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A LEADING gynaecologist has warned that the “misguided” drive to reduce caesarean section rates may be putting women and their babies at risk of avoidable injury and death.
Professor Hans Peter Dietz, professor of obstetrics and gynaecology at Sydney Medical School Nepean, University of Sydney, told MJA InSight that in the past 10 years, performance indicators for obstetric services had shifted away from perinatal and maternal morbidity and mortality towards the caesarean section rate, with “peculiar flow-on effects”.
Professor Dietz said the potential fallout included increasing rates of maternal pelvic floor tears from forceps deliveries, postpartum haemorrhages as a result of long second-stage labours, and uterine ruptures in vaginal births after previous caesarean deliveries.
The outspoken gynaecologist noted that while countries such as Denmark, Sweden and Germany had almost completely abandoned forceps in favour of vacuum extraction, their use was growing in parts of Australia, following a similar pattern to the UK.
He said that in NSW, forceps-assisted deliveries in public hospitals accounted for 4.3% of births in 2012, up from 3.1% in 2008 — a trend Professor Dietz linked to political pressure to allow women to labour for longer, citing NSW Health’s “Towards Normal Birth” policy directive. (1) (2)
“Due to the rise in forceps rates in NSW, about 1000 additional women may by now have suffered avoidable, often incurable pelvic floor trauma”, Professor Dietz said, noting that forceps doubled the risk of trauma to the levator ani and anal sphincter.
“This is highly clinically relevant, putting women at risk of later prolapse and incontinence”, he said. “We can no longer ignore this particular outcome of childbirth.”
Professor Dietz also raised concern about the growing enthusiasm for vaginal birth after caesarean section (VBAC), suggesting the risks may sometimes be downplayed.
He cited a recent study of VBAC at Sydney’s St George Hospital, in which 103 caesareans were avoided but two babies had died. The first death followed uterine rupture during postdates oxytocin induction, while the second was a stillbirth in the VBAC group at 40+6 gestation. Neither death was mentioned in the study abstract or conclusion. (3)
Figures from the Royal Hospital for Women in Sydney had shown a trebling in the rate of blood transfusions associated with postpartum haemorrhage for vaginal birth between 2009 and 2010 (0.79% to 2.16%). (1)
Professor Dietz suggested this may be the result of another observed trend, of women being allowed to have longer labours. (4)
However, others have noted that there has also been a doubling in transfusions associated with caesarean section over the same period.
Professor Michael Permezel, president of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, agreed that arbitrary targets for caesarean section rates could be harmful.
“[They are] are unhelpful and risk an inappropriate loss of confidence by women in the care currently being provided”, he told MJA InSight.
“The tacit implication that caesarean section is unsafe or less desirable may be misleading”, he said, adding that both planned vaginal and elective caesarean births had good outcomes for Australian mothers and babies.
Professor Permezel said pelvic floor and anal sphincter trauma were “significant factors to be considered” in decisions of vaginal versus caesarean birth, and about instrumentation. However, he said there were “many other considerations of at least equal or perhaps greater importance for mother and baby”.
He defended the use of forceps, saying that vacuum extraction had been linked with a greater risk of neonatal injury and death through subgaleal haemorrhage.
A major spike in reported cases of subgaleal haemorrhages occurred in NSW in 2012, with nine cases that year alone, compared with a total of four in the preceding 6 years. (5)
Dr Amanda Henry, an obstetrician at Sydney’s St George Hospital and a coauthor of the St George study, agreed the deaths in the VBAC group would not have occurred had the women undergone elective repeat caesarean at the usual time.
In view of the risks, Dr Henry supported an editorial accompanying the study, which argued VBAC was not a promising strategy to reduce caesarean delivery rates. (6)
However, Dr Henry argued that there remained a place for VBAC in sociodemographic areas where large families were common and “women undergoing a third, fourth or fifth caesarean” was a concern, given the risks of ectopic pregnancy, morbidly adherent placenta, surgical injury and hysterectomy rose with each subsequent caesarean.
1. NSW Health 2014: NSW Mothers and babies 2012
2. NSW Health 2010: Maternity – Towards Normal Birth in NSW
3. ANZJOG 2014; Online 30 July
4. RANZCOG O&G magazine 2014; 3: 62-65
5. Clinical Excellence Commission 2014: Vacuum Assisted Births – Are We Getting it Right?
6. ANZJOG 2014; 54: 295-297
(Photo: Antonia Reeve / Science Photo Library)
The word “intervention”is a negative and perjorative term that should not be used to describe the potentially life saving treatment that I as a specialist with 30 years experience recommemd to patients that I think need it.
I suggest using the term “obstetric treatment” or assistance as previous commentators have suggested rather than “obstetric intervention”.
hi in a compelling under-resourced and achingly over regulated clinical environment,”elective ” caesars are delayed and end up in “unplanned” labour and necessary caesar out of hours, weekends etc, essentially in an emergency state, with inadequate clinical resources and supervision. Hardly quality care and prospectively greater morbidity eg, recent repeat caesareans on JWs in the middle of the night. As former psychopaths have articulated: “Make the lie big, keep it simple, keep repeating it and eventually the masses will believe!” Ho hum….
Interesting range of comments – illustrating how strong the ideology is in this area. Commenters who note the changing demographics of first-time mothers – older, fatter, more IVF – are correct – all of these factors make caesarean delivery more likely. It’s also important to note that, overall, caesarean delivery results in better outcomes for babies, at a cost in maternal morbidity (almost all minor and short-lived). The comment above “”It is vitally important that women are afforded the opportunity to proceed to a normal birth” appears to prioritise the process over the outcome – which doesn;t not accord with the priorities of most families.
Many of the anti-caesarean ideologues start their comments with an acknowledgement that casarean surgery saves lives and should be used in life-threatening situations. But have they ever been in the situation of having to make this call? Because we have no reliable way of knowing which lives will be saved by caesarean delivery, the clinician making the call needs to respond to the evidence available, sometimes very quickly, and knowing that delaying may harm a baby. It’s easy to judge the procedure as ”unnecessary” in hindsight – but the decisions are made in real time, with high stakes. Mike Aitken is right – ”intervention” in obstetrics has become a demonised term, and “assistance” may be more apt.
The infiltration of ideology into maternity care has resulted in some really terrible patient experiences. By failing to provide informed consent for both planned delivery modes (planned vaginal delivery and planned cesarean delivery) women are denied a right to make an informed decision about their bodies. What is worse is that many women who wish to pursue a cesarean delivery for a wide variety of valid reasons are denied this choice and are forced to endure unwanted vaginal deliveries and their consequences. This is very much so a reproductive rights and justice issue and the biased information given to women is nothing short of shameful. I would highly recommend the book “Choosing Cesarean: A Natural Birth Plan” written by Pauline Hull and Magnus Murphy for an overview of this issue. For women considering choosing cesarean (and care providers who are open to providing access to maternal request cesarean) there is also a facebook group “Cesarean by Choice Awareness Network”.
In 2011 the UK, evidence-based NICE guidance recommended that if a woman chooses a caesarean, after discussion she should be supported in her choice.Nevertheless, this is not happening due to an ideological culture and more general maternity care policies that seek to reduce caesarean rates and increase ‘normal’ deliveries – even if that means more forceps deliveries. For many women choosing a caesarean birth, protecting their pelvic floor is a key consideration, with evidence to support this, and yet many medical professionals (midwives, GPs and OBGYNs included) remain unconvinced.Political intervention and ideological bias is far more dangerous when it comes to birth than ‘the number’ of caesareans carried out – because people stop looking at other data such as stillbirth, perinatal morality, infant and maternal morbidity and forceps rates (the latter is rising in the UK for example).
I wish we would all use the term obstetric “assistance” rather than “intervention” which reflects more accurately the nature of our work. With the shifting demographic of women having babies, eg older, fatter, more IVF etc, for the C/section rate to stay static would actually be a reduction in real terms.
This issue has become politicised with midwives and feminists generally anti-Caesarean section. The scientific facts become blurred when this happens. High section rates are deplored when there may be very good reasons eg an older primigravida cohort. Best to keep the politics out of it .
There is no doubt that caesarean surgery saves the lives of mothers and babies and is an essential part of maternity services. Nonetheless, there have been concerns over a long time about the rising rates of caesarean births. The vast majority of women set out on their maternity journey anticipating a normal birth. It is vitally important that women are afforded the opportunity to proceed to a normal birth, and are supported by the health professionals in charge of their care to achieve this. It is unhelpful to birthing women for health professionals to polarise to either end of the intervention spectrum. Instead, the focus of health professionals should be on providing women centred care that encourages collaborative discussions and appropriate care provision when deviations away from the normal occur and interventions are required. Remember that it is the women who must live with the outcomes of decisions made on their behalf. Providing each woman with a choice of primary carer to ensure that she is able to form a relationship of trust is the starting point of achieving an optimal outcome in the significant life event of childbirth. Until this occurs women will be sidelined in the turf war that exists between health professionals who see only the black and white and rarely the shades of grey that exist between.
The biggest problem is that epidemiology relies on large numbers/populations to gain meaningful/significant results. Clinicians then have to attempt to apply that academic knowledge to the one person sitting in front of them during the consultation and make plans in that patient’s best interests. This may include not exhausting the clinician thereby reducing their clinical acumen.
Dr Burgess’ comment is too far from the present state of clnical obstetric and midwifery practise to be clinically relevant to this dicussion but at least illustrates one extreme. After 35 years of this ongoing debate I can see it’s unlikely to end soon. One of the most important lessons we can teach trainees is knowing BOTH when and when not to intervene. Too often they are influenced by “expert opinion” (Level IV evidence) and not higher levels of evidence which is all too often simply not available.
Would these people advocating long labours and instrumentation want us to go back to the Dark Ages and end up with vesico-vagina/colo-vaginal fistula rates of places like Ethiopia? Why do we even bother to even listen to them? There are none so blind who will not see.
This is a vitally important discussion. The radical ideological movement that rejects obstetrical “interventions” has infiltrated some areas of care, with process becoming more important than outcome. The “correct” Caesarean rate is the one that achieves the best outcomes, balancing benefit and risk. Modern obstetrics and midwifery have made birth so safe that there is a risk of spectrum bias – where the risks of NOT intervening are forgotten.