Lamaze International Disputes Recommendations On Elective Cesarean Surgery

Main Category: Pregnancy / Obstetrics
Also Included In: Women's Health / Gynecology
Article Date: 02 Apr 2006 - 5:00 PDT

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Panelists at the National Institutes of Health (NIH) State-of-the-Science Conference on elective cesarean surgery (March 27-29 in Bethesda, Md.) determined that the quality of the existing research about long-term effects of elective cesarean is "weak." Lamaze International agrees that the research NIH examined is weak; however, their research also did not consider many recognized long-term adverse outcomes associated with cesarean surgery and they did not take into account the impact that avoidable obstetric practices can cause during vaginal birth. Failure to include these factors in the review of existing research renders their guidance to women and clinicians incomplete and inadequate.

According to the NIH panel's review of the existing research, long-term effects of elective cesarean surgery include subsequent infertility, as well as placenta previa (placenta attaches near or over the opening to her cervix), uterine rupture and/or stillbirth in future pregnancies. The NIH panel did not address future fetal or neonatal risks other than stillbirth.

A recent independent review of the research by Lamaze International found that cesarean surgery, including elective surgery, also is associated with a higher risk of hysterectomy, cesarean-scar ectopic pregnancy (pregnancies that develop outside the uterus or within the scar), surgical adhesions that may contribute to serious future surgical injuries or cause bowel obstruction and chronic pain, wound pain beyond six months, and birth of a preterm or "small for gestational age" baby in a future pregnancy.

Furthermore, conventional obstetric management may contribute to poor outcomes of vaginal birth including hemorrhage, pelvic floor disorders, sexual dysfunction and unplanned cesarean surgery in labor. For instance, continuous electronic fetal monitoring (EFM) has not been found to improve outcomes for low-risk mothers or babies, but routine use is associated with a higher rate of cesarean surgery in labor. Despite this body of research, continuous EFM is used in 89 percent of labors in the United States.

Pelvic floor disorders, such as incontinence and sexual dysfunction, are most often attributable to obstetric interventions during vaginal birth, rather than vaginal birth itself. In fact, routine episiotomy has not been found to improve maternal or newborn outcomes, but is linked to pain, pelvic floor injury and sexual dysfunction. According to a 2002 survey conducted by Childbirth Connection (formerly Maternity Center Association), 35 percent of women who gave birth vaginally had episiotomies. Unnecessary, forceful staff-directed pushing also contributes to a higher incidence of pelvic floor disorders.

"Any researcher who wishes to evaluate the safety of elective cesarean surgery must use a study design that includes long-term outcomes, including effects on subsequent pregnancies," said Lamaze International President Raymond De Vries, PhD. Future studies must also compare elective cesarean surgery to normal vaginal birth, or, at a minimum, control for the effects of harmful obstetric practices used routinely in hospitals. When elective cesarean surgery is compared to a style of obstetric management that has been shown to be harmful - including unnecessary episiotomies, forceps and vacuum deliveries - it gives the false appearance of equivalent risk between surgical and vaginal birth.

Lamaze International has developed evidence-based documents about the Six Care Practices that Support Normal Birth : 1) labor begins on its own (avoidance of unnecessary induction of labor), 2) freedom of movement throughout labor , 3) continuous labor support , 4) no routine interventions , 5) non-supine (upright or side-lying) positions for birth , and 6) no separation of mother and baby with unlimited opportunity for breastfeeding. Available research suggests that these care practices contribute to optimal outcomes for both mother and baby and are associated with high satisfaction among childbearing women. However, all six care practices are used in very few maternity care settings.

"Ideally, when making personal decisions about medical care, including routine interventions, women clarify their desires and expectations, discuss alternatives, access and understand best evidence as well as gaps in the research, continue discussions with their caregiver, and then make a personal decision," says Judith A. Lothian, RN, PhD, LCCE, FACCE, author of The Official Lamaze Guide: Giving Birth with Confidence .

Lamaze International, based in Washington, DC, envisions a world of confident women choosing normal birth. For more information about Lamaze and the Institute for Normal Birth, visit http:// www.lamaze.org.