Birthrites: Healing After Caesarean.

Medical Articles of interest.

CAN ELECTIVE CAESAR SAVE YOUR PELVIC FLOOR?

NO, says a recent South Australian study reported in the December 2000 edition of the British Journal of Obstetrics and Gynaecology.

The 1998 South Australian Health Omnibus Survey involved a random selection of 4400 households. 3010 men and women aged 15-97 years were interviewed in their own homes, to determine, among other things, the prevalence of pelvic floor disorders, and to determine the relationship to gender, age, number of children and their mode of birth. The prevalence of urinary incontinence (uncontrolled leakage of urine) in men was 4.4% and in women 35.3%.

Urinary incontinence in women increased after pregnancy according to the number of children and age.

Pregnancy (more than 20 weeks) REGARDLESS OF MODE OF BIRTH, greatly increased major pelvic floor dysfunction - defined as any type of incontinence, symptoms of prolapse or previous pelvic floor surgery.

Compared with a woman with no children, pelvic floor dysfunction was more than two and a half times as common in a woman who had birthed a baby by caesar, over three times as common in a woman birthing naturally and over four times as common in a woman who birthed with at least one forceps. The difference between caesar and forceps was significant, but not between caesar and a natural birth.

The investigators commented "...elective caesarean section is apparently not an effective way to reduce the prevalence of most subsequent pelvic floor disorders, except when instrumental vaginal delivery can be avoided".

MacLennan AH et al. The prevalence of pelvic floor disorders and their relationship to gender age, parity and mode of delivery. BJOG 2000;107:1460-70.

Comment: "We hear a lot in the media about preventing prolapse or incontinence by having elective caesar. This very important local study debunks this myth. The changes in a woman's body with pregnancy and aging are what cause these problems, and mode of birth seems to have less to do with it. Pelvic floor exercises are really important before and after the birth. It looks like it's important to try and avoid forceps too. Being well-prepared physically and emotionally for labour, having a great support team and being active in birth are good ways to maximise your chance of birthing naturally."

Dr.David Simon
Obstetrician


Raspberry Leaf in Pregnancy.

The study will be published this year in the 'Journal of Midwifery and Women's Health', April edition, 46(2).

A randomised, placebo-controlled, double-blind study performed by Myra Parsons and Michele Simpson in 1999-2000 at Westmead Hospital in Sydney demonstrated the safety of raspberry leaf tablets (2.4 gms daily) taken from 32 weeks pregnancy until commencement of labour. There were no side effects identified, for mother or baby, by the intake of this herb.

The analysis suggested that raspberry leaf tablets shortened the length of second stage of labour by an average of 10 minutes but made no difference to the length of first stage. It also reduced the incidence of 'artificial rupture of membrane' and forceps/ventouse deliveries. Although not statistically significant, these results are clinically significant.

Vaginal births after Caesarean (VBAC): a population study

Reference: http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11101021&dopt=Abstract 2000Oct;14(4):340-8

Stone C, Halliday J, Lumley J, Brennecke S
Perinatal Data Collection Unit, Public Health and Development Division, Department of Human Services, Victoria, Australia. christine.stone@dhs.vic.gov.au

This paper describes delivery outcomes for women from Victoria, Australia, who gave birth in 1995 and whose immediately previous (penultimate) delivery, within a 5-year search period, was a Caesarean section. Because of the large numbers of records involved, dedicated computer software for record linkage was used to identify the previous delivery and link it with the woman's current birth in 1995. Overall, 79% of the records from multiparous women were linked successfully. Approximately 15% were not linked because the previous birth was before the search period or was an abortion that would not have been reported to the Perinatal Data Collection Unit. Reasons for not being able to link the last 6% of the records include the previous pregnancy being overseas or interstate. Women who had a vaginal birth as the penultimate birth or a multiple birth at either event were excluded, resulting in a study population of 4663 linked records. More women (68%) had a repeat Caesarean than went into labour and, of the remaining women who laboured, 56% delivered vaginally. Overall, 18% of the women delivered vaginally. For the women who went into labour, the reported number experiencing a uterine rupture was two per 1000 births. Uterine rupture was not reported in the two-thirds who did not labour but had a repeat Caesarean. A review of the perinatal deaths identified only two deaths, one baby being born by elective Caesarean and one by a vaginal birth after a previous Caesarean (VBAC) where the choice of delivery methods may have contributed to the death. This large study is one of the few in the literature to provide population-based information on vaginal births after a previous Caesarean and related outcomes.


Uterine rupture during induced trial of labor among women with previous cesarean delivery

(Am J Obstet/Gynecol 2000;183:1176-9.)
Debra J. Ravasia, MD, Stephen L. Wood, MD, Jeffrey K. Pollard, MD, Calgary, Alberta, Canada

Objective: This study was undertaken to compare the rates of uterine rupture during induced trials of labor after previous cesarean delivery with the rates during a spontaneous trial of labor.

Study Design: All deliveries between 1992 and 1998 among women with previous cesarean delivery were evaluated. Rates of uterine rupture were determined for spontaneous labor and different methods of induction.

Results: Of 2119 trials of labor, 575 (27%) were induced. The overall rate of uterine rupture was 0.71% (15/2119). The uterine rupture rate with induced trial of labor (8/575; 1.4%) was significantly higher than with a spontaneous trial of labor (7/1544; 0.45%; P = .0004).

Uterine rupture rates associated with different methods of induction were compared with the rate seen with spontaneous labor and were as follows: prostaglandin E2 gel, 2.9% (5/172; P = .004); intracervical Foley catheter, 0.76% (1/129; P = .47); and labor induction not requiring cervical ripening, 0.74% (2/274; P = .63).

The uterine rupture rate associated with inductions other than with prostaglandin E2 was 0.74% (3/474; P = .38). The relative risk of uterine rupture with prostaglandin E2 use versus spontaneous trial of labor was 6.41 (95% confidence interval, 2.06-19.98).

Conclusion: Induction of labor was associated with an increased risk of uterine rupture among women with a previous cesarean delivery, and this association was highest when prostaglandin E2 gel was used.


Vaginal Birth After Cesarean Less Successful For Diabetics

Reference:
http://womenshealth.medscape.com/reuters/prof/2001/01/01.17/20010116clin003.html

WESTPORT, CT (Reuters Health) Jan 16 - Women with pregestational or gestational diabetes are less successful in having a vaginal delivery after cesarean (VBAC) than are nondiabetic women, researchers report.

"Although VBAC success rates are probably lower for women with pre-existing diabetes, complication rates of successful or unsuccessful VBAC are not higher," Dr. Sean C. Blackwell told Reuters Health.

Dr. Blackwell and colleagues at Hutzel Hospital in Detroit retrospectively reviewed the charts of 159 diabetic patients who delivered at 37 weeks or later between 1991 and 1997. Of the patients studied, 127 without a prior cesarean delivery were categorized as group 1. Group 2 was composed of 32 patients who had had one prior low transverse cesarean delivery and attempted VBAC.

The researchers found that the cesarean delivery rate was 26.3% in group 1 and 56.3% in group 2. The VBAC success rate was 43.7% for group 2, "somewhat lower than the 60% to 80% reported for nondiabetic women," the researchers report in the December issue of the Journal of Reproductive Medicine.

However, Dr. Blackwell's team notes that "there were no differences in the frequency of endometritis rates or neonatal intensive care unit admission, whether vaginal or cesarean delivery occurred."

The authors acknowledge their limited sample size and call for further studies "to determine the optimal role of VBAC in the management of the diabetic gravida with a prior cesarean delivery."

J Reprod Med 2000;45:987-990.

Comment:
Tina Pettigrew, who contributed information about this article, wished to respond to the findings with these comments &endash;

All sounds quite intriguing until you read the research.

Of the patients studied, 127 without a prior cesarean delivery were categorized as group 1. Group 2 was composed of 32 patients who had had one prior low transverse cesarean delivery and attempted VBAC.

The researchers then found that;

....."the cesarean delivery rate was 26.3% in group 1 (n=127) and 56.3% in group 2 (n=32). The VBAC success rate was 43.7% for group 2, "somewhat lower than the 60% to 80% reported for nondiabetic women," the researchers report in the December issue of the Journal of Reproductive Medicine."

This is a huge statement, is it not, given the sample size of the women that constituted the VBAC group (n=32)!! Not a representative sample, I would have thought, of the whole diabetic VBAC population.

Presenting this article, in the Birthrites Magazine, in the spirit of providing information to women on VBAC is important. It may be very useful information. Especially for that one diabetic woman who comes up against that one OB who read the study and says, "NO VBAC for you DEAR as diabetic women are less successful at VBAC than non-diabetic women." At least the woman can challenge the OB's assertion based on the inadequacies of the study.


20TH ANNUAL MEETING OF THE SOCIETY FOR MATERNAL-FETAL MEDICINE

January 31-February 5, 2000 Fontainebleau Hilton, Miami Beach, Florida

Reference: American Journal of Obstetrics and Gynecology 2000, Jan;182 (1, Pt 2):S12-224

18 THE EFFECT OF A CHANGE IN REMUNERATION ON OBSTETRIC INTERVENTION E. Bland(1x), L. Oppenheimer(1), Shi Wu Wen(2x). (1) Division of Maternal-Fetal Medicine, University of Ottawa, (2)Laboratory Centre for Disease Control Ottawa, ON, Canada.

OBJECTIVE: To test the hypothesis that a change in an obstetric call group's remuneration from individual fee-for-service billing to equal sharing of the pooled group income, would result in reduced rates of obstetric intervention, specifically rates of induction of labour and caesarean delivery.

STUDY DESIGN: On July 1st 1997 the call group at the Ottawa General Hospital changed its remuneration method from individual billing to revenue sharing. Using information from the obstetric data management system, intervention rates were compared for the 12 months prior to (PRE) and the 12 months subsequent to (POST) the change. Only those physicians who were in the group for the entire time period were studied. Data was collected on onset of labour, indication for induction of labour and mode of delivery and statistical analysis performed using chi-squared and the two-tailed t-test.

RESULTS: There were 8 eligible physicians who delivered 1601 patients in the PRE year and 2002 in the POST year.

Legend for Chart:
B - PRE
C - POST
D &endash; p

Intervention.
B
C
D
Elective Induction
37.1%
29.0%
.0001
Operative Delivery
34.4%
30.9%
.03
Length of Labour (Min)
540 +/- 393
583 +/- 415
.002
2nd Stage (Min)
57 +/- 66
66 +/- 75
.001

CONCLUSION: The change in remuneration was associated with a significant, and clinically important, decrease in rates of labour induction and operative delivery. Thus we suggest that physicians in call groups where individual billings are retained have an incentive to be more interventionist.