Highlights in Obstetrics From the 50th Annual Meeting of The American College of Obstetricians and Gynecologists

David Cole, MD

Disclosures

June 11, 2002

In This Article

Elective Primary Cesarean Delivery: What's the Big Deal?

A symposium was led by Michael Greene, MD, Director of Maternal-Fetal Medicine, Massachusetts General Hospital; Robert Resnik, MD, Professor of Obstetrics and Gynecology, University of California, San Diego; and Joseph Schaffer, MD, Director of Urogynecology and Reconstructive Pelvic Surgery, University of Texas, Southwestern. This was one of the most interesting sessions at the ACOG meeting, as 2 maternal-fetal medicine specialists and 1 urogynecologist lectured on the topic of elective primary cesarean delivery. The lectures were followed by discussion from the audience. The discussion was scheduled to last for 15 minutes but was extended to an hour because of the emotions expressed by the audience on this subject. The premise of the session was based on the following question: If patient can choose to have all types of surgery in the year 2002, including rhinoplasty, a breast enlargements and reductions, abdominoplasty, liposuction, and laparoscopic cholecystectomy, why can't the same patient choose to have a primary elective cesarean section?

Elective primary cesarean section was the topic of an ACOG Clinical Review by W. Benson Harer, Jr, MD, past-president of ACOG.[1]In this article, he discusses the change that has occurred in women's access to abortion and contraception services in America. He argues that women can make autonomous reproductive health decisions, except with regard to mode of delivery for their babies. The issue gained further publicity in the current issue of OBG Management, in which Dr. Harer notes that whereas obstetricians are well educated to provide good explanations of informed consent to their patients, they are less well educated about the concept of informed refusal.[2] This concept embodies the notion that patients can refuse to follow the advice of their physicians.

At the ACOG meeting, Dr. Greene began the discussion by stating that fetal outcomes with cesarean delivery are superior to outcomes with vaginal delivery. If 8% to 12% of cerebral palsy can be attributed to events in labor, then, he posited, doing elective primary cesarean deliveries could reduce this percentage. He argued that no data exist for or against doing a primary cesarean delivery. When people argue with Dr. Greene that cesareans are unnatural, he counters with "so is getting pregnant with assisted reproductive technologies." Dr. Greene cited a study of female obstetricians in London in 1995, in which 31% of them would have a primary cesarean section, if given the choice.[3] (However, Dr. Greene did not mention that a similar study[3] in London in 1999 showed that only 21% of female obstetricians in London would choose a primary cesarean.) In terms of morbidity attributed to a primary cesarean delivery, Dr. Greene believes that it is very low (< 1%).

Dr. Shaffer then discussed the issue related to the pelvic floor and normal delivery. He began by stating that, in an ideal world, we could randomize women to either cesarean delivery or vaginal delivery; then we could study which is the safer way to deliver. However, this could never happen, so we need to approach the issue as a timeline. Like many urogynecologists, Dr. Shaffer believes that vaginal delivery leads to urinary incontinence, anal incontinence, and uterine prolapse. He asked whether there is a biological plausibility for increased rates of urinary incontinence, anal incontinence, and uterine prolapse. Dr. Shaffer believes that the answer is "yes," as muscles can only stretch and retract so far. He commented that all studies show an increased prevalence of urinary incontinence by increased parity. Women who are para 4 have an 11-fold relative risk of pelvic organ prolapse. The lifetime risk of anal incontinence with vaginal delivery is not known. He states that we cannot predict which women will be affected. Furthermore, women in a second-stage arrest who push for many hours may be at risk for a pelvic floor injury, even if they eventually do not deliver vaginally and undergo a cesarean section. He closed by saying that cesarean delivery is a reasonable alternative for women with risk factors, such as a history of dystocia.

Dr. Resnik discussed why women request a primary cesarean. He cited a recent article in the British Medical Journal, which mentions that even in England, the birthing process has become medicalized.[4] Cesarean delivery rates in Canada, England, Italy, and the United States are all near 20%. In Brazil, the cesarean rate is 36%, and among private patients in Brazil, the cesarean rate is 80% to 90%.[4] Perhaps our patients now view cesarean delivery as being safer than vaginal delivery, or perhaps they like the convenience of a scheduled delivery.

Dr. Resnik also said a few words about placenta accreta. Placenta accreta rates are rising in the United States; this increase has been attributed to the higher incidence of cesarean delivery. He made the suggestion that placenta accreta was his generation's gift to the younger generation of obstetricians. A recent ACOG Committee Opinion discusses the fact that accreta rates are now 1/2500.[5] Even Dr. Greene, who is pro-cesarean, acknowledged that he was fearful of the increase in placenta accretas.

The discussion from the audience was lively, with university chairmen and private practitioners each giving their opinions. Dr. Ronald Gibbs, Professor and Chairman of OB/GYN at University of Colorado, Denver, remarked that obstetricians should not underestimate the morbidity of bleeding from hemorrhage. One female obstetrician commented that if women can choose to have plastic surgery every day, what is all the fuss about elective primary cesarean. After all, she said, all women really want is a healthy baby. On the other side, another obstetrician commented that in his private practice during the past few years, he has had a maternal mortality from a pulmonary embolus after cesarean section as well as a placenta accreta. One OB/GYN resident commented on the benefit of pulmonary stimulation for infants delivered vaginally.

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