Science & Sensibility

New research was published in the American Journal of Obstetrics and Gynecology. Katherine Laughon, MD, and her colleagues, D. Ware Branch, M.D., Julie Beaver, M.S, and Jun Zhang, Ph.D., M.D., (2012) examined differences in childbirth labor patterns over the past fifty years, comparing data from a large study in the 1960′s with data from a large study in the 2000′s.

The researchers found differences both in maternal characteristics and obstetric practice patterns. In the contemporary cohort, the authors found an increase in first stage labor of over two hours and a cesarean section rate four times as high as in the past cohort. In the cohort from the 1960′s, a higher operative vaginal delivery rate was found as compared to the contemporary cohort. The authors link these differences to changes in obstetric practice patterns. The authors state that even after controlling for maternal and obstetrician characteristics, the increased length of labor result for the contemporary cohort persists (Laughon, Branch, Beaver and Zhang, 2012).

Positive Action Items for Moms and Childbirth Educators

The National Institute of Child Health and Human Development (NICHD)ran a conference call on March 31, 2012, where Katherine Laughon, MD, the lead researcher on the study, gavea brief overview of the study and answered questions. Robin Elise Weiss, LCCE, was on the call and summarized Dr. Laughon’s positive steps to take by women and childbirth educators who are interested in natural childbirth. Dr. Laughon’s suggestions fall into Lamaze’s Six Healthy Birth Practices.

• These women might be comfortable waiting longer to get pitocin and other interventions, including cesareans.
• Choose your practitioner carefully. Dr. Laughon suggests a practitioner should be able to think about the differences in labor patterns in modern times, not from textbooks.
•  Remember there is not an ideal length of labor, long or short. It is based on the individual, woman to woman and baby to baby.

 As a Lamaze childbirth educator, do the results of this study surprise you?

What does this mean to you and the families you serve?

Below is a synopsis of the study methods, statistics and conclusions.

Study Design: Comparing Data from the 1960′s to Data from 2000′s

The researchers compared the data from the National Collaborative Perinatal Project (CPP) dating from 1959 – 1966 to the data from the Consortium on Safe Labor (CSL), dating from 2002- 2008. Data from a combined total of 137,850 women from the two studies were included in the 2012 study.

National Collaborative Perinatal Project (CPP) 1959-1966

The CPP (1959-1966) was a prospective study following 54,000 births to 44,000 women. Twelve university centers across the country enrolled pregnant women and collected data such as demographics, medical history, socioeconomic status, behaviors, blood samples, and information from regular physical exams, did interviews and gathered information from the senior obstetrician. The children were followed for seven years after birth. Laughon and her colleagues (2012) limited the use of the CPP data to only women known to be birthing for the first time. Thus, the 2012 study included data from 39,491 women from the CPP study.

Consortium on Safe Labor (CSL) 2002-2008

The CSL (2002 – 2008) was a retrospective cohort study of 228,668 births, with the majority of births (87%) occurring between 2005 and 2007. Information was examined from 12 clinical centers and 19 hospitals in 9 American College of Obstetrics and Gynecology (ACOG) districts. Data was extracted from both the electronically held maternal medical files and neonatal intensive care units. Data on demographics, medical history, maternal and neonatal outcome, and discharge disposition were extracted from the electronic files. Investigators at delivery sites collected information on obstetrician characteristics. Laughon and her colleagues (2012) limited their use of the CSL data to only those women in spontaneous labor with a single gestation. Thus, the 2012 study examined 98,359 women from the CSL study, inclusive of a total of 137,850 women from both the CPP and CSL dataset.

Results: Differences in Characteristics of the Women

Characteristics of the women, of their labors and of their newborns differed significantly between the earlier CPP and the contemporary CSL study.

Women in the CSL were older than in the CPP (26.8 years vs. 24.1), had a higher average BMI both pre-pregnancy (26.3 vs 24.1) and at delivery (29.9 vs 26.3), were more racially diverse, and delivered an average of 4.9 days earlier. Their babies weighed an average of 99 grams (3.48 ounces) more and Apgar scores were higher in the CLS than the CPP.

Results: Differences in Practice Patterns

Use of epidurals (55% vs. 12%), oxytocin (44% vs. 12%); and cesarean delivery (12% vs. 3%) was higher in the contemporary CSL cohort than the CPP. Cesarean delivery in the contemporary cohort is four times as high as in the 1960′s cohort.

Episiotomy (68% vs. 17%) and operative vaginal delivery (40% vs. 6%) were higher in the 1960′s CPP cohort than the contemporary CSL.

Results: First Stage – Differences in Length of Labor

For nulliparas, the first stage of labor (from 4 cm to completely dilated) was 2.6 hours longer in the contemporary cohort (CSL) than the former cohort (CPP).

For secundagravidas and multigravidas, the length of labor was, on average, 2.0 hours longer for the CSL cohort than the CPP cohort.

Results: Second Stage – Differences in Length of Labor

For nulliparas, in the second stage of labor, in the CLS cohort, there was a 10% operative vaginal delivery rate compared to 66% of the CPP cohort. Among women who spontaneously delivered, there was an increase of 27 minutes in the CSL group as compared to 13 minutes in the (CPP group.

Operative vaginal delivery, in secundagravidas and multigravidas, occurred in the CSL 4% and 2.5 % compared to 36% and 18% in the CPP. In secunagravidas and multigravidas, second stage labor did not have a clinically relevant difference in length of labor between the two groups.

Conclusion

The authors state firm conclusions merit further study.

In summary:

“…for women who presented in spontaneous labor at term, the duration of labor from 4 cm to 5 cm in multiparas to complete dilation and the 2^nd stages of labor were longer in the contemporary population than a cohort from the 1960s. The overall median differences in the first stage of labor persisted after controlling for maternal and obstetric characteristics, indicating that modern labor differs from the older cohort largely due to changes in obstetric practices. Since labor times are longer today than in the past,the benefit of extensive interventions such as oxytocin and cesarean delivery in modern labor management needs further evaluation.”(Laughon, Branch, Beaver and Zhang, p. 14).

Hopefully this study will generate increased study of obstetric intervention patterns with an eye towards improved contemporary obstetric process management.

References

Laughon, S.K., Branch, D.W., Beaver, J., Zhang, J., Changes in labor patterns over 50 years, American Journal of Obstetrics and Gynecology (2012), doi: 10.1016/j.ajog.2012.03.003.

Many thanks to Robin Elise Weiss, LCCE, who graciously helped out with her reporting expertise on this post!

Kathy Morelli Cesarean Birth, Childbirth Education, Evidence Based Medicine, Practice Guidelines, Research ACOG, cesarean, epidurals, Healthy Birth Practices, interventions, Kathy Morelli, lamaze

The headline on a recent BBC News health article reads: “Planned repeat C-sections ‘safer.’ The article goes on to report on two studies that appear to support that conclusion, but do they really? Let’s see what the article says and follow with a look at the actual studies.

One of the studies, the BBC News article tells us, is a U.K. study of 159 cases of uterine rupture in which 139 occurred in women with a prior cesarean. The risk of scar rupture in women with a prior scar, it reports, was seven times greater in women having VBAC labors compared with women planning repeat cesareans, and the risk of the baby dying was three times higher.

That would seem to make a clear case for elective (no medical indication) repeat cesarean (ERC), but if we turn to the study itself, we find that the risk of scar rupture in a VBAC labor was 2 per 1000 VBAC labors versus 0.3 per 1000 planned repeat cesareans, or roughly 2 more scar ruptures per 1000 VBAC labors, not the large difference that “seven times greater” suggests. Moreover, the likelihood of scar rupture was influenced by modifiable factors. The use of prostaglandin, oxytocin, or both for initiating or augmenting labor increased the risk without improving the VBAC rate. In fact, misoprostol was the induction agent in 18% of induced women experiencing scar rupture, but none of the women not having scar rupture were given this agent. ACOG’s 2006 induction guidelines for VBAC labors prohibits using misoprostol because of its strong association with scar rupture. Furthermore, study authors theorize that one reason the scar rupture rate was so low in their study compared with some others was because double-layer uterine suturing, another modifiable practice, is the norm in the U.K..

As for VBAC labor tripling the rate of perinatal (intrapartum + neonatal) death compared with ERC, the study doesn’t give us this number (or maternal morbidity or mortality rates either, for that matter). The study actually only reports maternal and perinatal outcomes in the population overall, which included 20 women with rupture of an unscarred uterus, an event that may be more likely to produce severe adverse outcomes than a scar rupture. In addition, some of the neonatal deaths in women with prior cesarean may have been in women having emergent nonlabor cesareans. For example, three women had a scar rupture in conjunction with placenta previa. The extensive NIH systematic review  of VBAC reported that 6% of babies died as a result of scar rupture in a VBAC labor. We can use that number to calculate the odds of a baby dying in a VBAC labor in the U.K. study by multiplying it (0.06) by the U.K. study’s scar rupture rate (0.002). The result equals 0.00012 or 1 perinatal death per 10,000 VBAC labors. To be sure, every death is a tragedy, but we must also put this into perspective: that mortality is equivalent to the maternal mortality rate with ERC, which is 3 per 10,000, and much less than the fetal loss rate as a result of having an amniocentesis, which one modern-day study found to be 60 per 10,000.

The other study, according to the BBC News article, is an Australian study  of more than 2000 women planning their second delivery after a first cesarean. The BBC article states that the planned VBAC group had more stillbirths, and women were more likely to have severe bleeding, but gives no numbers.

Again, let’s turn to the actual study. The two planned VBAC deaths were unexplained fetal demises in infants born at 39 weeks, the implication being that ERC before that gestational age would have averted them. Perhaps they would have, but as the study  I analyzed in another blog post found, ERC at 39 weeks would have prevented only two of the six antepartum deaths.

The excess in severe hemorrhage (defined as > 1500 ml or transfusion) amounted to 1.5 more instances per 1000 VBAC labors, again, a small absolute difference, and a difference, moreover, that probably would have favored planned VBAC had not so few women had vaginal births. Maternal morbidity mostly occurs in labors that end in intrapartum cesareans, and the VBAC rate in this study was a dismal 43%. With physiologic care, the rate could have been as high as 81%. Even with typical management, studies have reported rates ranging from 61-72% in women with no prior vaginal births. In any case, however worrisome at the time, no differences were found in permanent sequelae such as hysterectomy.

And there is more: neither these studies nor the BBC news article considers the downstream consequences of accumulating cesarean scars, but they should. Even women who plan no more children may change their minds or continue with an unplanned pregnancy. According to the NIH systematic review, as the number of cesareans rises so does the risk of serious neonatal and maternal morbidity and perinatal mortality. By contrast, once a woman has a VBAC under her belt, so to speak, she is almost certain to go on having uneventful VBACs. Also, the review found that the risk of forming dense adhesions (internal scar tissue) rises with number of cesareans as well, thus increasing the likelihood of chronic pain and making any future abdominal surgery, not just future cesareans, more risky and difficult. Add these considerations into the mix, and the balance tips toward planning VBAC as the safer option for almost all women.

Headlines and articles like the one from the BBC News obstruct informed decision making by obscuring the true degree of comparative risk, and the studies contribute by failing to emphasize that better labor management in the previous delivery and current labor would improve outcomes. Planned VBAC is not without risks, but neither is ERC. Women deserve accurate, complete, and, most importantly, quantified information on which to decide on mode of birth after a cesarean. They also should have care in the primary cesarean that promotes safety in future VBACs and care in VBAC labors that promotes safe, healthy vaginal birth. To do less than that does women and their babies a serious disservice.

Henci Goer Cesarean Birth cesarean

Last month yet another study appeared reporting that compared with first vaginal birth, first cesarean increased the likelihood of late antepartum fetal death in the next pregnancy. The study encompassed 10,712 women with one prior birth who had pregnancy duration of 34 weeks or more and were carrying a single, normally-formed fetus. With first delivery via cesarean (22%), the fetal death rate at or beyond 34 weeks’ gestation in the next pregnancy was 2.5 per 1000 compared with 0.5 per 1000 with first birth vaginally, or 2 more late antepartum fetal deaths per 1000 with first delivery via cesarean surgery.

I say “yet another study” because it joins eight others. Six of the eight, one each in Scotland, England , Germany, and Canada and two in Australia, one in South Australia and the other in New South Wales, also reported more late fetal deaths with first cesarean delivery. In two of them, the difference failed to achieve statistical significance, meaning the difference may have been due to chance, but the number of women having a first cesarean was too small to reliably detect a difference. A third study among the six did not perform a significance calculation. The seventh study, conducted in Missouri,  reported an excess among black women but not white women. Mortality rates varied substantially from study to study, but excesses with prior cesarean were similar, ranging from 0.3 to 1.6 per 1000 (mean 1.1 per 1000). The eighth study, a U.S. national study , reported no difference (0.7 per 1000 first cesarean delivery vs. 0.8 per 1000 first birth vaginal) in women with one prior birth, no underlying medical conditions, and a fetus with no structural or chromosomal abnormalities. The gap actually may be wider than appears. Some of the studies restricted analysis to unexplained deaths, which excluded deaths secondary to placenta previa, and accreta and placental abruption, all of which are associated with prior cesarean.

The consistency of this finding is compelling, but you may be thinking that it shouldn’t be surprising because some of the reasons that may lead to cesarean in the first pregnancy would increase the risk of fetal demise in the next pregnancy. Ah, but unlike the other studies, which used population databases, this one was conducted at a single hospital, which means investigators could explore the effect of confounding factors. They found that the association remained statistically significant after controlling for maternal age, height, weight, hypertension, and diabetes, and it strengthened when they confined analysis to women known to have first births to a full-term live infant (n = 4425): 6 per 1000 with first delivery by cesarean versus 1 per 1000 with first birth vaginal, or 5 more late antepartum deaths per 1000 in women with first cesarean delivery in this subgroup. The cause of the excess is unknown, but it would appear that a scarred uterus becomes a less hospitable environment for pregnancy.

Certainly, this risk should not deter performing a cesarean when the health of mother or baby is at stake or everything has been tried, but it seems unlikely that the baby can be born vaginally. However, with one in three first time mothers delivering via cesarean surgery, for many cesareans, clearly, this is not the case. Many cesareans could be prevented with better labor management and by having more patience. As the ninth study concludes, “Our findings reinforce the importance of considering the impact cesarean birth may have on future pregnancies when making decisions regarding method of birth” (p. 16). Amen to that.

Henci Goer Authoritative Knowledge, Cesarean Birth, Guest Posts cesarean, interventions

[Editor's Note: This is the last in a series of three posts by Dr. Michael Klein regarding the research behind risks, benefits and realities of epidural analgesia.  To read Dr. Klein's first two posts, go here and here.]

Not all women are alike in labour and delivery:
Because the experience of labour pain, including severity, tolerance and contraction patterns, differs greatly among women, so does their ability to cope with the labour process.  In consequence, some women feel the need to receive epidural analgesia prior to the onset of active labour.  In some cases, the use of an early epidural will relax a woman enough to help her labour progress to the active phase and thereby lead to less subsequent medical interventions.  However, if used early without specific indications, a woman may find herself exposed to a larger range of interventions, including a caesarean birth.

Dealing with the reality of the labour ward:
Given this paradox and the severity of some of the side-effects of epidural analgesia, it is time to be honest about the full effects of this excellent technology: there is no such thing as a side-effect. There are only effects, some of which we like and some of which we don’t. When epidurals are used specifically to problem-solve, the risks of complications and other interventions are in fact reduced. When used routinely and mindlessly, epidural analgesia increases problems and adverse outcomes. Women need to be fully informed of this before agreeing to an epidural. Today, women are usually only informed of the direct consequences of epidural analgesia, such as a headache or even very rare neurological complications, but they are not often informed of the consequences that can occur if epidurals are given routinely or too early. They are rarely told about the potential deleterious effects of an epidural on the woman’s labour, nor the cascade of other interventions that might ensue. They are unlikely to be informed that an epidural will increase the demand on their nurse to pay greater attention to the technology and in consequence provide less hands-on support for the labouring woman. They are unlikely to be made aware of an epidural’s purported interference with the initial success of implementing breastfeeding following the baby’s birth.

Epidural analgesia is clearly an effective form of pain relief but it can also have less desirable consequences. Women need to be accurately and completely informed of their choices for pain relief in labour before they can provide their true consent. No matter how well intended, epidural analgesia increases the likelihood that women will have a variety of other interventions, especially if the epidural is given without specific medical indication. Women need to know that when epidural analgesia is given before the active phase of labour, it more than doubles the probability of a cesarean section.

The importance of timing and setting:
Women also need to be reassured that when epidural analgesia is given in the active phase of labour, it does not increase the cesarean section rate. This may motivate women to use other pain relief modalities and methods to help them, if possible, get to the active phase before requesting an epidural.

Readers of the literature also need to remember the importance of setting when reading about the research on epidural analgesia and any other interventions. All the statistics and outcomes that have been discussed here are in fact specific to the setting or environment from which the individual study or meta-analysis emanate. It is important to remember that adverse effects of epidural analgesia can be mitigated, especially if the setting generally limits the use of interventions. It appears, for example that in settings with low cesarean section rates (below 10%), even early epidurals do not increase the cesarean section rate,(21) but in more typical settings where cesarean section rates are higher than 20%, it does. This illustrates a general principle: For all studies, randomized or not, the reader needs to ask the question: do the caregivers in the studies practice the way that I do? If they do, the study may apply but if not, they may not.

The bottom line is that epidural analgesia has completely transformed birth. This massive change in the way that many women receive care in labour and birth has been based on a technique that, when used selectively and as a back-up tool or second line approach, is an important and valuable technique, among the many ways of assisting women with labour and birth. However, when used routinely as a first line agent, epidural analgesia can create problems that could have been avoided. Our Canadian National Study of the Attitudes and Beliefs of Maternity Care Providers has illuminated the very different ways that different disciplines view birth. (22) Most Canadian younger obstetricians (23)and women approaching their first birth (24) do not even know that epidural analgesia interferes with labour. The older generation of obstetricians knows that it does. They have experienced the changes related to epidural analgesia availability and usage during their many years in practice before and after the common use of epidural analgesia. It is time we told the truth about epidural analgesia – to colleagues and women – and engaged in a truly informed decision-making discussion with women about the optimal use of epidural analgesia.

References for this entire series of posts can be found here: References _ michael klein post

Post by:  Michael C. Klein, MD, CCFP, FAAP(Neonatal-Perinatal),FCFP, ABFP
Emeritus Professor of Family Practice and Pediatrics
University of British Columbia
Senior Scientist Emeritus
Centre Developmental Neuroscience and Child Health
Child and Family Research Institute
4500 Oak Street
Vancouver, V6H 3N1
Tel: 604-875-2000 ext 5078
Fax: 604-875-3569
Email: mklein@interchange.ubc.ca

Michael Klein MD Epidural Analgesia, Evidence Based Medicine, Practice Guidelines, Research, Science & Sensibility, Uncategorized benefits of epidurals, cesarean, epidural analgesia, epidurals, epidurals in active labor, how epidurals have transormed birth, interventions, labor and delivery pain relief, Michael Klein MD, pain, Practice Guidelines, risks of epidurals, Understanding Research

Whether a woman is having her first baby or has already given birth, whether she is sitting in a prenatal appointment or in the midst of labor, if she is pregnant in the United States, there’s at least a 1 in 3 chance she will find herself hearing some version of the words, “You are going to need a c-section.”

Sometimes those words are spoken and heard with clear knowledge that cesarean is the only reasonable and safe option – a complete placenta previa or severe fetal distress in labor, for instance. But does every woman who hears these words really need a cesarean?  What if it’s a labor that seems to be going nowhere, or a fetal heart rate pattern that is not entirely reassuring, or something in the woman’s medical history that increases her risk slightly?

In these gray area cases, non-medical factors tend to influence decision-making. On the doctor or hospital side, it may be fear of malpractice, financial incentives, protocols, or impatience. On the woman’s side it could be her knowledge and values, her plans for future pregnancies, her own tolerance for risk, and her physical condition and support network that may profoundly affect postoperative recovery.

All “nonmedical factors” are not alike, however. Evidence suggests that factors on the physician and hospital side are exerting a much stronger influence than factors on the woman’s side.

How to correct this imbalance? Enter two new woman-centered tools to assist decision-making around cesareans.  I’m honored to have been involved in the development of both.

Just launched is a new resource from California Watch, a project of the Center for Investigative Journalism.  California Watch conducted an independent review of birth records from California hospitals and showed for the first time that for-profit hospitals have significantly higher c-section rates than not-for-profit hospitals, even when they are serving similar populations. As a companion to a powerful article that explains the findings, California Watch produced a set of “React and Act” tools that are available on their web site, including an open-access database of hospital c-section rates and related outcomes, an expert Q&A (with yours truly as the featured expert), and downloadable primers in English and Spanish for women to print and bring with them to their care provider’s office, childbirth class, or hospital tour.

Also, if you haven’t already heard, Lamaze launched another consumer primer earlier this week.  A Woman’s Guide to VBAC: Navigating the NIH Consensus Recommendations addresses the most common and pressing questions women face when considering or planning a VBAC and all of the content is derived from the NIH Consensus Conference that was held last spring. It breaks down into understandable language the pros and cons of planned VBAC and planned repeat cesarean, how to make sense of prediction models and candidacy for VBAC, how the risks of VBAC stack up to other obstetric risks, the history of hospital “VBAC bans” and how to challenge them, the critical gaps in the research and how to make choices in spite of them, how to discuss options with a care provider, women’s legal rights and protections, and how to take action to improve VBAC access at the community level. (This resource is web-only for now, but we hope to have printed or print-friendly versions available very soon.)

Please pass these important tools to women and I’d love to hear from readers about how they can be incorporated into childbirth classes.

Amy Romano Uncategorized cesarean, Childbirth Education, practice variation, transparency, VBAC