On the front page...
An independent panel of experts assembled by NIH
has determined that there is not enough quality evidence to fully
evaluate the risks and benefits of caesarean delivery on maternal
request (CDMR) as compared with planned vaginal delivery. More
research, they said, is needed.
The panel also found that until sufficient evidence
becomes available, "any decision to perform a CDMR should be carefully
individualized and consistent with ethical principles."
||Panel chair Dr. Mary V. D’Alton,
Columbia University’s director of obstetrics and gynecology
The State-of-the-Science conference on CDMR, convened Mar. 27-29,
sparked questions from both participants and reporters covering
"That's because birth is not only a physical process; it's an
emotional one," said Dr. Catherine Spong, chief of NICHD's Pregnancy
and Perinatology Branch and one of the conference's organizers. "Some
people think no baby should ever be delivered by caesarean," she
noted, "while others think all babies should be. People bring their
passion to this issue."
Spong's specialty focuses on maternal health, pregnancy, fetal
well-being, labor and delivery and the newborn's adjustment to
life outside the womb. In collaboration with the Office of Medical
Applications of Research, she and the NICHD team helped bring to
NIH a panel of 18 physicians, nurse-midwives, epidemiologists,
legal and patient safety experts, among others. Cosponsors included
NIDDK, ORWH and NINR.
The panel's report offered several caveats.
It stressed that CDMR is not recommended for women desiring large
families, since caesarean section increases the risk of placenta
previa and accreta. These conditions involve abnormal implantations
of the placenta, and each C-section increases risk. Complications
can include catastrophic hemorrhage.
Furthermore, the panel stated that CDMR should not be performed
before 39 weeks of gestation, or without having first verified
fetal lung maturity.
A baby born with immature lungs is at risk for respiratory complications,
which can be life-threatening.
The panel also found that "request for CDMR should not be motivated
by unavailability of effective pain management, and that efforts
must be made to assure its availability for all women."
Finally, the panel found that NICHD should establish and maintain
a web site "to provide up-to-date information on the benefits and
risks of all modes of delivery."
There are pros and cons to each mode, the panel stressed, so women
and their doctors should have a series of discussions to arrive
at the best choice.
What is known is that caesarean section can prevent certain birth
injuries, such as asphyxia or neurological injuries, but these
are rare. On the other hand, as major surgery it carries significant
risks, such as infection. And the baby born surgically hasn't been
exposed to the hormones in labor that help mature lung function;
in addition, its chest wall hasn't been compressed during delivery.
Both factors increase risk for respiratory distress as the baby
tries to adapt to life outside mom.
|Speaker Dr. Anthony G. Visco of the University
of North Carolina at Chapel Hill presents a review of short-term
||Panel member Dr. Patricia J. O’Campo,
University of Toronto epidemiologist, fields audience question.
Three out of 10 babies in the U.S. are delivered by caesarean
section; this figure includes both elective and emergency procedures.
A caesarean is planned, or elective, when it is foreseen that
vaginal birth would endanger mother, infant or both. Perhaps the
mother has already had one C-section, so to forestall a uterine
rupture, a repeat procedure is planned.
The unplanned procedure responds to trouble that suddenly crops
up, or to deterioration in the patient's condition. Hemorrhage,
disease, injury or anoxia can warrant emergency surgical intervention.
The current C-section rate, at an all-time high of 29 percent,
includes CDMR. While there is some evidence that the incidence
of CDMR is increasing, we don't know exactly how many of these
procedures are based solely on the woman's request or on which
factors: convenience, conflicts with other child care or family
needs, distance from the hospital, fear of a mishap or birth injury
or anxiety about pain management.
The panel report also included suggestions for future research,
- Surveys of women (before and after birth), providers, insurers
and health care facilities regarding CDMR;
- Development of strategies to predict and influence the likelihood
of successful vaginal birth;
- Establishment of uniform documentation of CDMR, to accurately
reflect prevalence of the procedure;
- Examination of existing large databases to assess incidence
of various complications, including rare but critical outcomes,
- A thorough assessment of the costs of CDMR.
"The strength of what came out of the conference," said Spong, "is
that we now have available the best information on the short- and
long-term risks and benefits for both the mother and baby on caesarean
delivery on maternal request. This will allow a woman and her physician
to have the critical discussion if she is interested in CDMR."
The full draft report is available at http://consensus.
nih.gov. The final version will be available at the same
web address soon.