Edmonton May 7Edmonton May 7thth 2011 2011

Cesarean Section On Maternal Request—Cesarean Section On Maternal Request—Whose request is it anyhow?Whose request is it anyhow?

Michael C. KleinMichael C. Klein Centre Community Child Health ResearchCentre Community Child Health Research

Senior Scientist Emeritus: Senior Scientist Emeritus:

BC Research Institute for Children’s and Women’s BC Research Institute for Children’s and Women’s Health Health

Emeritus Professor of Family Practice and Emeritus Professor of Family Practice and Pediatrics Pediatrics

University of British Columbia University of British Columbia

Adjunct Professor of Family MedicineAdjunct Professor of Family Medicine

McGill University Faculty of MedicineMcGill University Faculty of Medicine

What do these five What do these five women have in common?women have in common?

Besides being very rich and Besides being very rich and beautiful?beautiful?

“…So frequent these bad effects [of labour] that I often wonder whether nature did not deliberately intend women to be used up in the process of reproduction, in a matter analogous to that of the salmon, which dies after spawning.”

The public is demanding relief from the The public is demanding relief from the dangers to the childbearing woman. dangers to the childbearing woman. While we have decidedly improved While we have decidedly improved maternal mortality and morbidity and maternal mortality and morbidity and have reduced fetal deaths somewhat, have reduced fetal deaths somewhat, labor is still a painful and terrifying labor is still a painful and terrifying experience, still retains much experience, still retains much morbidity that leaves permanent morbidity that leaves permanent invalidism. The latter statement is invalidism. The latter statement is also applicable to the child.” also applicable to the child.”

““The prophylactic forceps operation is a The prophylactic forceps operation is a technique with the defined purpose of technique with the defined purpose of relieving pain, supplementing and relieving pain, supplementing and anticipating the efforts of nature, reducing anticipating the efforts of nature, reducing hemorrhage and preventing and repairing hemorrhage and preventing and repairing damage. It is not a complete reversal of damage. It is not a complete reversal of the watchful expectancy but I cannot deny the watchful expectancy but I cannot deny that it interferes much with nature’s that it interferes much with nature’s process. Were not the results I have process. Were not the results I have achieved so gratifying, I myself would call achieved so gratifying, I myself would call it meddlesome midwifery. For unskilled it meddlesome midwifery. For unskilled hands, it is unjustifiable.” hands, it is unjustifiable.” --DeLee 1920--DeLee 1920

Sultan 1993Sultan 1993

– Elegant rectal u/s work; collagen fiber Elegant rectal u/s work; collagen fiber disruptiondisruption

– Vaginal childbirth damages the rectum Vaginal childbirth damages the rectum and pelvic floorand pelvic floor

– Cesarean section does notCesarean section does not– Hence cesarean section--and why not Hence cesarean section--and why not

on demandon demand

DeLee’s power and influence DeLee’s power and influence changed the paradigmchanged the paradigm

Childbirth became a diseaseChildbirth became a diseaseThe obstetricians had the tools and techniques The obstetricians had the tools and techniques to give themselves hegemony over childbirthto give themselves hegemony over childbirthDeLee specifically told the Chicago meeting in DeLee specifically told the Chicago meeting in 1920 that if obstetricians adopted these 1920 that if obstetricians adopted these techniques they would supplant incompetent techniques they would supplant incompetent midwives and general practitioners and truly midwives and general practitioners and truly become a professionbecome a professionThe language of DeLee in 1920 has been The language of DeLee in 1920 has been adopted in the new millennium to justify adopted in the new millennium to justify Cesarean section on requestCesarean section on request

Al-Mufti 1997 survey of UK OB Consultants:Al-Mufti 1997 survey of UK OB Consultants:Showing that 33% of female and 10% of males Showing that 33% of female and 10% of males

would choose elective cxion for themselves or would choose elective cxion for themselves or their partnerstheir partners

88% based on fear of perineal/pelvic floor damage 88% based on fear of perineal/pelvic floor damage and fear for their own sexual functioning and fear for their own sexual functioning

But Scottish female consultant obstetricians But Scottish female consultant obstetricians don’t buy it. Virtually all opt for vaginal childbirth don’t buy it. Virtually all opt for vaginal childbirth for themselves--even though they see the same for themselves--even though they see the same diseases and consequences of childbirth. diseases and consequences of childbirth. Very Very Interesting! What are they telling us?Interesting! What are they telling us?

Cesarean section on demand Cesarean section on demand

is unethical---is unethical---

FIGO 1999FIGO 1999

It is ethically permissible to accede to It is ethically permissible to accede to a request for an elective Cesarean a request for an elective Cesarean section from an informed woman—section from an informed woman—

but it is also acceptable to refuse if but it is also acceptable to refuse if the surgeon feels it is not in the the surgeon feels it is not in the woman’s interest. woman’s interest.

----ACOG 2003----ACOG 2003

Cesarean section by choice acceptable Cesarean section by choice acceptable alternative for some women and alternative for some women and SOGC will be following ACOGSOGC will be following ACOG

---CMAJ March 2004--Mary Hannah---CMAJ March 2004--Mary Hannah

SOGC March 2004: SOGC March 2004: Vaginal birth remains the Vaginal birth remains the “preferred” approach and the “safest option for “preferred” approach and the “safest option for most women and carries with it less risk of most women and carries with it less risk of complications in pregnancy and subsequent complications in pregnancy and subsequent pregnancies than Cesarean births.”… The pregnancies than Cesarean births.”… The Society is concerned that a natural process Society is concerned that a natural process would be transformed into a surgical would be transformed into a surgical process…process…The SOGC will continue to promote natural The SOGC will continue to promote natural childbirth and make strong representation to childbirth and make strong representation to have adequate resources available for have adequate resources available for women in labor and during childbirth in women in labor and during childbirth in Canada.”Canada.”

BC Women’s March 2004BC Women’s March 2004 Placed a moratorium on Cesarean on Placed a moratorium on Cesarean on

demand while an interdisciplinary demand while an interdisciplinary committee reviewed the literature, committee reviewed the literature, deliberated the issue and determined that deliberated the issue and determined that preemptive Cesarean section results in preemptive Cesarean section results in increased risks for mother and fetus. increased risks for mother and fetus. Hence, it will only be possible a woman to Hence, it will only be possible a woman to obtain Cesarean on demand after she obtain Cesarean on demand after she receives structured counseling by a receives structured counseling by a trained and counselor in the context of a trained and counselor in the context of a research research

Consequences:Consequences:

Increased maternal demand for cesarean section Increased maternal demand for cesarean section without clear indications for mother or fetuswithout clear indications for mother or fetus

British research in late 90s on early bowel and bladder British research in late 90s on early bowel and bladder outcomes changed the landscapeoutcomes changed the landscape

Pressure from some OB/GYN leaders to declare this to Pressure from some OB/GYN leaders to declare this to be a women’s “civil rights” issue, even to equate it with be a women’s “civil rights” issue, even to equate it with “choice”, a very loaded term“choice”, a very loaded term

NIH Conference on Cesarean Section on “Maternal NIH Conference on Cesarean Section on “Maternal Request”Request”

Rise of no indication cesarean sections in US and Rise of no indication cesarean sections in US and creative indications in Canadacreative indications in Canada

Research evidence:Research evidence:Three lines of relevant research comparing elective Three lines of relevant research comparing elective cesarean with planned vaginal birthcesarean with planned vaginal birth::

1. 1. Classical surgical mortality/morbidityClassical surgical mortality/morbidity

2. Newborn outcomes2. Newborn outcomes

3. Pelvic floor issues3. Pelvic floor issues

Neglected areNeglected are::

-Value of vaginal birth—hard to -Value of vaginal birth—hard to measure: measure: we measure what we canwe measure what we can

-Spiritual and mastery/control issues-Spiritual and mastery/control issues

-Physician convenience and -Physician convenience and inherent conflict of interest and inherent conflict of interest and truly truly

informed consentinformed consent

Research evidenceResearch evidence: : Pelvic floorPelvic floor

Urinary Incontinence—many studies Urinary Incontinence—many studies

• Mostly only to 3 months postpartum and Mostly only to 3 months postpartum and generally uncontrolled for prior UI generally uncontrolled for prior UI

• Population based studies show little Population based studies show little difference or minimal benefit to Cxiondifference or minimal benefit to Cxion

• Even nuns have UI at the rate of 10-Even nuns have UI at the rate of 10-20%20%

• Elective cxion vs cxion at various times Elective cxion vs cxion at various times in labor shows little difference in UIin labor shows little difference in UI

Research evidence:Research evidence: Sexual outcomesSexual outcomes—few studies of —few studies of reasonable qualityreasonable quality• BUT 3-6 months too early to compare a vaginal BUT 3-6 months too early to compare a vaginal

related outcome like sexual satisfaction after vaginal related outcome like sexual satisfaction after vaginal birth with a non-vaginal birth like cesarean birth with a non-vaginal birth like cesarean

• But no studies control for breast feeding-- a low But no studies control for breast feeding-- a low estrogen stateestrogen state

• Nevertheless by 6 months the early Nevertheless by 6 months the early postpartum slight benefits for cesarean postpartum slight benefits for cesarean section vs vaginal disappearsection vs vaginal disappear

Research evidence:Research evidence:Surgical mortality/morbiditySurgical mortality/morbidity– Cesarean vs vaginal birthCesarean vs vaginal birth

4330 CS 1 extra maternal death4330 CS 1 extra maternal death

6102 CS 1 extra thromboembolic event6102 CS 1 extra thromboembolic event

632 CS to prevent 1 transfusion632 CS to prevent 1 transfusion

37 CS 1 extra operative trauma37 CS 1 extra operative trauma

159 CS 1 extra infection159 CS 1 extra infection

435 CS 1 extra case sepsis/DIC435 CS 1 extra case sepsis/DIC

Research evidence:Research evidence:Surgical mortality/morbiditySurgical mortality/morbidity (2) (2)– Cesarean vs vaginal birthCesarean vs vaginal birth

156 CS 1 extra readmission 156 CS 1 extra readmission

444 CS 1 extra abruption444 CS 1 extra abruption

489 CS 1 extra ectopic489 CS 1 extra ectopic

230 CS 1 extra placenta previa230 CS 1 extra placenta previa

694 CS 1 extra invasive placenta694 CS 1 extra invasive placenta

2667 CS 1 extra hysterectomy2667 CS 1 extra hysterectomy

Poorer outcomes in subsequent births for baby—Poorer outcomes in subsequent births for baby—increase prematurity and low birth weight increase prematurity and low birth weight (Hemminki Am J Obs and Gyn 2005; (Hemminki Am J Obs and Gyn 2005;

193: 169-77193: 169-77))

Urinary Incontinence (UI) structured review literature Urinary Incontinence (UI) structured review literature Press, Klein et al Press, Klein et al BIRTHBIRTH Sept 2007 Sept 2007

10.4 CS10.4 CS compared to VB to prevent one case of unspecified compared to VB to prevent one case of unspecified short-term UIshort-term UI

- - After removing instrumental births:After removing instrumental births:11.611.6 CS to prevent one case of short-term UI CS to prevent one case of short-term UI

109 CS109 CS to prevent one case of short-term urge to prevent one case of short-term urge incontinenceincontinence

14.6 CS14.6 CS compared to VB to prevent compared to VB to prevent one case of short term Stress UIone case of short term Stress UI

– After removing instrumental births After removing instrumental births 16 CS16 CS to prevent 1 case of short term Stress UI to prevent 1 case of short term Stress UI

No difference for No difference for severesevere UI even short term by UI even short term by mode of deliverymode of delivery

Fecal IncontinenceFecal Incontinence

When we combined 13 studies of any When we combined 13 studies of any level of FI: level of FI: – CS compared to VB: to prevent one case of CS compared to VB: to prevent one case of

short term fecal incontinence need to do short term fecal incontinence need to do 32 32 CSCS

But after removing instrumental births But after removing instrumental births NNT increased to NNT increased to 49 CS49 CS

Many more CS to prevent long-term FIMany more CS to prevent long-term FI

Sexual DysfunctionSexual Dysfunction

11 CS11 CS compared to VB to prevent one case of compared to VB to prevent one case of short term sexual dysfunctionshort term sexual dysfunction– After removing instrumental births After removing instrumental births 14 CS14 CS to prevent to prevent

one case of short-term sexual dysfunctionone case of short-term sexual dysfunction

10 CS10 CS compared to VB to prevent one case of compared to VB to prevent one case of short term sexual dissatisfactionshort term sexual dissatisfaction– No difference for sexual desire, frequency of No difference for sexual desire, frequency of

intercourse, or sense of sexual attractiveness by intercourse, or sense of sexual attractiveness by mode of deliverymode of delivery

BUT, after 6 months postpartum, no sexual differences BUT, after 6 months postpartum, no sexual differences by mode of birth.by mode of birth.

Research evidence:Research evidence:Newborn consequences that favor CSNewborn consequences that favor CS– Cesarean vs vaginal birth Cesarean vs vaginal birth

22,64122,641 CS prevent 1 subdural/intracranial bleed CS prevent 1 subdural/intracranial bleed

19,60119,601 CS prevent 1 IVH CS prevent 1 IVH

7,5497,549 CS prevent 1 subarachnoid hemorrhage CS prevent 1 subarachnoid hemorrhage

10,61310,613 CS prevent 1 neonatal convulsion CS prevent 1 neonatal convulsion

5,666 5,666 CS prevent 1 newborn CNS depression CS prevent 1 newborn CNS depression

2,1642,164 CS prevent 1 brachial plexus injury CS prevent 1 brachial plexus injury

Research evidence:Research evidence:Newborn consequences favoring vaginal birthNewborn consequences favoring vaginal birth

Cesarean vs vaginal birth Cesarean vs vaginal birth 338338 CS 1 extra severe feeding difficulty CS 1 extra severe feeding difficulty 69 69 CS 1 extra respiratory problem CS 1 extra respiratory problem 80 80 CS 1 extra TTNCS 1 extra TTN 129129 CS 1 extra RDS CS 1 extra RDS 247247 CS 1 extra pneumonia CS 1 extra pneumonia 162162 CS 1 extra level III admission CS 1 extra level III admission 153153 CS 1 extra 5 min Apgar less than 7 CS 1 extra 5 min Apgar less than 7

317317 CS 1 extra newborn on CS 1 extra newborn on respirator for more than respirator for more than 24 hours24 hours

Research evidence:Research evidence:WHO study from all of Latin AmericaWHO study from all of Latin America

Villar J et al Lancet 2006 May 23Villar J et al Lancet 2006 May 23rdrd

97,00097,000 CS in 120 institutions found that hospitals CS in 120 institutions found that hospitals with the highest CS rate had highest rates of with the highest CS rate had highest rates of maternal death and illness and highest rates of maternal death and illness and highest rates of neonatal death and ICU admissionneonatal death and ICU admission

French studyFrench study Deneux-Tharaux et al Obstet and Gynecol 2006; Deneux-Tharaux et al Obstet and Gynecol 2006; 108:541-8108:541-8

10,244 women10,244 women: after adjustment for confounders : after adjustment for confounders and removal of women hospitalized before delivery, and removal of women hospitalized before delivery, risk peripartum maternal death 3.6x higher after CS risk peripartum maternal death 3.6x higher after CS vs vaginal birth (mostly anaesthsia, infection & vs vaginal birth (mostly anaesthsia, infection & venous thromboembolism). venous thromboembolism).

– We are replicating this for all of Canada.We are replicating this for all of Canada.

Research evidence:Research evidence:Newborn consequence Newborn consequence US dataUS data

Cesarean vs vaginal birthCesarean vs vaginal birth 1998-2001 research on neonatal mortality vaginal 1998-2001 research on neonatal mortality vaginal vs. planned or elective vs. planned or elective CS—after controlling for CS—after controlling for indications for elective CSindications for elective CS (truly no indication CS) (truly no indication CS)

– 0.62 neonatal deaths per 1000 vaginal vs 0.62 neonatal deaths per 1000 vaginal vs

1.77 per 1000 CS 1.77 per 1000 CS

Based on Based on 5,762,0375,762,037 live births and 11,890 deaths live births and 11,890 deaths MacDorman et al BIRTH Sept 2006MacDorman et al BIRTH Sept 2006

– Employing Odds ratios--Employing Odds ratios--roughly twice the neonatal death roughly twice the neonatal death rate for CS @1/1000 vaginal and 2/1000 CS, after rate for CS @1/1000 vaginal and 2/1000 CS, after controlling for CS indicationscontrolling for CS indications

Research evidence:Research evidence:

US study maternal morbidity and US study maternal morbidity and rehospitalization rehospitalization Cesarean vs vaginal birthCesarean vs vaginal birth

Rehospitalizations Rehospitalizations 1919/1000 CS vs /1000 CS vs 7.57.5/1000 vaginal /1000 vaginal Declercq et al. in Obstetrics Declercq et al. in Obstetrics and Gynecology March 2007 pgs 669-77and Gynecology March 2007 pgs 669-77

Leading cause rehospitalizations wound Leading cause rehospitalizations wound infections/complications: infections/complications: 6.66.6 vs : vs : 3.33.3/1000/1000

Research evidence:Research evidence:Cesarean vs vaginal birthCesarean vs vaginal birth

First study truly planned vaginal birth vs. planned First study truly planned vaginal birth vs. planned cesarean delivery (breech surrogate) cesarean delivery (breech surrogate) Liu, Liston Kramer Liu, Liston Kramer etc CMAJ Feb 13, 2007 pgs 455-60etc CMAJ Feb 13, 2007 pgs 455-60

46,76646,766 elective breech vs. elective breech vs. 2,292,4202,292,420 planned planned vaginalvaginal

After adjustment for confounders to make low After adjustment for confounders to make low risk in risk in both groups:both groups:

Planned CS had more cardiac arrests x5, Planned CS had more cardiac arrests x5,

hysterectomy hysterectomy x3.2x3.2, infection , infection x3x3, thromboembolism , thromboembolism x2.2x2.2, hemorrhage requiring hysterectomy x, hemorrhage requiring hysterectomy x2.12.1, , anesthetic complications anesthetic complications xx2.3 2.3

Consequences of increasing CS on Request for USA for Consequences of increasing CS on Request for USA for each 5% increase or from 29%to 34%each 5% increase or from 29%to 34%

Plante L. Obstet Gynecol Survey 61 (12) 2006Plante L. Obstet Gynecol Survey 61 (12) 2006

•14 to 32 more maternal deaths•5000 to 24,0000 more surgical complications;•4000 to 6000 more postoperative infections;•2200 more postpartum readmissions to the hospital;•200 to 300 additional venous thromboses;•33,000 more neonatal intensive care unit admissions;•8000 more cases of neonatal respiratory complications;• 930,000 more hospital days

(for women; have not calculated infant length of stay)•Between $750 million and $1.7 billion in extra healthcare expenditures;•Higher rates of hospital occupancy;•Longer waiting times for elective operations of all kinds; and•Potential for an overall increase in medical error related to higher

hospital occupancy rates.

However—Term Breech Trial provided However—Term Breech Trial provided natural experiment addressing both natural experiment addressing both

maternal and newborn consequences of maternal and newborn consequences of mode of birth:mode of birth:

While at 3 months study showed bowel, urinary While at 3 months study showed bowel, urinary and sexual benefit to CS for breech compared and sexual benefit to CS for breech compared with vaginal birthwith vaginal birthAt 2 years postpartum At 2 years postpartum NO DIFFERENCENO DIFFERENCEAnd vaginal breech birth harder on pelvic floorAnd vaginal breech birth harder on pelvic floorStudy demonstrates Study demonstrates resilienceresilience and and self-healingself-healing capacity of the pelvic floor and resilience of the capacity of the pelvic floor and resilience of the newborn as well.newborn as well.

Urinary and Sexual Outcomes in Vaginal vs Urinary and Sexual Outcomes in Vaginal vs Cesarean BirthCesarean BirthMichael C. Klein Michael C. Klein

Janusz KaczorowskiJanusz Kaczorowski

Sally Jorgensen, Robert GauthierSally Jorgensen, Robert Gauthier

Maria Hubinette, Tabassum FirozMaria Hubinette, Tabassum Firoz

Centre Community Child Health Centre Community Child Health

BC Research Institute for Children’s and BC Research Institute for Children’s and Women’s Health and Women’s Health and

Department of Family Practice, University of Department of Family Practice, University of British Columbia , McGill University, British Columbia , McGill University,

McMaster University, Bridgewater, NS McMaster University, Bridgewater, NS

Department of OB/GYN University ofDepartment of OB/GYN University of MontrealMontreal

JOGC 2005; 27 (4): 313-320

Objectives our Study:Objectives our Study:Determine if urinary incontinence (UI) is more Determine if urinary incontinence (UI) is more common 3 months PP among vaginal vs common 3 months PP among vaginal vs cesarean birthscesarean births

Determine if the subjective sensation of bulging Determine if the subjective sensation of bulging is more common among vaginal vs cesarean is more common among vaginal vs cesarean birthsbirths

Determine if sexual difficulties are more common Determine if sexual difficulties are more common 3 months PP among vaginal vs cesarean births3 months PP among vaginal vs cesarean births

Design Design

Secondary analysis of all women who Secondary analysis of all women who were part of the only RCT of episiotomy in were part of the only RCT of episiotomy in North America—showed that episiotomy North America—showed that episiotomy caused the very problems it was supposed caused the very problems it was supposed to preventto prevent

According to various vaginal outcome According to various vaginal outcome cohorts vs cesarean sectioncohorts vs cesarean section

Subjects and SettingSubjects and SettingN: 1044N: 1044 women from The Montreal Episiotomy women from The Montreal Episiotomy RCT RCT

Enrolled at 30-34 weeks – very “low risk”Enrolled at 30-34 weeks – very “low risk”– Studied antepartum, intrapartum, early and late Studied antepartum, intrapartum, early and late

postpartum and 3 months postpartum postpartum and 3 months postpartum

Patients of 39 Obstetricians and Family Patients of 39 Obstetricians and Family Practitioners practicing at three sites in Montreal Practitioners practicing at three sites in Montreal 1990-911990-91

Population and MethodsPopulation and Methods

But for purposes of this analysis, all But for purposes of this analysis, all randomized and non-randomized women randomized and non-randomized women were includedwere included

Data for 3 month questionnaires available for Data for 3 month questionnaires available for 999999 women: 863 vaginal and 136 cesarean women: 863 vaginal and 136 cesarean births births (95.7% follow-up rate)(95.7% follow-up rate)

79 to 81% of study women were breast 79 to 81% of study women were breast feeding, slightly more who had a vaginal feeding, slightly more who had a vaginal birth. Numbers too small for sub-analysisbirth. Numbers too small for sub-analysis

Outcome MeasuresOutcome Measures 3 months PP 3 months PP

Urinary Incontinence (UI)Urinary Incontinence (UI)

Subjective sensation of vaginal bulgingSubjective sensation of vaginal bulgingSexual attractivenessSexual attractivenessTime to resumption of sexual intercourseTime to resumption of sexual intercoursePain on sexual intercoursePain on sexual intercoursePain intensity if present or type of painPain intensity if present or type of painSexual satisfactionSexual satisfaction

Demographics 999 womenDemographics 999 womenComparability for maternal age, weight, weight gain, height, gestational age, birth weight, education and social status--for the three main outcome groups:

1. Intact/first/second degree tears

2. Episiotomy with or without extensions or forceps

3. Cesarean section

Are you currently having trouble with loss of Are you currently having trouble with loss of urine? (3 months) - YESurine? (3 months) - YES

9.9 8.1 3.7

25.9 29.5

14.8

0

50

100

Intact/1/2

Epis/Ext

C-xion Intact/1/2

Epis/Ext

C-xion

Per

cent

p .221

No Hx UI Hx UI

Overall 162 or 16.3% had UI

Are you currently having trouble with loss of Are you currently having trouble with loss of urine? (3 months postpartum) by Parity and urine? (3 months postpartum) by Parity and

by Two-way Analysis by Two-way Analysis (Why 2-way?)(Why 2-way?)

17.9 17.1

6.4

16

0

50

100

Primips Multips

Pe

rce

nt Vaginal

Caesareanp .003

Unstratified by History of UI

Stress Incontinence During First Three Stress Incontinence During First Three Months PostpartumMonths Postpartum

by Parity and by Two-way Analysis by Parity and by Two-way Analysis

34.5 38.2

12.8

28

0

50

100

Primips Multips

Pe

rce

nt Vaginal

CaesareanP <.001

Unstratified by History of UI

Severe Urinary Incontinence at 3 months Postpartum Severe Urinary Incontinence at 3 months Postpartum Women with any degree of UI Women with any degree of UI (wears pad) (wears pad)

by Parity and by Two-way Analysis by Parity and by Two-way Analysis

1623.8

15.4

25

0

50

100

Primips Multips

Per

cent

Vaginal

Caesarean

Unstratified by History of UI

Resumption of Sexual Intercourse Resumption of Sexual Intercourse by 3 months Postpartumby 3 months Postpartum

Very few women had resumed sexual Very few women had resumed sexual intercourse by 3 monthsintercourse by 3 months

But among women of both parities:But among women of both parities:– Strong trend favoring resumption among Strong trend favoring resumption among

those women who had a vaginal birth those women who had a vaginal birth

– OR 2.17 (CI 0.98-4.80) OR 2.17 (CI 0.98-4.80) p .059p .059

Desire for Sexual Intercourse at 3 months Desire for Sexual Intercourse at 3 months Postpartum by Parity and by Two-way Postpartum by Parity and by Two-way

AnalysisAnalysis

46.2 44.441.8 44

0

50

100

Primips Multips

Per

cent

Vaginal

Caesarean

Unstratified by Prior Sexual History

Sexual Dissatisfaction at 3 months Sexual Dissatisfaction at 3 months Postpartum by Parity and by Two-way Postpartum by Parity and by Two-way

AnalysisAnalysis

70.1 64.2

54.5

71.4

0

50

100

Primips Multips

Per

cent

Vaginal

Caesarean

Unstratified by Prior Sexual History

p .003

Frequency of Sexual Intercourse Frequency of Sexual Intercourse at 3 months Postpartum by Parity and by at 3 months Postpartum by Parity and by

Two-way AnalysisTwo-way Analysis

66.8 61.462

71.4

0

50

100

Primips Multips

Per

cent

Vaginal

Caesarean

Unstratified by Prior Sexual History

Pain on Sexual Intercourse Pain on Sexual Intercourse at 3 months Postpartum by Parity and by at 3 months Postpartum by Parity and by

Two-way AnalysisTwo-way Analysis

30.7 33.831.6

00

50

100

Primips Multips

Per

cent

Vaginal

Caesarean

Unstratified by Prior Sexual History

0/5 women who had resumed

If you are currently having trouble with loss If you are currently having trouble with loss of urine, is it severe enough to wear a pad? of urine, is it severe enough to wear a pad?

(3 months postpartum—three way)(3 months postpartum—three way)

17.2 21.5 19

0

50

100

Intact/1/2 Epis with orwithout

extensions

C-xion

Pe

rce

nt

p .540

Are you currently having trouble with a feeling of Are you currently having trouble with a feeling of “bulging” or falling down in the vaginal area? (3 “bulging” or falling down in the vaginal area? (3

months postpartum—three way)months postpartum—three way)

7.5 7.6 4.4

0

50

100

Intact/1/2 Epis with orwithout

extensions

C-xion

Per

cen

t

p .424

Compared to before you were pregnant, Compared to before you were pregnant, how sexually attractive do you feel? how sexually attractive do you feel? (3 months postpartum—three way)(3 months postpartum—three way)

42.447.6

42.2

0

50

100

Intact/1/2 Epis with orwithout extensions

C-xion

Per

cen

t

p .256

Sexual dissatisfaction?Sexual dissatisfaction?(3 months postpartum)—three way(3 months postpartum)—three way

66.2 68.157.5

0

50

100

Intact/1/2 Epis with or withoutextensions

C-xion

Perc

en

t

p .097

For each year education, 7% decrease in sexual satisfaction

Pain and frequency of intercourse at Pain and frequency of intercourse at 3 months postpartum 3 months postpartum (mean scores—three way)(mean scores—three way)

Intact/1o/2o

Episiot/Exten

Cxion p

Frequency 3=same

2.3 2.2 2.3 .377

.153Pain on intercourse

1=mild2=discomforting

1.7 1.9 1.6

Are you experiencing pain or Are you experiencing pain or discomfort during intercourse?discomfort during intercourse?

at 3 months--%YESat 3 months--%YES

38.5

56.6

40.7

26.6

0

50

100

Intact/1/2 Epis /Ext/Forceps

Cxion Intact

Per

cen

t

p <.001 p .012

5551.5

4842.6

37.5

27 25.4

63.9

55.4

39.2

0

10

20

30

40

50

60

70

80

89-'9

0

90-'9

1

91-'9

2

92-'9

3

93-'9

4

94-'9

5

95-'9

6

96-'9

7

97-'9

8

Per

100

hos

pita

l vag

inal

del

iver

ies

Canada USA

Episiotomies per 100 Hospital Vaginal Deliveries

4.2 2.9 1.5Rectal Trauma Rates (3rd /4th

degree tears) - USA

Conclusion (1)Conclusion (1)

At 3 months PP, UI slightly less among women with At 3 months PP, UI slightly less among women with cxion—but this is too early to measure this outcomecxion—but this is too early to measure this outcome

Severe UI similar at 3 months PP for cxion and Severe UI similar at 3 months PP for cxion and vaginal birthsvaginal births

At 3 months PP, sexual functioning is similar among At 3 months PP, sexual functioning is similar among women with various vaginal outcomes compared to women with various vaginal outcomes compared to cesarean section--cesarean section-- with the exception of forceps with the exception of forceps birthsbirths

Conclusion (2)Conclusion (2)

However, cesarean section as an However, cesarean section as an alternative to difficult forceps is alternative to difficult forceps is reasonable from point view of sexual reasonable from point view of sexual functioning. Other studies also functioning. Other studies also implicate forceps in UI and suggest--implicate forceps in UI and suggest--Never too late for a cesarean—don’t Never too late for a cesarean—don’t have to decide in advance!!!!!!have to decide in advance!!!!!!

Conclusion (3)Conclusion (3)As the rate of intact perineum is rising and rectal As the rate of intact perineum is rising and rectal

trauma rate is falling in current practice, were this trauma rate is falling in current practice, were this study repeated today, we would expect even better study repeated today, we would expect even better outcomes for vaginal birth vs CS than demonstrated outcomes for vaginal birth vs CS than demonstrated by our studyby our study

Optimal, physiologic birth rather than current Optimal, physiologic birth rather than current “industrialized” birth would also be expected to “industrialized” birth would also be expected to enhance vaginal outcomes vs CSenhance vaginal outcomes vs CS

Informed decisions require unbiased presentation of Informed decisions require unbiased presentation of benefits and risks ofbenefits and risks of alternative birth modesalternative birth modes

The most comprehensive review to date on The most comprehensive review to date on Cesarean compared with spontaneous and Cesarean compared with spontaneous and assisted vaginal birth has been completed by assisted vaginal birth has been completed by The Maternity Center Association (MCA), now The Maternity Center Association (MCA), now Childbirth Connection.Childbirth Connection. In April 2004, MCA In April 2004, MCA published a booklet, published a booklet, What every pregnant What every pregnant woman needs to know about Cesarean woman needs to know about Cesarean section.section.

Using systematic review, MCA concluded that in Using systematic review, MCA concluded that in the absence of a clear, compelling and well-the absence of a clear, compelling and well-supported rationale for Cesarean section, supported rationale for Cesarean section, vaginal birth is far safer for mothers and babies. vaginal birth is far safer for mothers and babies.

The precautionary principle of non-The precautionary principle of non-maleficence (first do no harm), requires maleficence (first do no harm), requires that potentially harmful actions or routines that potentially harmful actions or routines in the “management” of vaginal birth be in the “management” of vaginal birth be eliminated before recommending a eliminated before recommending a potentially harmful intrusion like Cesarean potentially harmful intrusion like Cesarean on demand.on demand.

e.g. unphysiological positions and e.g. unphysiological positions and pushing; unsupported labor; epidurals pushing; unsupported labor; epidurals used routinely; routine episiotomy used routinely; routine episiotomy

What every pregnant woman needs to know What every pregnant woman needs to know about cesarean sectionabout cesarean section.. New York: New York: Childbirth Connection, April 2004 Childbirth Connection, April 2004

http://www.maternitywise.org/booklet/.http://www.maternitywise.org/booklet/.

NIH Conference “Cesarean Delivery on Maternal RequestNIH Conference “Cesarean Delivery on Maternal Request No data about maternal request: why a conference?No data about maternal request: why a conference? Inappropriate comparison groups Inappropriate comparison groups (used Term-Breech as (used Term-Breech as

surrogate for vaginal vertex births).surrogate for vaginal vertex births). Failed to study subsequent pregnancies Failed to study subsequent pregnancies (previas, accretas, (previas, accretas,

abruptions, ectopics, infertility etc)abruptions, ectopics, infertility etc) Employed large retrospective cohort studies of all births Employed large retrospective cohort studies of all births

of variable quality vs CS of higher qualityof variable quality vs CS of higher quality Did not compare best/physiologic birth practices with CSDid not compare best/physiologic birth practices with CS Recommendations made no senseRecommendations made no sense eg recommended no CS eg recommended no CS

onlyonly for women planning “several” births when data suggests “more for women planning “several” births when data suggests “more than one”than one”

Opened the door to CS on request—since not enough Opened the door to CS on request—since not enough data on vaginal vs CS in comparable groups—reason to data on vaginal vs CS in comparable groups—reason to accept CS on request?accept CS on request?

Accepted pathological model of birth Accepted pathological model of birth (birth is nothing more (birth is nothing more than an opportunity for side effects or adverse outcomes)than an opportunity for side effects or adverse outcomes)– No mention of powerful and transformative nature of vaginal birthNo mention of powerful and transformative nature of vaginal birth

Question: Is it possible that vaginal childbirth Question: Is it possible that vaginal childbirth

is becoming an extreme sport?is becoming an extreme sport? ((Modified from Vicki van Wagner)

Midwives and family physicians will become ecotourist guides who Midwives and family physicians will become ecotourist guides who will cater to those super-atheletes (read nuts), who will insist on will cater to those super-atheletes (read nuts), who will insist on subjecting themselves to obsolete and dangerous practicessubjecting themselves to obsolete and dangerous practices

They will practice their arcane rites in secret, usually in rural and They will practice their arcane rites in secret, usually in rural and remote settings, with the back-to-the-landers and the end-of-the-remote settings, with the back-to-the-landers and the end-of-the-worldersworlders

If caught, the caregivers will be have licenses removed, be If caught, the caregivers will be have licenses removed, be prosecuted or burned at the stake, while the birthing women will be prosecuted or burned at the stake, while the birthing women will be charged with child abusecharged with child abuse

Sound absurd? Read, re-read Margaret Atwood’s “A Handmaid’s Sound absurd? Read, re-read Margaret Atwood’s “A Handmaid’s tale”tale”

What can we do? What can we do? EducationEducation, , research, analysis, critique, engage research, analysis, critique, engage women in the struggle to women in the struggle to get childbirth back on the women’s get childbirth back on the women’s health agendahealth agenda– Narratives???Narratives???

Who cares?