Midwifery is catching

Maternal Outcomes Associated With Planned Primary Cesarean Births Compared With Planned Vaginal Births

Eugene Declercq, PhD1, Mary Barger, CNM, MPH1, Howard J. Cabral, MPH, PhD2, Stephen R. Evans, MPH3, Milton Kotelchuck, MPH, PhD1, Carol Simon, MS, PhD5, Judith Weiss, ScD1 and Linda J. Heffner, MD, PhD4

From the 1 Department of Maternal and Child Health, 2Department of Biostatistics, 3Data Coordinating Center, 4Boston University School of Public Health; Department of Obstetrics and Gynecology, Boston University School of Medicine; and 5Abt Associates, Boston, Massachusetts.

OBJECTIVE: To compare the outcomes and costs associated with primary cesarean births with no labor (planned cesareans) to vaginal and cesarean births with labor (planned vaginal).

METHODS: Analysis was based on a Massachusetts data system linking 470,857 birth certificates, fetal death records, and birth-related hospital discharge records from 1998 and 2003. We examined a subset of 244,088 mothers with no prior cesarean and no documented prenatal risk. We then divided mothers into two groups: those with no labor and a primary cesarean (planned primary cesarean deliveries-3,334 women) and those with labor and either a vaginal birth or a cesarean delivery (planned vaginal-240,754 women). We compared maternal rehospitalization rates and analyzed costs and length of stay.

RESULTS: Rehospitalizations in the first 30 days after giving birth were more likely in planned cesarean (19.2 in 1,000) when compared with planned vaginal births (7.5 in 1,000). After controlling for age, parity, and race or ethnicity, mothers with a planned primary cesarean were 2.3 (95% confidence interval [CI] 1.74-2.9) times more likely to require a rehospitalization in the first 30 days postpartum. The leading causes of rehospitalization after a planned cesarean were wound complications (6.6 in 1,000) (P<.001) and infection (3.3 in 1,000).

The average initial hospital cost of a planned primary cesarean of $4,372 (95% C.I. $4,293-4,451) was 76% higher than the average for planned vaginal births of $2,487 (95% C.I. $2,481-2,493), and length of stay was 77% longer (4.3 days to 2.4 days).

CONCLUSION: Clinicians should be aware of the increased risk for maternal rehospitalization after cesarean deliveries to low-risk mothers when counseling women about their choices.

LEVEL OF EVIDENCE: II

So this week is week 2 of my placement and I am having a lot more fun. My finger is much better and I only have to splint it occassionally so that I don’t use it too much. I have been brave and am trying to use it more, but I can’t bend it enough to write properly so my writing looks like chicken scrawl at the moment.

Today I got a case load for the first time! I got 3 patients assigned to me, two of whom had c-sections yesterday and 1 who had a c-section a few days ago. I took out catheters, helped them shower, helped with breastfeeding, helped with pain relief, chatted to assess their mental health and how they’re processing the transition, and generally looked after their care for 8 hours. I got to hold babies (the true perk of the job!!!) and change clothes and change nappies and burp babies and had so much fun while all the while keeping an eye on the mothers and how they’re dealing with babies. I now smell like  babies (well, actually baby cleaning cloths and lotions and stuff).

One of the babies was a surprise girl (well, not a surprise but she doesn’t suit the names chosen by her parents so far) and has an older brother. He came in today, all of 2 or 3 years old to see his baby sister and on one of my visits, his mum was asking him what the babies name was going to be, with the options being Poppy or Sarah… and he said "Popah" in all seriousness cause really, who can choose. *dies of cuteness*

The next time I visited, he petted my leg and said, "Lady - baby shishter!!" while pointing at the baby. I asked him what noise babies made and he looked thoughtful for a moment before saying, "Squeak squeak squeak!" with his face all scrunched up (baby’s eyes are still closed). *again dies of cuteness*

Yesterday I attended two births in rapid succession. The first was a lovely birth with the woman pushing her bub into the world with dad and mum looking on, and tears all round. I’m not sure I’ll get over the whole tearing up thing when babes are born. This babe had a very short umbilical cord though, which lead to all sorts of rapid responses when it snapped mid-delivery. All is well now though! The parents were delighted with the baby’s gender, which was a surprise (which certainly is a trend I’ve noticed recently - most parents don’t know the babe’s gender unless they have had in-depth tests for another reason) and names were immediately bestowed. In a stroke of bad luck, dad had left their cameras behind at home and was going to use only their camera phone… but for some strange reason, I had tucked my camera into my bag on the way out that day, and was able to take amazing photos for them of the first few moments of life, and the weighing and measuring. I even burnt them to a cd last night and took it back this morning so they had them immediately.

The other birth was with a multip (someone who’s given birth at least once before) who previously had a very fast birth… but this one went quite slowly to start with. The midwife left to call the obstetrician to update him on the progress and I stayed with mum, watching her labouring and helping her with water and breathing. The moment the midwife stepped out, the contractions doubled and in the 20 minutes it took for the ob to get to the hospital, mum went from 4cm to 10cm in several bone-rattling contractions. In a few very vocal pushes, a new babe entred the world! And - I got to catch!!! Not a true whole catch, but I did get handed the baby immediately after she entred the world, and watched as the cord was cut and babe handed to mum. Mum looked stunned that it was over so quickly!

Today I was lucky to only have 3 patients today because I had the time to sit and chat to them all, and get to know them a lot better, and offer one details on CARES for some help with debriefing, and someone else advice on nipple care. I also had time to speak to an obstetrician about attending clinic with them so I can see some ante-natals in what is supposed to be an antenatal placement.

I have been pondering on the power dynamics of a healthy young woman with a low risk pregnancy choosing an obstetrician and a private hospital for her pregnancy and birth. On average, women see the ob 12 times during their pregnancy (compare this to the WHO recommendation of 2-4 times). The woman then turns up at a hospital when she may or may not be in labour, submits to a (what looks like an excruciatingly painful) vaginal exam only to be told that she’s not in labour, and is sent away. Or, is "offered" an induction seeing as she’s there already. The gels are placed, contractions may start a few hours later, membranes are ruptured when the ob is in checking on their other patients, contractions pick up, the woman is VE’d again and told she is only at 3-4cm and the enthusiasm goes out of her. Syntocin is administered and either it hurts a whole lot more to have the contractions sped up (so an epidural in done), or the baby doesn’t deal with it, and off they go for a c-section. All the while it seems like birth is a horrendously dangerous thing and the ob is the only one who knows how to do it safely. There is an aura of fear and tension in the birthing suite, and little privacy, and a lot of paperwork.

Informed consent? I think not. Not for anything prenatally, interpartum or post natally. Women-centred care? Nope. Power in the hands of the patient? Nope. Good outcomes because they have an alive and healthy baby? Perhaps - even if she also have a large abdominal wound.

Who am I to question this? Who am I to ask questions of my elders/seniors on practices they learnt before I was born? Who am I to say that this model of care goes against everything I’ve been taught about evidence based, women centred care?  

Well, it’s 1 week down and one to go. Placement has been interesting. I’ve now seen two births!! Woo! Neither I can write about right now because my hand is too sore to unstrap and type, but I have lots of notes and will write about them when I can. One was a ventouse delivery and the other a c-section so I’ve seen a variety on "normal" but no normal births. I have another week to go, and then a few days of study, a test, two exams and another assignment to do and it’s over for this semester. I got a HD (high distinction, 91%) for one assignment, and a C for the other (credit, 70%). I can’t get a straight answer from anyone as to why I can hand up two assignments and get such different marks. From the fact that some of my classmates failed the essay despite writing good ones and getting no feedback on what’s wrong, I wonder whether there’ll be moderation of the marks.