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Maternal Morbidity Associated With Cesarean Delivery Without Labor Compared With Induction of Labor at Term

Victoria M. Allen, MD, MSc1, Colleen M. O’Connell, PhD2 and Thomas F. Baskett, MB1

From the 1Department of Obstetrics and Gynaecology, and 2Perinatal Epidemiology Research Unit, Dalhousie University, Halifax, Nova Scotia, Canada.

 
OBJECTIVE: To estimate the maternal morbidity associated with cesarean deliveries performed at term without labor compared with morbidity associated with induction of labor at term.

METHODS: A 15-year population-based cohort study (1988–2002) using the Nova Scotia Atlee Perinatal Database compared maternal outcomes in nulliparous women delivering by cesarean delivery without labor and nulliparous women at term undergoing induction of labor for planned vaginal delivery with singleton, cephalic presentation.

RESULTS: A total of 5,779 pregnancies satisfied inclusion and exclusion criteria, 879 of which were cesarean deliveries without labor. There were no maternal deaths. There was no difference in wound infection, puerperal febrile morbidity, blood transfusion or intraoperative trauma. After controlling for potential confounders, women undergoing cesarean delivery without labor were less likely to have complications of early postpartum hemorrhage (relative risk 0.61, 95% confidence interval 0.42–0.88, number needed to treat 32) and composite maternal morbidity (relative risk 0.71, 95% confidence interval 0.52–0.95, number needed to treat 34) compared with women undergoing induction of labor. Subgroup analyses of maternal outcomes after induction of labor in women by method of delivery were also performed and demonstrated additional risks of traumatic morbidity after induction of labor. The highest morbidity was found in the assisted vaginal delivery and cesarean delivery in labor groups.

CONCLUSION: Early postpartum hemorrhage and composite maternal morbidity were decreased in cesarean delivery without labor compared with induction of labor. Hemorrhagic and traumatic morbidities with labor induction are increased after assisted vaginal delivery and cesarean delivery in labor compared with cesarean delivery without labor.

LEVEL OF EVIDENCE: II-2

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ACOG NEWS RELEASE

July 16, 2004

ACOG Office of Communications



Medical Liability Survey Reaffirms More Ob-Gyns Are Quitting Obstetrics

Washington, DC -- The fear of being sued is the driving force behind many obstetricians-gynecologists' decision to stop delivering babies, according to the latest medical liability survey conducted by The American College of Obstetricians and Gynecologists (ACOG). The national survey of ACOG ob-gyn members confirms that the medical liability insurance crisis has worsened in recent years, with one in seven ACOG Fellows reporting that they had stopped practicing obstetrics because of the high risk of liability claims. Ob-gyns have an average of 2.6 claims filed against them during their career.

"This crisis is getting more serious by the day. It's not only threatening today's ob-gyns, but also the future of our specialty," says ACOG President Vivian M. Dickerson, MD. The number of US medical students entering the specialty of ob-gyn has declined for the third year in a row. In 2004, only 65% of the ob-gyn residency slots were filled by US medical school seniors, compared with 86% a decade earlier. "Women's health is in jeopardy as new doctors turn away from our specialty," she adds.

Highlights from ACOG's Medical Liability Survey*:

Impact of Claims

  • One in seven ACOG Fellows has stopped practicing obstetrics because of the risk of liability claims.
  • Changes made by ACOG Fellows because of the risk of liability claims or of being sued:
    • Decreased the amount of high-risk obstetric care - 22%
    • Stopped offering/performing VBACs - 14.8%
    • Decreased the number of deliveries - 9.2%
    • No longer practicing obstetrics - 14%
    • Decreased gynecologic surgical procedures performed - 12.3%
    • No longer doing major gynecologic surgery - 5.6%
  • Changes made by ACOG Fellows because of liability insurance costs and availability:
    • Decreased the amount of high-risk obstetric care - 25.2%
    • Decreased the number of deliveries - 12.2%
    • No longer practicing obstetrics - 9.2%
    • Decreased gynecologic surgical procedures performed - 14.8%
    • No longer doing major gynecologic surgery - 5.4%

Frequency of Claims

  • In 2003, one in two Fellows had been involved in a claim in the last four years.
  • Over 76% of ACOG Fellows reported they had been sued at least once; 57% had two or more claims filed against them, and 41.5% had three or more claims.
  • Ob-gyns have an average of 2.6 claims filed against them during their career.
  • About three in ten (29.6%) of ob-gyns have been sued for care provided during their residency.

Type of Claims

  • Obstetric claims accounted for 61% of claims against ob-gyns; 38% were gynecologic claims.
  • From 1999-2002, the top four primary obstetric allegations were: neurologically impaired infant (34%); stillbirth/neonatal death (15%); other infant injury - major (7%); and delay in or failure to diagnose (7%).
  • From 1999-2002, the top four primary gynecologic allegations were: delay in or failure to diagnose (29%); patient injury - major (25%); patient injury - minor (15%); and other/non-specified (12%).

Resolution of Claims

  • Almost half (49.5%) of claims against ob-gyns are dropped by plaintiffs' attorneys, dismissed or settled without payment.
  • Of cases that do proceed to court, ob-gyns win eight out of ten times (81.3%).
  • From 1999-2002, on average the length of time from occurrence to closing of the claim was four years; 13% of claims took seven or more years to resolve.
  • Closed claim resolution experience:
    • No payout - 49.5%
      • Dropped by plaintiff - 33.6%
      • Dismissed by court - 13%
      • Settled without payment - 2.9%
    • Settled with payment - 36.0%
    • Arbitration or other alternative dispute resolution mechanism - 2.7%
    • Jury/court verdict - 8.6%

ACOG has identified 23 Red Alert** states with a medical liability insurance crisis now threatening the availability of physicians who deliver babies. The Red Alert crisis states are the District of Columbia, Florida, Georgia, Mississippi, Nevada, New Jersey, New York, Ohio, Oregon, Pennsylvania, Texas, Virginia, Washington, West Virginia, and Wyoming. The other Red Alert states where a crisis is brewing are Alabama, Arizona, Connecticut, Illinois, Kentucky, Maryland, Missouri, and Utah. Mississippi, Texas, and West Virginia are being monitored by ACOG since their crisis status is pending outcome of recently enacted state laws.

Medical liability reform is ACOG's top priority. When ob-gyns can't find or afford medical liability insurance, they are forced to stop delivering babies, curtail surgical services, or close their doors. Across America, pregnant women cannot get the prenatal and delivery care they need but ACOG warns that the liability crisis hurts all women. With physician shortages, there are also fewer ob-gyns available to provide gynecologic surgery and preventive care, such as screening and special procedures. Women lose care that helps protect fertility, end pelvic pain, or treat cancer early. Women travel longer distances to find a doctor, have longer waiting periods for appointments, and have shorter visits once they get there.

"This crisis in health care is critical for both physicians and the women they treat. This is a national problem, and we need a national solution," states Dr. Dickerson.

 

*Every two to four years since 1986 ACOG has commissioned a national survey on the medical liability experiences of its members. This survey, designed and conducted with Princeton Survey Research Associates, covered the period 1999-2003. The response rate was 45.5%.

**ACOG Criteria for Identifying Red Alert States
ACOG considered a number of factors in determining the hardest hit states in the escalating medical liability insurance crisis for ob-gyns. The relative weight of each factor could vary by state. Factors included: the lack of available professional liability coverage for ob-gyns in the state; the number of carriers currently writing policies in the state, as well as the number leaving the medical liability insurance market; the cost, and rate of increase, of annual premiums based on reports from industry monitors; a combination of geographical, economic, and other conditions exacerbating an already existing shortage of ob-gyns and other physicians (for example, Mississippi and West Virginia, having a number of medically underserved areas ); the state's tort reform history, and whether tort reforms have been passed by the state legislature - or are likely to be in the future - and subsequently upheld by the state high court.

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Causes of Pruritus in Pregnancy


Cause


Features


Pruritic urticarial papules and plaques of pregnancy (PUPPP) (common in third trimester)

Intense pruritus involving abdomen, with spread to thighs, buttocks, breasts, and arms

Prurigo of pregnancy (common in second half of pregnancy)

Associated with atopic dermatitis

Excoriated papules and nodules on extensor arms and abdomen

Herpes gestationis or pemphigoid gestationis (uncommon)

Autoimmune condition associated with Graves' disease

Vesicles and bullae on abdomen and extremities in second half of pregnancy

Responsive to prednisone (dosage: 20 to 40 mg per day)33

Intrahepatic cholestasis of pregnancy (uncommon)

Trunk and extremity itching without rash in late pregnancy

No jaundice in mild form

Responsive to cholestyramine (Questran) and vitamin K130

Pruritic folliculitis of pregnancy (uncommon, occurs in second half of pregnancy)

Erythematous follicular papules over trunk, with spread to extremities

Possibly a variant of prurigo of pregnancy

Other common pruritic conditions exacerbated in pregnancy

Atopic dermatitis, allergic contact dermatitis

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Planned caesarean section decreases the risk of adverse perinatal outcome due to both labour and delivery complications in the Term Breech Trial.

Su M, Hannah WJ, Willan A, Ross S, Hannah ME; Term Breech Trial collaborative group

Maternal Infant and Reproductive Health Research Unit, Centre for Research in Women's Health, University of Toronto, Canada.

OBJECTIVE: To determine if the decreased risk of adverse perinatal outcome, with a policy of planned caesarean, in the Term Breech Trial, was due to a reduction of problems of labour, problems of delivery or unrelated problems. DESIGN: Secondary analysis of data from the Term Breech Trial, a randomised controlled trial of planned caesarean versus planned vaginal birth for the singleton fetus in frank or complete breech presentation at term. SETTING: Women were recruited from 121 centres in 26 countries. POPULATION: Women who were enrolled in the Term Breech Trial. METHODS: Adverse perinatal outcome was classified as due to labour, due to delivery, due to neither labour nor delivery or unexplained by an experienced obstetrician who was masked to allocation group. The risk of an adverse outcome in each category was compared according to intention to treat and also by actual method of delivery. MAIN OUTCOME MEASURES: Adverse perinatal outcome (excluding lethal congenital anomalies) that was due to labour, due to delivery, due to neither labour nor delivery or unexplained. RESULTS: Planned caesarean was associated with a lower risk of adverse outcome due to both labour (RR 0.14, 95% CI 0.04-0.45, P < 0.001) and delivery (RR 0.37, 95% CI 0.16-0.87, P= 0.03), compared with planned vaginal birth. Prelabour caesarean and caesarean during early labour were associated with the lowest risk and vaginal birth was associated with the highest risk of adverse outcome due to both labour (0%, 0.4% and 2.2%, respectively) and delivery (0.2%, 0% and 3.1%, respectively). CONCLUSIONS: Planned caesarean decreases the risk of adverse perinatal outcome due to both problems of labour and problems of delivery for the singleton fetus in breech presentation at term, compared with planned vaginal birth.

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Why mothers should be offered caesareans

Is the ideal of a 'natural childbirth' a myth, driven by an NHS desire to save money? In this personal and passionate article our Health Editor says that it's time for women to consider surgical births as the best for mother and baby

My sister Vicki had a terrible time during the birth of her first child. The second stage of labour was long and there were times when she didn't know how she would get through it. The right pain relief - an epidural - only arrived when the doctor was finally called. And then it didn't work properly. Immediately after the birth of her son, Edward, she had to go into the operating theatre because staff discovered a haematoma, or blood clot, in her womb.

So when she fell pregnant a second time, she made it clear to her doctor and midwives that she wanted a caesarean. She was lucky to have a GP and an obstetrician who were understanding. They realised she had been deeply traumatised by the whole experience. Her second child, Oliver was born surgically just 13 days ago.

The difference between the births was extraordinary. 'It was amazing to go into the operating theatre, knowing that you aren't going to suffer pain, knowing that your husband isn't going to be under the stress of watching you in pain and that there is a whole team of people around you,' Vicki said.

'I was nervous beforehand, but it was all so calm. Once I had the anaesthetic and they made the incision, you could feel them rummaging around inside you, but it didn't hurt, it just felt strange. We put a Coldplay CD on, the doctors were chatting with Jon [her husband] about the World Cup, and before I knew it the baby was out. It was an intensely happy moment.'

Her experience, and that of many other women I have spoken to, has made me think a lot about the way we bring children into the world. The highly politicised debate about whether birth is a social or a medical experience has been raging for years but the crucial question still remains the role of caesareans.

I have had two children, both unremarkable 'natural' deliveries. I know, just as most women do, that any kind of birth carries risk factors with it, although now they are far smaller than they were. But what has become increasingly clear is that an elective, or routine, caesarean section is just as safe as a normal delivery, thanks to advances in anaesthesia and antibiotics. What I find so galling is that women who want caesareans are being denied them on the NHS for essentially political reasons. Midwives hate them because they challenge the very ethos of 'natural' birth as well as taking away the midwife's role as chief carer, and politicians hate them because they cost more.

We are fast approaching the point where logically we should encourage women to have a caesarean whether or not they have a medical or psychological reason for wanting one. This is because women are having babies later and because the babies themselves are becoming bigger.

By having a planned surgical delivery, you simply avoid the biggest risk factor of all: the possibility of an emergency caesarean. This is a deeply controversial opinion to express, but it's one that many doctors - and some midwives - privately hold because they have realised that by taking away the unpredictability, pain and fear associated with normal birth you may be doing both mother and child a great service.

The most vehement opposition to caesareans comes from the Royal College of Midwives, which runs a campaign for natural birth. Its aim is to lower the number of women having surgical births and it runs under the banner: 'Intervention and caesarean shouldn't be the first choice - they should be the last.'

The college website says: 'All births can be rewarding. Even the woman who has a caesarean section under general anaesthetic still has the miracle of a newborn baby. But certain kinds of birth may be more rewarding than others. A woman who goes through labour without analgesia or intervention will experience a birth with the full potential of which she is capable, enjoying one of nature's great "highs" thanks to her increased levels of endorphins.'

This suggests birth can be a blissful experience thanks to a woman's own hormones - something I believe would be disputed by the vast majority of mothers who usually find themselves in agony at some point in their labour. Of course pain thresholds differ greatly between women. Some sail through the experience, but for many it is much more distressing.

The only person who can know how much pain she can bear is the woman herself, and the problem is that she cannot know this until it may be too late.

Most first-time mothers, for example, want to give birth naturally and say they do not want an epidural - a local anaesthetic which kills the sensation in the lower part of the body. However, one-quarter of mothers do end up having one, because the pain is simply too great for them to bear. The midwives would argue that the figure is so high because doctors encourage women to have epidurals, as they like to 'interfere' with the birth.

The crunch point over childbirth really came in April 2004 when the government health experts, the National Institute for Health and Clinical Excellence (Nice), produced official guidance on the issue. They told the NHS it should discourage caesarean sections and not offer them unless there was a clear medical reason.

This judgment was partly based, however, on the cost implications. Caesareans are twice as expensive as normal births, costing the NHS about £3,500 each, compared with £1,800.

Maureen Treadwell, founder of the Birth Trauma Association, which supports women who have suffered distressing births, said: 'There needs to be a fundamental shift in attitudes in the maternity services so that there is much more compassion, kindness and above all respect for individual choice.' She is critical of the way ministers talk about patient choice, but fail to act on it. 'There is no point in the government having a strategy document which is all about choice and respect for informed decision making if information is being distorted to encourage women to make only those choices that certain groups of professionals approve of,' Treadwell said.

The Nice guidance, which gives hospital managers an opportunity to save money, has made it harder for women to have an NHS caesarean. Yet still one in five births is a surgical delivery. The degrading label of 'too posh to push' implies that richer women can spend their way out of pain and pay the £4,000 needed to go private.

What is Nice's evidence for denying a surgical delivery? I looked at the studies it used and found they made no clear comparison between healthy women choosing a normal delivery and healthy women choosing a surgical birth. Instead, the figures for caesareans include women who may have important medical reasons for needing the operation. The risks for them would be higher anyway.

There are risks attached to both sorts of birth. If you have a caesarean, there is the risk of wound infection. There is a longer recovery time. Women who have a surgical birth will take longer to conceive a second child - although this finding is from data taken years ago when infection rates were higher - possibly affecting their fertility. There is also double the risk of the subsequent baby dying in the womb, although the reasons for this are not clear.

But if you have a normal delivery, there is the risk of a tear to the perineum. Some 30 per cent of women suffer urinary incontinence afterwards. There is the risk of psychological distress caused by a long and difficult birth. Many years later, women who have several children through normal deliveries can suffer a prolapse, where the womb sags through the vaginal wall, which can necessitate a hysterectomy.

Speaking to many experts in the field, I have found increasing support for caesareans. Purely on safety grounds, it is hard to support the argument that the surgery is more risky.

As women start their families later, as they choose to have fewer children - the average now in the UK is 1.7 children - and as babies become bigger, the case for caesareans becomes greater, according to Professor Nick Fisk, the leading obstetrician at Queen Charlotte's Hospital in London, which is part of the Hammersmith Hospitals Trust.

'We are the only animal species where the baby's head occupies nearly 100 per cent of the mother's pelvis - in most species it is around 50 per cent,' Fisk explained. 'The head puts tremendous pressure on the woman's tissues. Babies are also heavier than they were 20 years ago, and that has implications for the foetal and maternal health.

'I think that for many women, normal childbirth can be long and painful and very difficult, and one of the problems is that your first birth is far more likely to be the worst.'

Fisk, who is known as a strong advocate of caesareans, says there is now an overwhelming need for a randomised controlled trial - the gold standard for scientific evidence - which would directly compare the safety of elective caesarean sections with the safety of normal births.

'We so badly need this information,' he said. 'It would have to involve thousands of women, and be carried out across many centres, and it would take five years - but how else are we going to decide which kind of birth is safe? You can have people crusading for one form or another of birth, but in the end it's only a trial that will enable doctors to make the right decisions.'

Trends in childbirth come and go. In the Fifties when the vast majority of women were giving birth at home, very often without midwife support and with high mortality rates due to prolonged labours - the women's movement and patient groups were encouraging women to go into hospital. Now the opposite is true.

Professor James Walker, head of obstetrics and gynaecology at St James's University Hospital in Leeds, said: 'If you look at the figures from the Thirties, the mortality maternal death rate was one in 200, and now it is one in 10,000. We have remarkably safe maternity care which now allows us to look at a lot of problems which were ignored in the past.

'What has happened is that caesareans have become much much safer, due to advances in anaesthesia, with epidurals, but also because we can cut back on infection rates and the risk of sepsis [blood poisoning] by giving antibiotics.'

Walker, who is also the official spokesman for the Royal College of Obstetricians and Gynaecologists, added: 'The idea that caesarean section is per se dangerous and therefore should not be done is simply untrue. If you look at the data surrounding the birth itself, you could make the argument that an elective caesarean is actually the safest approach, simply because it avoids all possibility of needing an emergency caesarean, which carries the highest risks of all.'

There is a sense that women are becoming increasingly angry at being denied choice. Pauline McDonagh, a BBC journalist, started writing a book on the subject but has instead set up a website, electivecesarean.com, because she became convinced that if she were to have a child she would want a surgical birth. The site went live last week. 'I grew tired of having to explain to my friends why I wouldn't want to give birth naturally. In some way, they found it offensive that I didn't want the pain or the uncertainty of labour. But the more I researched it, the more I realised that although it involves an abdominal operation, it's a very safe one. I decided the only solution was to put all the facts up on the website so that women could make their own choice,' said McDonagh.

The guilt that a woman can be made to feel for exercising choice can be terrible. When Kate Winslet had to undergo an emergency caesarean for the birth of her first child, Mia, the actress admitted she 'felt a failure' in some way. She went as far as lying to her friends about it at first.

But childbirth is not a competition. It is not a challenge to see who can have the 'most natural' birth or be the most courageous. It is about bringing a child into the world in a safe and humane way, and it is time for the real facts about caesareans to be considered, and for all the pretence and lies to end.

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