in many practices, especially if the mother is a first-time mom or received fertility treatment. One study found four times the rate of elective cesareans in older first-time moms. But why?

Some doctors see vaginal birth in an older mom as so risky that they prefer to just bypass labor altogether and plan a cesarean. Although the risk for stillbirth does seem to go up somewhat as women age, recent research confirms that this risk is quite modest (and not all research finds an increase in risk). Most healthy older women will do just fine.

Furthermore, a recent study confirms that the difference in outcomes between planned cesareans and planned vaginal births in older moms is quite small. Each choice has its own pros and cons to consider.

Risks probably increase as a woman ages; a woman of 54 probably has a much different risk than a woman of 41. However, many women with very advanced maternal ages have safe vaginal births too. Age alone should not be used as an absolute guide for a planned cesarean.

Although the risk for needing a cesarean during labor does increase as a woman gets older, the research shows that the majority of older women who are given a chance at having a vaginal birth actually do give birth normally. Giving birth under the care of midwives or in a non-obstetric unit setting may improve chances for a vaginal birth in older women who labor.

That is not to say that a planned cesarean is never appropriate in an older mom, only that the decision should be a nuanced one. Risks are higher in those with multiples, with those who have their first pregnancies after 40, and in those who required fertility treatments. Older women who have serious pre-existing health conditions, who have multiple major risk factors, or whose babies do not seem to be growing well have a much different risk profile than an older woman who is healthy, has no pregnancy complications, and has a healthy baby who is growing well.

It would be nice to see further research that provided concrete quantification of absolute risks at various ages in combination with various risk factors. That would be more helpful in guiding decision-making.

Still, all the factors must be considered and birth decisions should be made by the woman and her providers together. The decision should never be imposed on a woman by her provider; age does not negate a woman's right to personal autonomy in her medical decisions.

The bottom line is that routine use of a planned cesarean in older women simply because of age puts that mother's health at risk. Better to have the mother go into labor and see how labor goes. A cesarean can be done in labor if needed, but this very large study shows that routine cesareans for age leads to greater harm overall.

As the authors of the study conclude:
Planned cesarean section is a key factor significantly influencing maternal morbidity and mortality in healthy women with advanced maternal age. When possible, planned cesarean deliveries should be avoided in this population.
For an excellent review of the overall research around pregnancy in ages 35 and older, please see this article.


Reference

Matern Child Health J. 2016 Jul 29. [Epub ahead of print] Effect of Planned Mode of Delivery in Women with Advanced Maternal Age. Lavecchia M1, Sabbah M1, Abenhaim HA2,3. PMID: 27473092
OBJECTIVES: The purpose of this study was to determine the prognostic value of planned primary elective cesarean section versus planned vaginal delivery in women with advanced maternal age. METHODS: We conducted a population-based, retrospective cohort study using the United States' Health Care Cost and Utilization Project's Nationwide Inpatient Sample to evaluate maternal outcomes in women with advanced maternal age delivering from 2003 to 2012. Healthy women who underwent primary elective cesarean section constituted a surrogate for low-risk planned cesarean delivery. Logistic regression was used to compare outcomes between women with planned cesarean and planned vaginal delivery. RESULTS: Among seven million births, we identified 442,067 deliveries in healthy women with advanced maternal age. The planned cesarean group comprised 7.96 % of women in the cohort. When compared to healthy women in the planned vaginal group, women in the planned cesarean group had a significantly higher mortality ratio (2.56/10,000 vs. 0.44/10,000, p < 0.01). The planned cesarean group was also at higher odds of numerous complications, including peripartum hysterectomy OR 1.81 (1.36-2.40), p < 0.01, cardiac arrest OR 5.39 (4.54-6.38), p < 0.01, acute renal failure OR 3.39 (1.78-6.46), p < 0.01 and sepsis OR 2.27 (1.25-4.14), p < 0.01. CONCLUSIONS FOR PRACTICE: Planned cesarean section is a key factor significantly influencing maternal morbidity and mortality in healthy women with advanced maternal age. When possible, planned cesarean deliveries should be avoided in this population.