Mode Birth Review Points

8/9/2019 Mode Birth Review Points

http://slidepdf.com/reader/full/mode-birth-review-points 1/82

Comparing Harms of Vaginal and Cesarean Birth:Comparing Harms of Vaginal and Cesarean Birth:

Maternity Center Association¶s Systematic ReviewMaternity Center Association¶s Systematic Review& Education & Quality Improvement Campaign& Education & Quality Improvement Campaign

Carol Sakala, PhD, MSPHCarol Sakala, PhD, MSPH

Maureen P. Corry, MPHMaureen P. Corry, MPHMaternity Center AssociationMaternity Center Association

June 2005June 2005

[Maternity Center Association¶s name changed to Childbirth Connection on 1/1/2006.[Maternity Center Association¶s name changed to Childbirth Connection on 1/1/2006. All documents referenced in these slides are available through Childbirth Connection¶s All documents referenced in these slides are available through Childbirth Connection¶s

redesigned expanded website at http://www.childbirthconnection.org.redesigned expanded website at http://www.childbirthconnection.org.Speaking points are available in Notes view.Speaking points are available in Notes view.

Download source for this file:Download source for this file:

http://www.childbirthconnection.org/article.asp?ck=10271&ClickedLink=200&area=2http://www.childbirthconnection.org/article.asp?ck=10271&ClickedLink=200&area=22006 Childbirth Connection. All rights reserved.2006 Childbirth Connection. All rights reserved.] ]



Maternity Center Association (MCA)Maternity Center Association (MCA)Improving maternity care since 1918Improving maternity care since 1918

Key audiences: childbearing women, healthKey audiences: childbearing women, healthprofessionalsprofessionals

EvidenceEvidence- -based maternity care focus, 1999based maternity care focus, 1999- -

www.maternitywise.orgwww.maternitywise.org



Maternity Center AssociationMaternity Center AssociationMissionMission

To promote safe, effective and satisfyingTo promote safe, effective and satisfyingmaternity care for all women and their familiesmaternity care for all women and their families

through research, education and advocacythrough research, education and advocacy



Maternity Center AssociationMaternity Center AssociationMajor Program AreasMajor Program Areas

Maternity WiseMaternity Wise ®® websitewebsiteL istening to MothersL istening to Mothers ®® InitiativeInitiativeLabor Pain InitiativeLabor Pain InitiativeLabor Support InitiativeLabor Support Initiative

Cesarean Alert InitiativeCesarean Alert InitiativeSee many related resources at www.maternitywise.orgSee many related resources at www.maternitywise.org



Context for Decision to Focus onContext for Decision to Focus onCesarean SectionCesarean Section

Rapid Shifts in Belief, Including New IdeasRapid Shifts in Belief, Including New Ideas

³Vaginal birth is harmful.´³Vaginal birth is harmful.´³Vaginal birth is causing pelvic floor problems, after birth and³Vaginal birth is causing pelvic floor problems, after birth and

later in life.´later in life.´

³Having a cesarean will prevent later life pelvic floor problems.´³Having a cesarean will prevent later life pelvic floor problems.´

³The benefit/harm ratio is shifting to equipoise or now favors³The benefit/harm ratio is shifting to equipoise or now favorscesarean.ćesarean.´

³Cesarean delivery, especially elective cesarean, is safe.´³Cesarean delivery, especially elective cesarean, is safe.´





Context for Decision to Focus onContext for Decision to Focus onCesarean Section (cont)Cesarean Section (cont)Rapid Change Without Benefit of aRapid Change Without Benefit of aSystematic Look at the EvidenceSystematic Look at the Evidence

some systematic reviews for specific indications (e.g.,some systematic reviews for specific indications (e.g.,previous cesarean)previous cesarean)

no attempt to understand full range of harms that differ no attempt to understand full range of harms that differ

³narrative´ reviews generally appear to make case for or ³narrative´ reviews generally appear to make case for or against casual/liberal use of cesareanagainst casual/liberal use of cesarean

narrative reviews are unreliable! narrative reviews are unreliable!



Context for Decision to Focus onContext for Decision to Focus onCesarean Section (cont)Cesarean Section (cont)

ACOG Committee on Ethics, 2003 Committee Opinion ACOG Committee on Ethics, 2003 Committee Opinion³Surgery and Patient Choice´³Surgery and Patient Choice´

³The ethical evaluation is clouded by the limitations of data³The ethical evaluation is clouded by the limitations of dataregarding relative shortregarding relative short- - and longand long- -term risks and benefits of term risks and benefits of cesarean versus vaginal delivery.ćesarean versus vaginal delivery.´

³If the physician believes that [elective] cesarean delivery³If the physician believes that [elective] cesarean deliverypromotes the overall health and welfare of the woman and her promotes the overall health and welfare of the woman and her fetus more than vaginal birth, he or she is ethically justified infetus more than vaginal birth, he or she is ethically justified inperforming a cesarean delivery.´performing a cesarean delivery.´



Context for Decision to Focus onContext for Decision to Focus on

Cesarean Section (cont)Cesarean Section (cont)Confusion and Controversy Among ProfessionalsConfusion and Controversy Among Professionals

Professionals divided, uncertain how to help pregnant womenProfessionals divided, uncertain how to help pregnant womenmake sense of the issuesmake sense of the issues

Large practice variation for many indications: gray areas thatLarge practice variation for many indications: gray areas thatcould benefit from better understanding of associated harmscould benefit from better understanding of associated harms

Large practice variation across hospitals: NYC 2002 hospitalLarge practice variation across hospitals: NYC 2002 hospitalcesarean rates ranged from 10% to 37% (seecesarean rates ranged from 10% to 37% (seewww.choicesinchildbirth.org)www.choicesinchildbirth.org)



Context for Decision to Focus onContext for Decision to Focus on

Cesarean Section (cont)Cesarean Section (cont)Confusion and Controversy Among Women,Confusion and Controversy Among Women,

General PublicGeneral Public

Media coverage incomplete, misleading, potentiallyMedia coverage incomplete, misleading, potentiallyinaccurateinaccurate

Informed consent, and informed refusal, not possibleInformed consent, and informed refusal, not possiblewithout full and accurate informationwithout full and accurate information



MCA¶s Plan in ResponseMCA¶s Plan in ResponseInvite participation of multiInvite participation of multi- -disciplinarydisciplinarypartnerspartners

Carry out systematic reviewCarry out systematic reviewDevelop brochure to help inform pregnantDevelop brochure to help inform pregnantwomen about the issueswomen about the issues

Plan media outreach about review results andPlan media outreach about review results andavailability of brochureavailability of brochure

Plan online resources for womenPlan online resources for women



PartnershipPartnershipInvitations sent to national nonInvitations sent to national non- -profits in the field, toprofits in the field, to

participate in one or more ways:participate in one or more ways:

provide feedback on initial proposal provide feedback on initial proposal

send relevant documents that group has prepared send relevant documents that group has prepared provide feedback on review document and draft brochure provide feedback on review document and draft brochure consider endorsing revised brochure consider endorsing revised brochure consider participating in media outreach consider participating in media outreach

Many groups participated in one or (mostly) multipleMany groups participated in one or (mostly) multiplewaysways



Partnership (cont)Partnership (cont)Review and booklet reflect input and support from:Review and booklet reflect input and support from:

obstetricians obstetricians childbirth educators childbirth educators family physicians family physicians doulas doulas pediatricians pediatricians researchers researchers midwives midwives advocates advocates nurses nurses consumers consumers

Multidisciplinary = highMultidisciplinary = high- -quality products, excitingquality products, excitingprocessprocess



Systematic Review ProtocolSystematic Review Protocol

ScopeScopeFocus on comparing harms (benefits depend uponFocus on comparing harms (benefits depend upon

specific indications and may be well understoodspecific indications and may be well understoodthrough available sources)through available sources)

Core question: what adverse outcomes differ Core question: what adverse outcomes differ between cesarean and vaginal birth?between cesarean and vaginal birth?

Consider various comparisons, as harms may vary:Consider various comparisons, as harms may vary:

cesarean or vaginal overallcesarean or vaginal overallplanned or unplanned cesareanplanned or unplanned cesareanspontaneous or instrumental vaginal birthspontaneous or instrumental vaginal birth



Systematic Review ProtocolSystematic Review ProtocolScope (cont)Scope (cont)

What Outcomes to Include?What Outcomes to Include?

Anything ³clinically relevant´ or ³mother relevant´ Anything ³clinically relevant´ or ³mother relevant´ ± ±what mothers may want to know about:what mothers may want to know about:

maternal and infant/childmaternal and infant/childshorter shorter- - or longer or longer- -termtermphysical and mental healthphysical and mental healthmother mother- -baby relationship, attachment, breastfeedingbaby relationship, attachment, breastfeeding

Exclude surrogate markers, as we don¶t know whatExclude surrogate markers, as we don¶t know whatthey mean for lives of mothers, babiesthey mean for lives of mothers, babies



Systematic Review ProtocolSystematic Review ProtocolProcessProcess

Use Oxford Centre for EvidenceUse Oxford Centre for Evidence- -based Medicinebased MedicineResearch Grading SystemResearch Grading System

Include best identified research in reviewInclude best identified research in review

Level 1: rarely available for review questionsLevel 1: rarely available for review questions

Level 2 and/or 3: best identified and included evidence for Level 2 and/or 3: best identified and included evidence for most outcomes; better quality observational studies andmost outcomes; better quality observational studies and

systematic reviews of observational studiessystematic reviews of observational studies

Level 4: include only when nothing else foundLevel 4: include only when nothing else found

Level 5 (incl. narrative reviews): lowest, excludeLevel 5 (incl. narrative reviews): lowest, exclude

www.cebm.net/levels_of_evidence.aspwww.cebm.net/levels_of_evidence.asp



Additional Review Questions Additional Review QuestionsWhat is the relationship between mode of deliveryWhat is the relationship between mode of delivery

and pelvic floor dysfunction?and pelvic floor dysfunction?

What factors contribute to pelvic floor dysfunction?What factors contribute to pelvic floor dysfunction?

method of delivery method of delivery other obstetric practices other obstetric practices maternal and fetal factors maternal and fetal factors non non--obstetric factorsobstetric factors

Important for women: understand factors contributingImportant for women: understand factors contributingto pelvic floor problems, especially modifiable onesto pelvic floor problems, especially modifiable ones



Additional Review Question Additional Review Question

In light of very broad practice variation andIn light of very broad practice variation and

uncertainty about optimal rates:uncertainty about optimal rates:

Do high rates of cesarean or instrumental birthDo high rates of cesarean or instrumental birthconfer benefits relative to more conservative use?confer benefits relative to more conservative use?



Challenge:Challenge:Balancing Needs Against ResourcesBalancing Needs Against Resources

Large agendaLarge agenda

series of relevant and interrelated questionsseries of relevant and interrelated questionsmany potential outcomes that may differ by method of many potential outcomes that may differ by method of delivery and be important to womendelivery and be important to women

Belief and practice shifting very rapidlyBelief and practice shifting very rapidly

Finite resources and no external funding in handFinite resources and no external funding in hand





Solution (cont):Solution (cont):Balancing Needs Against ResourcesBalancing Needs Against Resources

MCA had initiated dialogue with Agency for MCA had initiated dialogue with Agency for Healthcare Research and Quality (AHRQ) aboutHealthcare Research and Quality (AHRQ) aboutneed for full evidence report on these mattersneed for full evidence report on these mattersthrough their Evidencethrough their Evidence- -based Practice programbased Practice program

MCA would continue this dialogueMCA would continue this dialogue



Systematic Review, in Summary:Systematic Review, in Summary:Limiting Bias, Having Credible ResultsLimiting Bias, Having Credible ResultsEstablished guidelines in advanceEstablished guidelines in advance

Made them transparent, and adhered to themMade them transparent, and adhered to them

Scrupulously used these criteriaScrupulously used these criteria and not study resultsand not study results totodecide whether to include or exclude a studydecide whether to include or exclude a study

Summarized results of included studiesSummarized results of included studies

U nique contributionU nique contribution : goal of full accounting of differences: goal of full accounting of differencesin harm achieved by validated systematic proceduresin harm achieved by validated systematic procedures



Results OverallResults Overall

Over 300 research reports evaluated for inclusion inOver 300 research reports evaluated for inclusion inreview, described in evidence tablesreview, described in evidence tables

Included studies described dozens outcomes related toIncluded studies described dozens outcomes related tokey review questions, which were incorporated into ankey review questions, which were incorporated into anoutline of key questionsoutline of key questions

Outline of questions and outcomes used as framework for Outline of questions and outcomes used as framework for developing evidence tables with details of studiesdeveloping evidence tables with details of studies



Results Overall (cont)Results Overall (cont)PDF files available online:PDF files available online:

methods and sources documentmethods and sources documentoutline of questions and outcomesoutline of questions and outcomesfull evidence tablesfull evidence tablessummary of results for professionalssummary of results for professionalsSeeSee www.maternitywise.org/prof/cesarean/www.maternitywise.org/prof/cesarean/

In preparation:In preparation:manuscripts for professional journalsmanuscripts for professional journals



Results Overall (cont)Results Overall (cont)Many adverse effects appear to differ by mode of deliveryMany adverse effects appear to differ by mode of delivery

Overall, results strongly favor vaginal birthOverall, results strongly favor vaginal birth

Vaginal instrumental delivery associated with series of Vaginal instrumental delivery associated with series of adverse effects (could limit harm by avoiding episiotomyadverse effects (could limit harm by avoiding episiotomyand offering cesarean late vs.and offering cesarean late vs. difficult difficult instrumental birth)instrumental birth)

Overall, spontaneous vaginal birth is associated with fewestOverall, spontaneous vaginal birth is associated with fewestharmsharms

Consumer booklet, results summary for professionals, andConsumer booklet, results summary for professionals, andmanuscripts report absolute risk differences whenmanuscripts report absolute risk differences whenavailable through included studiesavailable through included studies



Shorter Shorter- -term Harms of Cesarean toterm Harms of Cesarean toMothersMothers

In comparison with vaginal birth, increased harmIn comparison with vaginal birth, increased harmdue to:due to:

death, related to surgery or anesthesia (rare)death, related to surgery or anesthesia (rare)emergency hysterectomyemergency hysterectomyblood clots and strokeblood clots and strokeinjuries from surgeryinjuries from surgery

longer hospitalizationlonger hospitalizationrehospitalizationrehospitalizationinfectioninfectionsevere and longsevere and long- -lasting painlasting pain



Social & Emotional Harms of Social & Emotional Harms of Cesarean to MothersCesarean to Mothers

In comparison with vaginal birth, increased harm dueIn comparison with vaginal birth, increased harm due

to:to:poor birth experiencepoor birth experienceless early contact with babyless early contact with babyearly unfavorable reaction to babyearly unfavorable reaction to baby

psychological trauma (unplanned cesarean)psychological trauma (unplanned cesarean)depression??depression??poor overall mental health and self poor overall mental health and self- -esteemesteempoor overall functioningpoor overall functioning



Ongoing Physical Harms of CesareanOngoing Physical Harms of Cesareanto Mothersto Mothers

In comparison with vaginal birth, increased harm dueIn comparison with vaginal birth, increased harm dueto:to:

ongoing pelvic painongoing pelvic painbowel obstructionbowel obstruction

(due to scar tissue and adhesions)(due to scar tissue and adhesions)



Harms of Cesarean to BabiesHarms of Cesarean to Babies

In comparison with vaginal birth, increased harm dueIn comparison with vaginal birth, increased harm dueto:to:

accidental cuts during surgeryaccidental cuts during surgerymild to severe respiratory problemsmild to severe respiratory problems

not initiating breastfeedingnot initiating breastfeedingasthma, in childhood and adulthoodasthma, in childhood and adulthood



Harms of Cesarean toHarms of Cesarean toMothers in Future PregnanciesMothers in Future Pregnancies

In comparison with vaginal birth, increased harmsIn comparison with vaginal birth, increased harms

due to:due to:infertilityinfertility ± ± involuntaryinvoluntaryinfertilityinfertility ± ± voluntaryvoluntaryectopic pregnancy/cesarean scar pregnancyectopic pregnancy/cesarean scar pregnancy



Harms of Cesarean to Mothers inHarms of Cesarean to Mothers inFuture Pregnancies (cont)Future Pregnancies (cont)In comparison with vaginal birth,In comparison with vaginal birth,

increased harms due to:increased harms due to:placenta previaplacenta previaplacenta accretaplacenta accretaplacental abruptionplacental abruptionuterine ruptureuterine rupturematernal deathmaternal death



Harms of Cesarean to Babies inHarms of Cesarean to Babies inFuture PregnanciesFuture Pregnancies

In comparison with vaginal birth, increased harmsIn comparison with vaginal birth, increased harmsdue to:due to:

death, before or shortly after birthdeath, before or shortly after birthlow birth weight and preterm birthlow birth weight and preterm birthmalformationmalformationcentral nervous system injurycentral nervous system injury





Are Planned Cesareans Are Planned Cesareans(Before Labor) the Answer?(Before Labor) the Answer?

Some advantages relative toSome advantages relative to

unplanned cesareans:unplanned cesareans:less shortless short- -term surgical injuryterm surgical injuryless emotional tollless emotional toll



Are Planned Cesareans Are Planned Cesareans(Before Labor) the Answer? (cont)(Before Labor) the Answer? (cont)Planned cesarean is still major surgeryPlanned cesarean is still major surgery

excess shortexcess short- -term surgical harms relative to vaginal birthterm surgical harms relative to vaginal birthconditions associated with scarring and adhesions (theseconditions associated with scarring and adhesions (theseharms likely to be similar to unplanned cesareans)harms likely to be similar to unplanned cesareans)

all all future fertility and pregnancy risks associated withfuture fertility and pregnancy risks associated withuterine scar (these harms likely to be similar to unplanneduterine scar (these harms likely to be similar to unplannedcesarean)cesarean)

potential for iatrogenic respiratory problems in babiespotential for iatrogenic respiratory problems in babies



Harms of Assisted Vaginal BirthHarms of Assisted Vaginal Birth

to Mothersto MothersIn comparison with spontaneous vaginal birth,In comparison with spontaneous vaginal birth,

increased harms due to:increased harms due to:

3rd and 4th degree perineal tears3rd and 4th degree perineal tearsexcessive bleeding and transfusionexcessive bleeding and transfusionrehospitalizationrehospitalizationInfectionInfection Adverse impact of midlineAdverse impact of midline

painful perineumpainful perineum episiotomy coepisiotomy co- -interventioninterventionurinary incontinenceurinary incontinence appears to be substantialappears to be substantialany bowel problemsany bowel problems for this set of outcomesfor this set of outcomesbowel incontinencebowel incontinence



Harms of Assisted Vaginal BirthHarms of Assisted Vaginal Birthto Mothers (cont)to Mothers (cont)

In comparison with spontaneous vaginal birth,In comparison with spontaneous vaginal birth,increased harms due to:increased harms due to:

poor birth experiencepoor birth experiencepsychological trauma (traumatic symptoms, PTSD)psychological trauma (traumatic symptoms, PTSD)sexual problems (pain, frequency, satisfaction)sexual problems (pain, frequency, satisfaction)poor overall functioning/prolonged recoverypoor overall functioning/prolonged recovery



Harms of Assisted Vaginal BirthHarms of Assisted Vaginal Birthto Mothers (cont)to Mothers (cont)

To limit adverse effects of assisted delivery:To limit adverse effects of assisted delivery:maintain assisted delivery skillsmaintain assisted delivery skillsavoid routine episiotomy coavoid routine episiotomy co- -interventioninterventionoffer cesarean if and when clear that assisted delivery willoffer cesarean if and when clear that assisted delivery will

bebe difficult difficult Excellent recent SOGC guidelines available at:Excellent recent SOGC guidelines available at:

sogc.medical.org/SOGCnet/sogc_docs/common/guide/library_e.shtml#obstetricssogc.medical.org/SOGCnet/sogc_docs/common/guide/library_e.shtml#obstetrics



Harms of Assisted Vaginal BirthHarms of Assisted Vaginal Birthto Babiesto Babies

In comparison with spontaneous vaginal birth,In comparison with spontaneous vaginal birth,increased harm due to:increased harm due to:

brain injurybrain injurybrachial plexus injurybrachial plexus injury



Harm of Vaginal Birth*Harm of Vaginal Birth*to Babiesto Babies

In comparison with cesarean, increased harmIn comparison with cesarean, increased harmdue to:due to:

brachial plexus injurybrachial plexus injury

* spontaneous or overall* spontaneous or overall





Problem of Overly BroadProblem of Overly Broad

Definitions of IncontinenceDefinitions of IncontinenceU rinaryU rinary

may include any or minimal incontinence, at any pointmay include any or minimal incontinence, at any point(e.g., ³drop or 2´)(e.g., ³drop or 2´)

BowelBowelmay include any leaking gas, any leaking feces, or anymay include any leaking gas, any leaking feces, or anyurgency without leakage, at any pointurgency without leakage, at any point

N eed to focus onN eed to focus onactual concerns and experiences of womenactual concerns and experiences of womenimpact on women¶s quality of lifeimpact on women¶s quality of lifedegree to which any problems persist after recoverydegree to which any problems persist after recovery

periodperiod



Problem of Use of Problem of Use of Surrogate MarkersSurrogate Markers

Uncertain whether group differences in physiologicUncertain whether group differences in physiologicmeasurements have any practical meaning for women¶smeasurements have any practical meaning for women¶ssymptoms and quality of life and, if so, the durationsymptoms and quality of life and, if so, the duration

Inappropriate to use these studies to guide practice andInappropriate to use these studies to guide practice and

policypolicy



Problem of CoProblem of Co- -Interventions thatInterventions thatContribute to Pelvic Floor DysfunctionContribute to Pelvic Floor Dysfunction

Practices associated with pelvic floor injury:Practices associated with pelvic floor injury:

episiotomyepisiotomyinstrumental deliveryinstrumental deliverypushing in supine or lithotomy positionpushing in supine or lithotomy position

forceful, directed pushingforceful, directed pushingfundal pressurefundal pressureperineal pressureperineal pressure



Problem of CoProblem of Co- -Interventions (cont)Interventions (cont)

Many women experience several with vaginal birthMany women experience several with vaginal birth

Liberal or routine use is not evidenceLiberal or routine use is not evidence- -based practicebased practice

Large practice variation (e.g., 2002 episiotomy ratesLarge practice variation (e.g., 2002 episiotomy ratesacross NYC hospitals: 1% to 88% of vaginal births)*across NYC hospitals: 1% to 88% of vaginal births)*

Potential to reduce much harm with conservativePotential to reduce much harm with conservativepractice style and judicious usepractice style and judicious use

* www.choicesinchildbirth.org* www.choicesinchildbirth.org



Relationship Between Vaginal BirthRelationship Between Vaginal Birth

and Pelvic Floor Dysfunctionand Pelvic Floor DysfunctionWe did not find a single study that attempted to minimize or We did not find a single study that attempted to minimize or control for harmful cocontrol for harmful co- -interventions to try to understand whether interventions to try to understand whether giving birth through the vagina increases risk of pelvic floor giving birth through the vagina increases risk of pelvic floor problemsproblems

Inappropriate at this time to state that ³vaginal birthÍnappropriate at this time to state that ³vaginal birthćauses pelvic floor dysfunctioncauses pelvic floor dysfunction

Given current knowledgeGiven current knowledgeimperative to improve management of vaginal birthimperative to improve management of vaginal birthinappropriate to promote cesarean as preventive measureinappropriate to promote cesarean as preventive measure



Relationship Between Vaginal BirthRelationship Between Vaginal Birth

and Pelvic Floor Dysfunction (cont)and Pelvic Floor Dysfunction (cont)We must do a better job:We must do a better job:

Understanding the scope of problemsUnderstanding the scope of problems

Understanding causes of problemsUnderstanding causes of problemsmaternity factors (which ones?)maternity factors (which ones?)nonnon--maternity factors (modifiable?)maternity factors (modifiable?)

Reducing risk through improvements in vaginal birthReducing risk through improvements in vaginal birthmanagement practicesmanagement practices

Understanding and applying nonUnderstanding and applying non- -invasive preventioninvasive preventionand treatment strategies (e.g., Kegels)and treatment strategies (e.g., Kegels)



Incontinence Results with Usual CareIncontinence Results with Usual CareIncontinence after vaginal birth:Incontinence after vaginal birth:

infrequent for most who experience itinfrequent for most who experience itminimal to mild severity for mostminimal to mild severity for most

falls off sharply during recovery periodfalls off sharply during recovery period

A year after vaginal birth: A year after vaginal birth:

about 3% have any newabout 3% have any new- -onset urinary incontinenceonset urinary incontinence

about 3% have any newabout 3% have any new- -onset anal incontinenceonset anal incontinencesevere and troubling problems raresevere and troubling problems raresevere urinary or anal incontinence due primarily tosevere urinary or anal incontinence due primarily tocombined forceps with episiotomycombined forceps with episiotomy



Incontinence Results with Usual Care:Incontinence Results with Usual Care:Longer TermLonger Term

Vaginal Birth and Later Vaginal Birth and Later- -life Incontinence?life Incontinence?

incontinence problems arising at birth diminish over timeincontinence problems arising at birth diminish over time

differences between cesarean and vaginal groups for differences between cesarean and vaginal groups for urinary & bowel incontinence disappear by about age 50urinary & bowel incontinence disappear by about age 50

high rates of later high rates of later- -life incontinence associated with other life incontinence associated with other factorsfactors



NonNon--Maternity Factors Associated withMaternity Factors Associated withIncontinenceIncontinence

Excess weightExcess weightSmokingSmokingHRTHRT

HysterectomyHysterectomyUrinary tract infectionsUrinary tract infectionsSome chronic diseasesSome chronic diseasesSome medicationsSome medicationsImpaired mobilityImpaired mobilityGeneticsGenetics

Many impact large numbers of womenMany impact large numbers of womenMany are modifiableMany are modifiable



Life Course PerspectiveLife Course Perspective

Need to sort timing of onset of notable problems:Need to sort timing of onset of notable problems:

before pregnancybefore pregnancy

during pregnancyduring pregnancyafter postpartum periodafter postpartum period

Vaginal birth cannot cause, cesarean cannot preventVaginal birth cannot cause, cesarean cannot prevent

Increasingly common popular and professionalIncreasingly common popular and professionalpresumption that vaginal birth is associated withpresumption that vaginal birth is associated withany pelvic floor dysfunction: flawedany pelvic floor dysfunction: flawed



Practice Variation:Practice Variation:Price for Lower Intervention Rates?Price for Lower Intervention Rates?

Over 25 studies examined practice variation for Over 25 studies examined practice variation for rates of:rates of:

cesarean sectioncesarean sectioninstrumental vaginal birthinstrumental vaginal birthepisiotomyepisiotomy

N o evidence of adverse effects in mothersN o evidence of adverse effects in mothers

and babies with conservative careand babies with conservative careBut challenging to fully account for possibleBut challenging to fully account for possible

differences in riskdifferences in risk



Review Conclusion:Review Conclusion:Safest Way to Give BirthSafest Way to Give Birth

Without clear, compelling and wellWithout clear, compelling and well- -supportedsupported justification for cesarean section or assisted justification for cesarean section or assistedvaginal birth, a spontaneous vaginal birthvaginal birth, a spontaneous vaginal birthminimizing use of interventions that may beminimizing use of interventions that may beinjurious to mothers and babies is the safest wayinjurious to mothers and babies is the safest wayfor women to give birth and babies to be born.for women to give birth and babies to be born.



Myth and RealityMyth and Reality

Myth:Myth:Cesarean section is safeCesarean section is safe

RealityReality ::

Vaginal birth is far safer overall for mothers andVaginal birth is far safer overall for mothers andbabiesbabies

Although cesarean section is safer than in the Although cesarean section is safer than in thepast, it is major abdominal surgery and posespast, it is major abdominal surgery and posesmany extra harms for mothers and babies inmany extra harms for mothers and babies incomparison with vaginal birthcomparison with vaginal birth



Myth and Reality (cont)Myth and Reality (cont)

Myth:Myth:Planned cesarean is on optimal solution for Planned cesarean is on optimal solution for mothers and babiesmothers and babies

Reality:Reality:Vaginal birth is far safer overall for mothers andVaginal birth is far safer overall for mothers andbabiesbabies

Planned cesarean is very convenient for busyPlanned cesarean is very convenient for busyhospitals and caregivershospitals and caregivers




Myth:Myth:Vaginal birth is harmful for mothers and babiesVaginal birth is harmful for mothers and babies

Reality:Reality:

Vaginal birth is far safer overall for mothers andVaginal birth is far safer overall for mothers andbabies than cesarean sectionbabies than cesarean section

Some overused medical practices during vaginalSome overused medical practices during vaginal

birth are harmful to mothers and babiesbirth are harmful to mothers and babiesResearch has not been done to determine whether Research has not been done to determine whether giving birth through the vagina hasgiving birth through the vagina has intrinsic intrinsic risks inrisks incomparison with cesarean sectioncomparison with cesarean section




Myth:Myth:Having an elective cesarean section will preventHaving an elective cesarean section will preventincontinence later in lifeincontinence later in life

Reality:Reality:Current research suggests that having a cesareanCurrent research suggests that having a cesareansection will havesection will have no effect no effect on incontinence later inon incontinence later in

lifelifeHaving an elective cesarean section poses manyHaving an elective cesarean section poses manyharms and limited benefit to mothers and babiesharms and limited benefit to mothers and babies



Evidence Into Education, Advocacy:Evidence Into Education, Advocacy:

Tips for Reducing RiskTips for Reducing RiskOverall Tips: PregnancyOverall Tips: Pregnancy

Find doctor or midwife with low rates of interventionFind doctor or midwife with low rates of interventionDiscuss goals & preferences with caregiver Discuss goals & preferences with caregiver Choose birth setting with low rates of interventionChoose birth setting with low rates of interventionCreate your own birth statementCreate your own birth statement

Arrange for continuous labor support Arrange for continuous labor supportExplore options for pain relief Explore options for pain relief






Tips for Reducing Risk (cont)Tips for Reducing Risk (cont)Tips for Avoiding Unnecessary Cesareans: PregnancyTips for Avoiding Unnecessary Cesareans: Pregnancy

If cesarean proposed, make informed decisionIf cesarean proposed, make informed decisionIf had previous cesarean, make informed decisionIf had previous cesarean, make informed decisionIf baby is breech, make informed decisionIf baby is breech, make informed decisionIf you fear vaginal birth, consider inIf you fear vaginal birth, consider in- -depth counselingdepth counseling




Tips for Reducing Risk (cont)Tips for Reducing Risk (cont)Tips for Avoiding Unnecessary Cesareans: Labor Tips for Avoiding Unnecessary Cesareans: Labor

Avoid routine interventions when possible (in addition Avoid routine interventions when possible (in additionto EFM, epidural: induction, AROM, arbitrary timeto EFM, epidural: induction, AROM, arbitrary timelimits)limits)

If a cesarean is proposed, make informed decisionIf a cesarean is proposed, make informed decision




Tips for Reducing Risk (cont)Tips for Reducing Risk (cont)Tips for Avoiding Unnecessary Assisted Birth:Tips for Avoiding Unnecessary Assisted Birth:

Labor Labor

Push in an upright or sidePush in an upright or side- -lying positionlying position Avoid time limits for pushing Avoid time limits for pushingLet your body guide pushing, when possibleLet your body guide pushing, when possible




Tips for Reducing Risk (cont)Tips for Reducing Risk (cont)Tips for Avoiding Unnecessary Pelvic Floor Injury:Tips for Avoiding Unnecessary Pelvic Floor Injury:

PregnancyPregnancy

Talk with caregivers about avoiding routine use of Talk with caregivers about avoiding routine use of interventions that can increase riskinterventions that can increase risk

Carry out pelvic floor muscle exercisesCarry out pelvic floor muscle exercises





1. Labor 1. Labor

Avoid routine use of interventions while pushing Avoid routine use of interventions while pushing

2. After Birth2. After Birth

Continue pelvic floor muscle exercisesContinue pelvic floor muscle exercises





Throughout LifeThroughout Life

Maintain healthy body weightMaintain healthy body weight Avoid smoking Avoid smokingContinue pelvic floor muscle exercisesContinue pelvic floor muscle exercisesMinimize repeated urinary tract infectionsMinimize repeated urinary tract infections

Avoid hysterectomy, when possible Avoid hysterectomy, when possible Avoid HRT, when possible Avoid HRT, when possible



Evidence Into Education, Advocacy:Evidence Into Education, Advocacy:Cesarean BookletCesarean Booklet

What Every Pregnant Woman Needs to Know What Every Pregnant Woman Needs to Know About Cesarean Section About Cesarean Section

Guided by recent literature onGuided by recent literature oninformation needs of childbearing womeninformation needs of childbearing womenrisk communication, decision aids (e.g.,risk communication, decision aids (e.g., B MJ B MJ 9/27/03)9/27/03)evidenceevidence- -based risk reductionbased risk reduction

Many partners providedMany partners provided

extensive feedback on drafts to strengthen qualityextensive feedback on drafts to strengthen qualityeventual endorsementeventual endorsement




Cesarean Booklet (cont)Cesarean Booklet (cont)Main body:Main body:

backgroundbackgroundinformed consent/informed refusalinformed consent/informed refusalreview results in brief review results in brief main indicationsmain indicationstips for reducing risktips for reducing risk

Appendix: Appendix:details of outcomes that differ by mode of deliverydetails of outcomes that differ by mode of deliveryabsolute risk differenceabsolute risk difference




Resources for Pregnant WomenResources for Pregnant WomenPrinted booklet + summary insert (for purchase, bulk rates)Printed booklet + summary insert (for purchase, bulk rates)Booklet PDF file (no charge)Booklet PDF file (no charge)

www.maternitywise.org/mw/topics/cesarean/cesareanbookletwww.maternitywise.org/mw/topics/cesarean/cesareanbooklet

InIn--depth online Maternity Topicsdepth online Maternity Topics

What should I know about cesarean section?What should I know about cesarean section?Should I choose VBAC or repeat cShould I choose VBAC or repeat c- -section?section?How can I prevent pelvic floor problems when giving birth?How can I prevent pelvic floor problems when giving birth?

www.maternitywise.org/mw/topics/www.maternitywise.org/mw/topics/




Media OutreachMedia OutreachMedia briefing at New York Academy of MedicineMedia briefing at New York Academy of Medicine

to release results of review and bookletto release results of review and booklet

Press release and outreachPress release and outreachwww.maternitywise.org/mw/topics/cesarean/cesareanbookletwww.maternitywise.org/mw/topics/cesarean/cesareanbooklet

Matte releaseMatte release

Print PSAs for partners¶ journals, newslettersPrint PSAs for partners¶ journals, newsletters




Professional OutreachProfessional OutreachPresentations, often by clinical partners and withPresentations, often by clinical partners and with

booklet distribution to all registrantsbooklet distribution to all registrants

Booklets/flyers at conference exhibitsBooklets/flyers at conference exhibits

Core review documents available online as PDFsCore review documents available online as PDFsavailable at www.maternitywise.org/prof/cesarean/available at www.maternitywise.org/prof/cesarean/




Professional Outreach (cont)Professional Outreach (cont)PDF summary of review resultsPDF summary of review resultsavailable at www.maternitywise.org/prof/cesarean/available at www.maternitywise.org/prof/cesarean/

Manuscripts in preparationManuscripts in preparation

CME resources anticipatedCME resources anticipated




Consultations, AdaptationsConsultations, AdaptationsPolicy and guidelines developmentPolicy and guidelines development

Adaptation for Kaiser Permanente/Northern Adaptation for Kaiser Permanente/NorthernCaliforniaCalifornia

Adaptation for Canada (English, French), Adaptation for Canada (English, French),Canadian Women¶s Health NetworkCanadian Women¶s Health Network

SpanishSpanish

Lower LiteracyLower Literacy



Moving Forward: AHRQ UpdateMoving Forward: AHRQ Update

MCA participated in EvidenceMCA participated in Evidence- -based Women¶s Healthbased Women¶s HealthStakeholder meeting, encouraged fully resourcedStakeholder meeting, encouraged fully resourcedfederal review comparing cesarean/vaginal harmsfederal review comparing cesarean/vaginal harms

MCA submitted invited overview of key issuesMCA submitted invited overview of key issues

AHRQ subsequently decided to limit scope of question to AHRQ subsequently decided to limit scope of question toplanned noplanned no- -indication cesarean requested by womenindication cesarean requested by women

Federal agencies have identified parameters for review;Federal agencies have identified parameters for review;EvidenceEvidence- -Based Practice Center is carrying it outBased Practice Center is carrying it out



Moving Forward:Moving Forward:Randomized Controlled Trials?Randomized Controlled Trials?

Various Calls Throughout World:Various Calls Throughout World:RCT(s) to Assess Cesarean Without Medical IndicationRCT(s) to Assess Cesarean Without Medical Indication

³It will require a randomized, controlled, prospective study³It will require a randomized, controlled, prospective studyto clearly define the benefits of elective prophylacticto clearly define the benefits of elective prophylacticcesarean delivery versus trial of labor. As the evidencecesarean delivery versus trial of labor. As the evidencesuggesting superior outcomes from elective prophylacticsuggesting superior outcomes from elective prophylacticcesarean delivery continues to mount, the time has comecesarean delivery continues to mount, the time has comefor a controlled multicenter clinical trial to deny or confirmfor a controlled multicenter clinical trial to deny or confirmthe benefit of elective prophylactic cesarean delivery.´the benefit of elective prophylactic cesarean delivery.´

ACOG Clinical Review ACOG Clinical Review 2005 editorial: Ralph W. Hale, W. Benson Harer, Jr 2005 editorial: Ralph W. Hale, W. Benson Harer, Jr ..



Moving Forward:Moving Forward:Randomized Controlled Trials?Randomized Controlled Trials?

Not EthicalNot Ethical

Trials justified with ³equipoise´ and adequate informedTrials justified with ³equipoise´ and adequate informedconsentconsent

Assertions of ³equipoise´ based on selective attention to Assertions of ³equipoise´ based on selective attention to just a few outcomes just a few outcomes

Skewed results strongly favoring vaginal birth render trialsSkewed results strongly favoring vaginal birth render trialsunethicalunethical

Would women be willing to enroll with truly informedWould women be willing to enroll with truly informedconsent?consent?

Cannot (and will not) wait 20Cannot (and will not) wait 20- -25 years for results25 years for results





Moving Forward:Moving Forward:RCT Not Information PanaceaRCT Not Information Panacea

Over Over--represent Harms of Vaginal Birthrepresent Harms of Vaginal Birth

Harms of vaginal birth management practices would beHarms of vaginal birth management practices would beassigned to ³vaginal birthássigned to ³vaginal birth´

Urogynecologic measurement standards exaggerate harms:Urogynecologic measurement standards exaggerate harms:

measuring during rather than after recovery period (moremeasuring during rather than after recovery period (morelikely with RCT)likely with RCT)

relying on surrogate markersrelying on surrogate markersrelying on liberal definitions of incontinence withoutrelying on liberal definitions of incontinence withoutregard to women¶s experiences, quality of liferegard to women¶s experiences, quality of life



Moving Forward: RCTs on ThisMoving Forward: RCTs on ThisTopic will Profoundly Distort ResultsTopic will Profoundly Distort Results

Under Under- -represent harms of cesareanrepresent harms of cesarean (inability to measure(inability to measuremany serious outcomes or inability to detect differences)many serious outcomes or inability to detect differences)

Over-represent harms of vaginal birth (measurement(measurementissues: coissues: co- -interventions, definitions, timing, surrogateinterventions, definitions, timing, surrogatemeasures)measures)

Measure well only small proportion of harms that differ Measure well only small proportion of harms that differ

Would erroneously confirm assertion of ³equipoise´Would erroneously confirm assertion of ³equipoise´ whenwhenbalance sheet in fact strongly favors vaginal birthbalance sheet in fact strongly favors vaginal birth

Beware of calls to settle matter through single RCTBeware of calls to settle matter through single RCT

P i i RCTP i i RCT



Priority RCT:Priority RCT:How Can We Improve Vaginal Birth?How Can We Improve Vaginal Birth?

Need large wellNeed large well- -funded andfunded and - -executed trial comparingexecuted trial comparingusual care vaginal birthusual care vaginal birthphysiologic vaginal birthphysiologic vaginal birth

With appropriate sample sizes, definitions, followWith appropriate sample sizes, definitions, follow- -upupperiod, etc.period, etc.

Outcomes of interest include: mode of delivery,Outcomes of interest include: mode of delivery,intrapartum interventions, and outcomes thatintrapartum interventions, and outcomes thatdiffered in MCA review and could be measured welldiffered in MCA review and could be measured well



Moving Forward:Moving Forward:

DES Tragedy Revisited?DES Tragedy Revisited?

Belief that DES offered benefits, had no serious downsidesBelief that DES offered benefits, had no serious downsideshas led to catastrophic outcomes many years later has led to catastrophic outcomes many years later

Is this being repeated with casual and liberal use of Is this being repeated with casual and liberal use of cesarean and effects of scarring, adhesions andcesarean and effects of scarring, adhesions andcompromised placentation?compromised placentation?



Presentation BibliographyPresentation Bibliography

Full bibliography available at:Full bibliography available at:

www.maternitywise.org/mw/topics/cesarean/booklet.htmlwww.maternitywise.org/mw/topics/cesarean/booklet.html

See Methods and Sources PDFSee Methods and Sources PDF



Moving ForwardMoving Forward

We welcome the opportunity to collaborate with others toWe welcome the opportunity to collaborate with others topromote evidencepromote evidence- -based maternity care.based maternity care.

Maureen P. Corry, MPHMaureen P. Corry, MPH [email protected]@maternitywise.orgExecutive Director Executive Director 212 777212 777- -5000, x 45000, x 4

Carol Sakala, PhD, MSPHCarol Sakala, PhD, MSPH [email protected]@maternitywise.orgDirector of ProgramsDirector of Programs 212 777212 777- -5000, x 55000, x 5

Documents

Mode Birth Review Points