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Why Posh has the right not to push: Caesareans are no more dangerous than natural births By CLIVE SPENCE-JONES, Consultant obstetrician and gynaecologistLast updated at 11:40 PM on 25th June 2011

One of Britain's leading obstetricians argues passionately that caesareans are no more dangerous than natural births.   The phrase 'too posh to push' was coined for women who choose a caesarean delivery over a natural one. It's a derogatory term and one which I believe demeans mothers-to-be.  Every woman has a right to decide how they give birth, whatever the method.  Yet the debate over how women do give birth  -  naturally or through surgery  -  shows no sign of abating.   This issue is in the spotlight yet again with Victoria Beckham booked in for her fourth caesarean, or what Californians call a c-section, delivery this month.   With her due date imminent, some experts have been warning that women who have multiple caesareans are putting their lives at risk.   This scaremongering is outrageous, misleading and does nothing to help women become better informed about the realities of delivering a baby.  The fact is that all childbirth still comes with risks, whether via an elective caesarean or a natural delivery. For example, about one in three women who have a natural birth will suffer from bladder problems because their pelvic floor muscles are weakened.   The majority will get better after physiotherapy, but I've had patients who have suffered so much that they pour water over themselves when they jog so their problem can be passed off as sweat stains to avoid embarrassment.   With a caesarean, there are also risks. It involves major abdominal surgery  -  but when performed as an elective procedure on a set date as Mrs Beckham's will be, there are fewer complications than if carried out in an emergency.   There are also rarely problems as a result of multiple caesareans. Complications can arise when a woman requests a natural birth after a caesarean  -  known as VBAC  -  because the existing scar can thin and sometimes rupture during labour, which can be life-threatening for both baby and child, although this is rare.   This is why about one in four mothers who request a natural birth after a surgical delivery will actually end up having another caesarean. Most obstetricians would recommend another caesarean after two previous ones to minimise the risks.   Of course, the natural childbirth evangelists would question why women would opt for a caesarean in the first place. I can't answer why Mrs Beckham has always given birth this way  -  she's stated it's medically necessary.   The vast majority of women who opt first time for a caesarean section do so for medical reasons. The baby could be in the wrong position or become distressed during labour.   The fact is that all childbirth still comes with risks, whether via an elective caesarean or a natural delivery.   Alternatively, the mother could have a very small pelvis, posing the risk of the baby getting stuck during delivery, or the mother could have had a pelvic fracture.   A minority may go under the surgeon's knife to give birth because they fear a natural delivery. The health watchdog the National Institute for Clinical Excellence (NICE) has recently issued draft guidelines recommending that women who fear normal childbirth are offered therapy from a mental health specialist. If wrongly interpreted, this guidance could allow health professionals to coerce or bully women into opting for a natural birth.   This is not the intention. NICE is advising that mothers-to-be are given the choice of a referral to a psychologist, which I support.   It's about giving women much needed support, not labelling them neurotic or mad. If they turn down the offer, or even accept counselling only to opt for a caesarean, then that's their right  -  a right that must not be denied. It is the doctor's and midwife's job to make sure every mother-to-be is aware of this right.   Which brings me back to this myth of 'too posh to push'. NICE claims that around seven per cent of caesareans are down to maternal choice. In my professional opinion this figure is a bit high, but it still means that only a minority chooses to have caesareans, and very few are carried out for the sake of convenience.   In each case the mother will be carefully assessed according to her individual situation.   Despite the headlines, the caesarean section rate is actually plateauing at about 24 per cent of all births. What is on the rise, though, is the number of obese women and older mothers who have no option but to undergo a surgical delivery.   Obese women often have so much fat inside their pelvis that it's impossible for the baby to pass down the birth canal.   Women over 40 are also advised to have a caesarean because the uterus becomes less efficient as women age, so natural childbirth is more difficult. We can't prevent women giving birth late in life but if we tackled the obesity epidemic, then the caesarean rate would fall.   Of course, there are those who would argue that caesareans that are not a medical necessity are draining the NHS of much needed resources in these cash-strapped times.   NICE estimates that a normal birth is £800 cheaper than a pre-booked caesarean and that every one per cent reduction in the number of women having c-sections would save the NHS £5.6million. This means health trusts are also under pressure to reduce their caesarean rates.   But you can't just define cost in terms of pounds and pence. It is also about the cost of damage to a mother's emotional well-being from a bad birth experience or to the health of her child resulting from a traumatic delivery. For example, about ten per cent of cerebral palsy cases are the result of physician errors during a natural delivery.   No one likes a drama or a terrible outcome. And that is why childbirth should be about the safest outcome for mother and baby, as well as the staff involved. There is no ideal caesarean rate.   With huge advances in medical care, the NHS has the ability to offer women informed choice over the type of birth that best suits their individual needs.




Two midwives who think obstetrical lacerations are normal- yikes.  I would like you to put this on your website.  I had NO IDEA of this stuff.  I was thinking of midwife/ homebirth until I read this.  One of them thinks they are positive because they slow women down and are a starting point to introduce her to herbs.  Plus she gets to know her pelvic floor.  I think the only herbs are the ones in their brownies.

 

Such an important point Usha – tearing is NORMAL. Most women tear with their first baby regardless of what they do to avoid it. We are designed to tear and heal, it is all part of the process. No woman should blame herself for tearing – it was what her body needed to do to birth her baby – no shame in that.

Tear Prevention – Is It Always the Best Cure?

This article (one of those WTF???), written by Sara Wickham, asks the reader to consider the possibility that tear prevention (meaning hot packs, massage, perineal support and oil applied during labor by the midwife). Is this too much intervention? I would love to know your thoughts.

Without having seen the other articles in this issue of Midwifery Today {which was a compilation of articles about tear prevention}, I feel fairly confident that a number of my midwife friends will have written brilliant articles sharing tips, tricks and ideas for preventing perineal tears. And I am very glad they have; it is always good to learn new ways of helping women through birth.

Yet I’m wondering whether ‘tear prevention’ is as important a goal as we think? Given that I believe we should always be ready to question even the most sacredly held of our practices, I’ve been giving some thought to what lies behind the ideal of tear prevention. Is a high intact perineum rate an unequivocally noble goal and the mark of a ‘good’ midwife (as we have generally come to believe), or does tear prevention constitute another set of interventions which may be beneficial to individual women, but whose routine use should be carefully reflected upon and questioned with the aim of improving our practice?

The perineum in nature and culture

We hear and read a lot these days about the need to focus on physiology and ‘normal birth’. Yet how ‘physiological’ is it to routinely squirt oil onto a woman’s perineum during labour, to place (or move) our hands in strategic positions or to apply packs to raise or lower the temperature of body tissue? I have had the privilege of watching a number of animals giving birth, but I have never seen a cow instructing another cow to pant, or a rabbit carefully lining her paws up on her friend’s bottom while she pushed her bunnies out. I understand that babies of different species are birthed differently, but are the practices we use to attempt to prevent tears really necessary on a physiological level, or are they cultural rituals which we have developed over the years which may or may not be helpful to the women we attend?

As far as the perineum is concerned, perhaps it would be better to let nature and the woman’s body choose. I wrote a paper a couple of years ago (Wickham 2000) where I discussed Midwife Jane Evans’ suggestion that the labia are designed to guide the baby out as it is born. We both suggested that midwives might consider a hands-off approach at birth, unless there is a reason for our hands to become involved, and I remember stating at a study day where I presented this paper that, “if nature had intended hands to routinely guide the baby out, women would be born with an extra pair attached to their inner thighs”. I feel much the same way about tear prevention; if nature needed all woman to routinely have a hot pack on their perineum, I am fairly confident that a self-warming one would be provided in a handy zip-up flap just inside the labia majora. (If I just haven’t managed to locate mine yet, instructions on how to do this would be very much appreciated!)

Let’s not forget that the perineum was not normally in view until men forced women to lie on their backs to give birth. Where women are upright it can be difficult, if not impossible, to put anything near the perineum, including our hands. On occasion, I have had enough trouble getting my body into a position to ‘catch’ under a woman where I wasn’t in danger of overbalancing, or rolling on the three-year old sitting next to me. In that situation, it is hard enough to try to keep your gloved hands reasonably clean, let alone using them to anoint or support the perineum which is swaying to and fro above your head.

The positive side of tears?

One of the other questions we need to ask ourselves is whether perineal tears are always a bad / negative / harmful thing for women, or whether they could be neutral in their effects. Maybe they could even have advantages? Having a tear does help women to slow down after they give birth; they are not physically capable of moving too quickly, which might make some women take better care of their bodies and get more rest. A tear also offers the woman (and her midwife) an easy ‘marker’ by which to gauge healing. If a woman tries to do more than her body wants her to, her tear will usually let her know about this.

A healing perineum helps remind women that they have had a baby. (Which might initially sound like a stupid thing to say, but I don’t believe there can be many midwives who haven’t occasionally met a woman who needed reminding of this.) Having a tear might enable some women to learn more about their bodies, their pelvic muscles, how they can work with these. It might also be a way for the midwife to introduce women to herbs or other ways of healing that the woman might not have previously encountered. For at least one woman that I worked with, having a tear meant she had a valid reason to not engage in unwanted sexual activity after the birth. More generally, helping a woman to deal with a tear can open up discussion of a woman’s sexuality, and issues which she has never before been able to talk about.

Birth is a rite of passage, which takes women’s bodies on a journey. We become marked with the symbols of our passage into motherhood and retain the cellular memories of the experience. Whether we judge these marks as “good”, “bad” or “neutral”, we hold them as women whose bodies tell the stories of our lives. To what extent does the fact that we midwives often judge all tears to be “bad” impact on the way that women perceive their bodies, their tears and scars?

What do we need to know?

For the record, I can think of a number of good reasons not to question the noble and ancient art of tear prevention. I understand that a deep tear can be traumatic, painful and debilitating to a woman. I understand that some tears can need stitches to promote haemostasis (or for other good reasons), and it is because of my understanding of these things that I am not suggesting that we should never attempt to prevent a tear. Instead, I believe that we should attempt to develop our knowledge about when it might be appropriate to use particular substances, manoeuvres or ‘tricks’ for individual women, rather than doing things routinely to everyone whose perineum ever appears before us.

Unfortunately, the research studies on the long term effects of perineal tears are, unfortunately, often too confounded by the impact of medical birth, semi-recumbent positioning and directed pushing on the woman’s body to tell us anything really useful about the effects of tears in environments where midwives support women to work with their bodies. We are going to need more midwifery debate on this; more sharing of ideas, experiences and intuitions. More unravelling of those practices which are truly helpful and those which we only perceive to be so. In our quest for authentic midwifery knowledge, we need to continue to unravel the tension between knowing when to simply ‘be’ beside a woman as she embarks on her journey of childbirth and when to step in and ‘do’ something that may change the course of events, and the journey of her body.

S Wickham (2000)
Perineal Pampering- before, during and after birth.
MIDIRS Midwifery Digest, Vol 11, suppl 1, March 2001, p S23-S27.

Article can be found here: http://www.withwoman.co.uk/contents/info/tears.html

This article was originally published in Midwifery Today.

___________________________________________________________________

FDA Safety Communication: UPDATE on Serious Complications Associated with Transvaginal Placement of Surgical Mesh for Pelvic Organ Prolapse

Date Issued: July 13, 2011

Audience:

  • Health care providers who implant surgical mesh to repair pelvic organ prolapse and/or stress urinary incontinence
  • Health care providers involved in the care of patients with surgical mesh implanted to repair pelvic organ prolapse and/or stress urinary incontinence
  • Patients who are considering or have received a surgical mesh implant to repair pelvic organ prolapse and/or stress urinary incontinence

Medical Specialties: gynecology, urogynecology, urology, general surgery, internal medicine, family practice, emergency medicine

Device:
Surgical mesh is a medical device that is generally used to repair weakened or damaged tissue. It is made from porous absorbable or non-absorbable synthetic material or absorbable biologic material. In urogynecologic procedures, surgical mesh is permanently implanted to reinforce the weakened vaginal wall to repair pelvic organ prolapse or to support the urethra to treat urinary incontinence.

Background:
Pelvic Organ Prolapse
Pelvic organ prolapse (POP) occurs when the tissues that hold the pelvic organs in place become weak or stretched. Thirty to fifty percent of women may experience POP in their lifetime with 2 percent developing symptoms. When POP happens, the organs bulge (prolapse) into the vagina and sometimes prolapse past the vaginal opening. More than one pelvic organ can prolapse at the same time. Organs that can be involved in POP include the bladder, the uterus, the rectum, the top of the vagina (vaginal apex) after a hysterectomy, and the bowel.

Stress Urinary Incontinence
Stress urinary incontinence (SUI) is a leakage of urine during moments of physical activity, such as coughing, sneezing, laughing, or exercise.

Purpose:
On Oct. 20, 2008, the FDA issued a Public Health Notification and Additional Patient Information on serious complications associated with surgical mesh placed through the vagina (transvaginal placement) to treat POP and SUI.

Based on an updated analysis of adverse events reported to the FDA and complications described in the scientific literature, the FDA identified surgical mesh for transvaginal repair of POP as an area of continuing serious concern.

The FDA is issuing this update to inform you that serious complications associated with surgical mesh for transvaginal repair of POP are not rare. This is a change from what the FDA previously reported on Oct. 20, 2008. Furthermore, it is not clear that transvaginal POP repair with mesh is more effective than traditional non-mesh repair in all patients with POP and it may expose patients to greater risk. This Safety Communication provides updated recommendations for health care providers and patients and updates the FDA’s activities involving surgical mesh for the transvaginal repair of POP.

The FDA continues to evaluate the effects of using surgical mesh to repair SUI and will communicate these findings at a later date.

For detailed information, please see:

Urogynecologic Surgical Mesh: Update on the Safety and Effectiveness of Transvaginal Placement for Pelvic Organ Prolapse.


Summary of Problem and Scope:
In the Oct. 20, 2008 FDA Public Health Notification, the number of adverse events reported to the FDA for surgical mesh devices used to repair POP and SUI for the previous 3-year period (2005 – 2007) was “over 1,000.” Since then, from Jan. 01, 2008 through Dec. 31, 2010, the FDA received 2,874 additional reports of complications associated with surgical mesh devices used to repair POP and SUI, with 1,503 reports associated with POP repairs and 1,371 associated with SUI repairs. Although it is common for adverse event reporting to increase following an FDA safety communication, we are concerned that the number of adverse event reports remains high.

From 2008 – 2010, the most frequent complications reported to the FDA for surgical mesh devices for POP repair include mesh erosion through the vagina (also called exposure, extrusion or protrusion), pain, infection, bleeding, pain during sexual intercourse (dyspareunia), organ perforation, and urinary problems. There were also reports of recurrent prolapse, neuro-muscular problems, vaginal scarring/shrinkage, and emotional problems. Many of these complications require additional intervention, including medical or surgical treatment and hospitalization.

In order to better understand the use of surgical mesh for POP and SUI, the FDA conducted a systematic review of the published scientific literature from 1996 – 2011 to evaluate its safety and effectiveness. The review showed that transvaginal POP repair with mesh does not improve symptomatic results or quality of life over traditional non-mesh repair. The FDA continues to evaluate the literature for SUI surgeries using surgical mesh and will report about that usage at a later date.

In particular, the literature review revealed that:

  • Mesh used in transvaginal POP repair introduces risks not present in traditional non-mesh surgery for POP repair.
  • Mesh placed abdominally for POP repair appears to result in lower rates of mesh complications compared to transvaginal POP surgery with mesh.
  • There is no evidence that transvaginal repair to support the top of the vagina (apical repair) or the back wall of the vagina (posterior repair) with mesh provides any added benefit compared to traditional surgery without mesh.
  • While transvaginal surgical repair to correct weakened tissue between the bladder and vagina (anterior repair) with mesh augmentation may provide an anatomic benefit compared to traditional POP repair without mesh, this anatomic benefit may not result in better symptomatic results.

The FDA’s literature review found that erosion of mesh through the vagina is the most common and consistently reported mesh-related complication from transvaginal POP surgeries using mesh. Mesh erosion can require multiple surgeries to repair and can be debilitating for some women. In some cases, even multiple surgeries will not resolve the complication.

Mesh contraction (shrinkage) is a previously unidentified risk of transvaginal POP repair with mesh that has been reported in the published scientific literature and in adverse event reports to the FDA since the Oct. 20, 2008 FDA Public Health Notification. Reports in the literature associate mesh contraction with vaginal shortening, vaginal tightening and vaginal pain.

Both mesh erosion and mesh contraction may lead to severe pelvic pain, painful sexual intercourse or an inability to engage in sexual intercourse. Also, men may experience irritation and pain to the penis during sexual intercourse when the mesh is exposed in mesh erosion.

The complications associated with the use of surgical mesh for POP repair have not been linked to a single brand of mesh.

Recommendations for Health Care Providers:

As stated in the Oct. 20, 2008 Public Health Notification, the FDA continues to recommend that health care providers should:

  • Obtain specialized training for each mesh placement technique, and be aware of the risks of surgical mesh.
  • Be vigilant for potential adverse events from the mesh, especially erosion and infection.
  • Watch for complications associated with the tools used in transvaginal placement, especially bowel, bladder and blood vessel perforations.
  • Inform patients that implantation of surgical mesh is permanent, and that some complications associated with the implanted mesh may require additional surgery that may or may not correct the complication.
  • Inform patients about the potential for serious complications and their effect on quality of life, including pain during sexual intercourse, scarring, and narrowing of the vaginal wall in POP repair using surgical mesh.
  • Provide patients with a copy of the patient labeling from the surgical mesh manufacturer if available.

In addition, the FDA also recommends that health care providers:

  • Recognize that in most cases, POP can be treated successfully without mesh thus avoiding the risk of mesh-related complications.
  • Choose mesh surgery only after weighing the risks and benefits of surgery with mesh versus all surgical and non-surgical alternatives.
  • Consider these factors before placing surgical mesh:
    • Surgical mesh is a permanent implant that may make future surgical repair more challenging.
    • A mesh procedure may put the patient at risk for requiring additional surgery or for the development of new complications.
    • Removal of mesh due to mesh complications may involve multiple surgeries and significantly impair the patient’s quality of life. Complete removal of mesh may not be possible and may not result in complete resolution of complications, including pain.
    • Mesh placed abdominally for POP repair may result in lower rates of mesh complications compared to transvaginal POP surgery with mesh.
  • Inform the patient about the benefits and risks of non-surgical options, non-mesh surgery, surgical mesh placed abdominally and the likely success of these alternatives compared to transvaginal surgery with mesh.
  • Notify the patient if mesh will be used in her POP surgery and provide the patient with information about the specific product used.
  • Ensure that the patient understands the postoperative risks and complications of mesh surgery as well as limited long-term outcomes data.


Recommendations for Patients:
Before Surgery
Be aware of the risks associated with surgical mesh for transvaginal repair of POP. Know that having a mesh surgery may put you at risk for needing additional surgery due to mesh-related complications. In a small number of patients, repeat surgery may not resolve complications.

Ask your surgeon about all POP treatment options, including surgical repair with or without mesh and non-surgical options, and understand why your surgeon may be recommending treatment of POP with mesh.

In addition, ask your surgeon these questions before you agree to have surgery in which surgical mesh will be used:

  • Are you planning to use mesh in my surgery?
  • Why do you think I am a good candidate for surgical mesh?
  • Why is surgical mesh being chosen for my repair?
  • What are the alternatives to transvaginal surgical mesh repair for POP, including non-surgical options?
  • What are the pros and cons of using surgical mesh in my particular case? How likely is it that my repair could be successfully performed without using surgical mesh?
  • Will my partner be able to feel the surgical mesh during sexual intercourse? What if the surgical mesh erodes through my vaginal wall?
  • If surgical mesh is to be used, how often have you implanted this particular product? What results have your other patients had with this product?
  • What can I expect to feel after surgery and for how long?
  • Which specific side effects should I report to you after the surgery?
  • What if the mesh surgery doesn’t correct my problem?
  • If I develop a complication, will you treat it or will I be referred to a specialist experienced with surgical mesh complications?
  • If I have a complication related to the surgical mesh, how likely is it that the surgical mesh could be removed and what could be the consequences?
  • If a surgical mesh is to be used, is there patient information that comes with the product, and can I have a copy?

After Surgery

  • Continue with your annual and other routine check-ups and follow-up care. There is no need to take additional action if you are satisfied with your surgery and are not having complications or symptoms.
  • Notify your health care provider if you have complications or symptoms, including persistent vaginal bleeding or discharge, pelvic or groin pain or pain with sex, that last after your follow-up appointment.
  • Let your health care provider know you have surgical mesh, especially if you plan to have another surgery or other medical procedures.
  • Talk to your health care provider about any questions you may have.

If you had POP surgery, but do not know whether your surgeon used mesh, ask your health care provider at your next scheduled visit.

FDA Activities:
The FDA is working in several areas to assess and improve the safety and effectiveness of urogynecologic mesh products. The FDA will:

  • Convene the Obstetrics-Gynecology Devices Panel of the Medical Device Advisory Committee, on September 8-9, 2011.The panel will discuss and make recommendations regarding the safety and effectiveness of transvaginal surgical mesh for POP and SUI.
  • Explore regulatory solutions to answer questions about the safety and effectiveness of urogynecologic mesh products that are now being marketed and those that will be reviewed for marketing in the future.
  • Continue to monitor adverse events reported to FDA associated with surgical mesh used to repair POP and SUI, as well as assessing any and all data as it becomes available.

Reporting Problems to the FDA:

Prompt reporting of adverse events can help the FDA identify and better understand the risks associated with medical devices. If you suspect a problem with surgical mesh, we encourage you to file a voluntary report through MedWatch, the FDA Safety Information and Adverse Event Reporting program. Health care personnel employed by facilities that are subject to the FDA's user facility reporting requirements should follow the reporting procedures established by their facilities. Device manufacturers must comply with the Medical Device Reporting (MDR) regulations.


To help us learn as much as possible about the adverse events associated with surgical mesh to repair POP and SUI, please include the following information in your reports, if available:

  • Manufacturer's name
  • Product name (brand name)
  • Catalog number
  • Lot number
  • Size
  • Date of implant
  • Date of explant (if mesh was removed)
  • Details of the adverse event and medical and/or surgical interventions (if required)
  • Type of procedure (e.g., anterior or posterior repair, sacral colpopexy, sling procedure for SUI)
  • Surgical approach: (e.g., vaginal, abdominal, laparoscopic)
  • Reason for mesh implantation: (e.g., POP of the uterus, bladder, rectum, vaginal apex or bowel, SUI)
  • Specific postoperative symptoms experienced by the patient with time of onset and follow-up treatment

Contact Information:
If you have questions about this communication, please contact the Division of Small Manufacturers, International and Consumer Assistance (DSMICA) at DSMICA@FDA.HHS.GOV , 800-638-2041 or 301-796-7100.

This document reflects the FDA’s current analysis of available information, in keeping with our commitment to inform the public about ongoing safety reviews of medical devices.



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