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THE interpretation of a study of potentially avoidable retrievals of newborns has been criticised by a leading Australian obstetrician as “not balanced” and “in need of broader input”.
Professor Michael Permezel, president of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, said conclusions drawn from the research, published in the MJA, were unduly critical of caesarean sections performed pre-labour. (1)
The retrospective analysis of 2494 newborn retrievals performed in NSW by the Newborn and Paediatric Emergency Transport Service between 2006 and 2009 found 30 retrievals described as “potentially avoidable”.
“There was a reduction in the potentially avoidable retrieval (PAR) rate (per 10 000 live births) over the study period (from 3.9 in 2006 and 4.2 in 2007 to 2.2 in 2008 and 2.3 in 2009) despite an increase in the total retrieval rate over the same time”, the authors wrote.
They found that discretionary caesareans, defined as elective (pre-labour) caesarean section without documented fetal or maternal indications before 39 weeks gestation, accounted for two-thirds of the PARs.
“Most of these babies required retrieval for need of respiratory support. The increased risk of respiratory morbidity in newborns born by elective caesarean section before 39 weeks of gestation has been repeatedly demonstrated”, the authors wrote.
They said it was important to optimise the outcomes for late preterm babies “through planned births in facilities that are able to provide an appropriate level of care to the baby at birth, and that adhere strictly to elective caesarean section guidelines”.
However, Professor Permezel said the researchers had not balanced the risks of delaying delivery against the risks of earlier delivery.
“For every 40 transfers at 38 weeks we’re saving one baby”, Professor Permezel told MJA InSight. “That’s not a bad result and that should have been argued in the discussion.”
He said the transfer rate needed to be balanced against the increased risk of stillbirth if delivery was delayed by a week.
Leaving delivery to 39–40 weeks could also increase the need for caesarean section, making it more likely an emergency procedure would be needed, “which also comes with increased risks”, Professor Permezel said.
“This study is not balanced and would have benefited from broader input on why the caesarean sections were done before 39 weeks.
“There needs to be some common sense. It’s up to the obstetrician to weigh the risks in consultation with the mother.”
Associate Professor Kei Lui, an epidemiologist from the School of Women’s and Children’s Health at UNSW and director of the Newborn Care Centre at Royal Women’s Hospital in Sydney, said the results of the study were “quite robust”.
Professor Lui told MJA InSight there was still room for improvement, describing the 40% reduction in potentially avoidable retrievals in the last 2 years of the study as providing “some encouragement”.
Professor Lui also suggested that the longer-term consequences of early delivery, like poor school performance, should be taken in to account when discussing elective caesareans with patients.
“It could be that the reason for the early delivery might also be the reason for poor school performance”, he said. “It is not a straightforward thing.”
Would it be more cost-effective to retrieve the high-risk mother prior to delivery, or better still, send the high risk mother prior to labour to a larger centre-the latter seems logical, as the larger centre is usually where they shop.
I agree with the eminent Obstetrician.
The study does not consider the reasons for Caesarian sections performed prior to 39 weeks.
It is all very well for Teaching hospital staff to pontificate but in the real world, where there are no 24/7 facilities or on-site medical staff, increasing the likelihood of an after hours Caesarian section is potentially much more serious.
Perhaps they would rather be retrieving more babies at 3 am.