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.
|