ConseNsus DEVELOPMENT CONFERENCE ol Geren Chieosiai DRAFT REPORT OF THE Task FOrRce oN CESAREAN CHILDBIRTH U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES PUBLIC HEALTH SERVICE NATIONAL INSTITUTES OF HEALTH Preface This draft report was prepard by a Task Force supported by a contract from the National Institute of Child Health and Human Development, National Institutes of Health (NIH), Bethesda, Maryland. Its purpose is to serve as a working document for discussion at a Consensus Development Conference on Cesarean Childbirth at the NIH on September 22-23, 1980. Comments on it from interested parties, orally or in writing, are invited at or prior to that conference, following which a revised final version will be prepared. Detailed information on this conference and how to present comments appears on the following page. \ J XDA 1685 PUBL / i we - Peders] Recister / Vol 45, Noo 128 / Tueeeceov, Tulv 1, 1856 / Notices 44403 ala] National Institute of Child Health and Human Development; Lieeting Notice is hereby aiven that th» National Institutes of Health Consensus Development Conference on Cesarean Childbirth will be held on September 22- 23, 1920 in the Masur Auditoriun, Clinic::! Center, National Institutes of Heweh, Bethesda, Maryland. The conference is sponsored by the National Institute of Child Health and Human Development in conjunction with the National Center for Health Care Technotogy and assisted by the Office for Medical Applications of Research, The conference will convene at 8:15 a.m. on September 22 and 10:00 aan. on September 23 und will be open to the public. Attendance will be limited to space « vailable. One Hf a series of NIH consensus develonment conferences, this conierence will consider the medical, psyche cgical, ethical, social, lezil, and econoriic issues concerning childbirth by cesirean section as currently practic: 1; contemporary guidelines for performance of cesarean delivery; and the nee tor ¢ ditional research, A wa Jtidisciplinary Task Force on Cesare in Childbirth is preparing a draft repoit and recommendations on these issues. Advance copies of the draft repart vill be available {rom the NICHD (addres below) by August 5, 1960. Interesiad groups or individuals are encouraged to corunent on'the draft report «1 writing to the NICHD by Septenber 19 and/or present their views at the conference. Those planning to make an oral presentation at the conference must file a written statement or detailed summary of their presentation with the NICHD before 5:00 p.m. EDT on September 19. Speakers will be scheduled in order of ol 9) | C RG 7¢r1 receipt of their written stateraent of A summary. Whenever statistical data are C GG presentzd in support of a position, appropriate reference to the scientific 5 literature should be included. T3 7 Each speaker will be allotted approx.mately 5 minutes, although more / g RO time may be available depending upon the number of scheduled speakers. It will b> the prerogative of the Chairman Cup L to extiid or terminate oral testimeny and to direct interchange belwecn speakes and Task Force members. The draft report of the Task Force will be presented at the conference on Septen ber 22, followed by oral comments and discussion. Written and oral comments and discussion at the conference will be used by the Task Force to prepare a final consensus staterient which will be presented orally on September 23, and a final full report for publication by the NICHD. Statements received after the meeting cannot be considered by the Tusk Force in preparing the final report, A press summary of the final consensus statement and recommendations will be available on the las« day of the conference, and full summaries of the conference will be published in the professional literature. Inquiries about the conference, requests for Task Force reports, and written tater ents and summaries should be addireceed to Par Diiscoll or joan Muller, Office of Research Reporting, NICHD, Building 51 Room 2A-32, Bethesda, Maryland 29208. Telephoe number: (301) 466-5133. Dated: {une 23, 1550. Suzanne . Fremeau, Committe e Management Officer, NIH. [FR Doc. 80-966 Filed 6-30-80; B45 am) BILLING CC OE 4110-08-M i ESARIAN CHILUBIRTR | — (eH | 48 Pub) MEMBERS TASK FORCE ON CESAREAN CHILDBIRTH Mortimer G. Rosen, M.D. Chairman Professor, Department of Reproductive Biology Case Western Reserve University Director, Department of Obstetrics and Gynecology Cleveland Metropolitan General Hospital Cleveland, Ohio Milton H. Alper, M.D. Associate Professor of Anesthesia Harvard Medical School Anesthesiologist-in-Chief Boston Hospital for Women Boston, Massachusetts Randall Bloomfield, M.D. Director, Department of Obstetrics and Gynecology Kings County Hospital Center Brooklyn, New York Robert C. Cefalo, M.D., Ph.D. Acting Chairman and Professor of Obstetrics and Gynecology University of North Carolina School of Medicine Chapel Hill, North Carolina Tiffany Field, Ph.D. Associate Professor of Pediatrics and Psychology University of Miami School of Medicine Mailman Center for Child Development Miami, Florida Jean Guillemin, Ph.D. Associate Professor of Sociology Boston College Chestnut Hill, Massachusetts Robert B. Hilty, M.D., F.A.C.O0.G. Chairman, Department of Obstetrics and Gynecology Kettering Medical Center Practicing Obstetrician-Gynecologist Dayton, Ohio Melita Jordan, C.N.M. Department of Obstetrics and Gynecology Pennsylvania Hospital Philadelphia, Pennsylvania Barbara F. Katz, J.D. Associate Counsel University of Massachusetts Boston, Massachusetts Luella Klein, M.D. Professor of Gynecology and Obstetrics Emory University School of Medicine Grady Hospital Atlanta, Georgia Nicholas M. Nelson, M.D. Chairman, Department of Pediatrics Milton S. Hershey Medical Center Pennsylvania State University Hershey, Pennsylvania Diana Petitti, M.D. Epidemiologist Department of Medical Methods Research Permanente Medical Group Oakland, California Jack Provonsha, M.D., Ph.D. Professor of Christian Ethics Loma Linda University Loma Linda, California Sam Shapiro Professor, Health Services Administration Director, Health Services Research and Development Center Johns Hopkins School of Hygiene and Public Health Baltimore, Maryland Beth Shearer C/SEC, Inc. Chestnut Hill, Massachusetts Michael Simmons, M.D. Associate Professor of Pediatrics and Obstetrics Co-Director, Newborn Services Johns Hopkins University School of Medicine Baltimore, Maryland Judith Wagner, Ph.D. Senior Research Associate Urban Institute Washington, D.C. Annette Warrenfeltz, M.D. Family Practitioner Quincy, Pennsylvania Peggy Whalley, M.D. Professor of Obstetrics and Gynecology University of Texas Southwestern Medical School Dallas, Texas NICHD Liaison Duane Alexander, M.D. Assistant to the Director, NICHD James G. Hill Director, Office of Planning and Evaluation, NICHD NCHCT Liaison Holly Atkinson, M.D. Health Science Analyst Medical and Scientific Evaluation Staff, NCHCT SECTION Chapter Chapter Chapter Chapter Chapter Chapter SECTION Chapter Chapter Chapter SECTION Chapter Chapter Chapter Chapter Chapter Chapter Chapter Chapter SECTION Chapter Chapter SECTION Chapter Chapter Chapter SECTION Chapter TABLE OF CONTENTS I - INTRODUCTION I An Overview to the Task Force Report on Cesarean Childbirth....cccveeeenen ER ESR II A Description of the Cesarean OperationS.....cceeeeess III Cesarean Births: A Historical Overview......... over Iv Fetal Considerations ssssassves svn snrsnnvmrsnsy I Vv Other Methods for Studying the Changing Trends in Cesarean Birth Rates...... FER ERR RERR ESE TR VI An Overview of the Additional Issues to be Presented.. II - EPIDEMIOLOGIC INFORMATION RELATING TO CESAREAN BIRTH VII Canadian and Western European Experienc€.............. VIII The National Experience..... 0 IX The New York City Experience.ssssevensrssnsnnvvavvenns IIT - MEDICAL, OBSTETRICAL AND NEONATAL PROBLEMS X Maternal Mortality and Morbidity....cceeeeeeeninnnnne. XI Anesthesia.eeeeeeceeereceenees SE "Re XII Neonatal RDS..ssssvesvinecsnessassinssncns Sink res nw PE XI11 Dystocid.eceisssesecenccssse .% wine cess NNER te XIV Repeat Cesarean Birth............. 0 0 LW XV The Problem of the Breech Presentation..... DEE OBEN XVI Fetal Distress..ivicecettieeeessscennssncnnsssnncnnnnns XVII Other Maternal and Fetal Indications for Cesarean Birth............... AE RO LS IV - BEHAVIORAL STUDIES RELATING TO CESAREAN BIRTH XV111l CEffects on Mother and FamilYssssveersrsvenns vuveonvenns XIX Effects on Infant Development......ceevvve..n.. eve. w en V - OTHER ISSUES RELATING TO CESAREAN BIRTH XX Ethical ConcernNSicecessnessovssmsrnsssnse WEE XXI Medicolegal ConcernS....eeeceeees ERY EC ARGC ORRRS ECOG XXII Economic ConCerNS...cceeececess CRAMER A BEER SOE VI - SUMMARY AND TENTATIVE CONSENSUS CONCLUSIONS AND RECOMMENDATIONS XXIII Summary and Tentative Consensus Conclusions and RecommendationS..ceeececescesess SEE 21 3) 45 57 529 PREFACE A BACKGROUND FOR UNDERSTANDING THIS REPORT When any medical practice changes, it is critical to understand not only the reasons leading to the change, but also whether improved patient outcomes result from these changes. Thus the central purpose pursued by this Task Force is to evaluate effects on patient wellbeing as influenced by the increase in the number of operative births. However, at the outset, it is important for the reader to understand some of the complexities of this issue. Although the cesarean birth* may be described as a single operative procedure, it is a single procedure which is used for many reasons. In comparison, and as an example, we may look at the surgical procedure, the appendectomy. In almost all cases that single operative intervention is used in order to eliminate a single pathological event, infection of the appendix. The results of acute appendicitis are well known and may be lethal if an appendectomy is not performed. While this analogy can be carried further, for our purposes, we note a single illness is treated with a single intervention. In the case of cesarean birth, the single illness system is replaced by an incredibly more complex system. Pregnancy-related illnesses which may result in cesarean births affect two distinct patients - mother and fetus. This single operation is the endpoint intervention reflecting back on the entire discipline of obstetrics, and is performed for an almost endless number of diagnoses whose outcomes without surgical intervention are not always clear. At times in this two patient obstetrical system, * Throughout this report the words "cesarean birth" will be used in place of cesarean section. The reasons for this are described in Chapter III, A Historical Overview. the performance of a cesarean for maternal reasons may not benefit the fetus or neonate. The reverse situation may also occur.As will be seen, not only is the fetus a second consideration, but fetal development in utero changes rapidly over short time periods. The fetus is not in a steady state as is the adult. Changes in growth and maturation make evaluating fetal health even more complex. Thus the decision to perform this operation and the evaluation of the outcome are not as simple as in the analogy with the appendectomy. A second caution is also offered to the reader. This draft report is not meant to be a textbook for obstetrical or neonatal care. That is what the entire body of medical literature exists for. The medical literature represents the efforts of thousands of people over their lifetimes. This draft report represents the efforts of a small group of people working on a project begun in October of 1979 and completed to this stage in July of 1980, with additional revisions to be made in September of 1980. This draft report also represents a response to a public concern and a need for information exchange. Therefore it is written not only for review by professional health care providers, but also for review by the interested general public. In editing the report an attempt has been made to meet the needs of this very broad audience. In the introductory section, we will present the problems to be discussed in more detail later in the report: the issues of concern, the background relating to cesarean birth, its historical development, the recent upward trend in cesarean births, and the social and technologic changes that related to this increase. The issues examined will include not only the maternal and fetal medical aspects of cesarean births, but also the ethical considerations of two patients and their rights to medical care; the legal issues relating to mother, child and physician; the economic issues of concern to both individuals and society; Wr the psychological and social impact of the cesarean birth upon mother, infant and father. ACKNOWLEDGEMENTS It is important to, at the very least, mention the many people without whose help this Task Force could not have worked effectively. Mrs. Gladys Stowell is singularly thanked for her dedicated support and efforts, working days, nights and weekends. Without her tireless concern and efficiency, this report could not have been completed. Many members of the staff of The Department of Obstetrics and Gynecology at Cleveland Metropolitan General Hospital supported me while I took the time to work on this report. Several who assisted us in information gathering included Dr. Robert Sokol, Dr. Yoram Sorokin, Dr. Sidney Bottoms, and Dr. Donald Barford. In addition, Mrs. Anne LaGania held our departmental office together while Mrs. Stowell and I were writing. Other very important persons or agencies must be acknowledged. These include the staff of the National Institute of Child Health and Human Development for their efficient arrangements, data collection, and advice; Ms. Charlotte Kenton of The National Library of Medicine, for conducting the initial literature search; Paul Placek, Ph.D., of The Natality Statistics Branch, Division of Vital Statistics, National Center for Health Statistics, for furnishing that center's national data; Dr. Schuyler Kohl, for providing data from The Obstetrics Statistical Cooperative; and various officials from the military services, CHAMPUS, the dian Health Service, and the Public Health Service, for providing their data on cesarean birth rates. I must also most gratefully acknowledge the use of the New York City data on births. This information, and its use, was made available in an efficient form by Dr. Reinaldo A. Ferrer, Commissioner of Health, New York City. The use of the data was supported and interpreted in an unstinting manner by Dr. Jean Pakter, Director of the Bureau of Maternity Services and Family Planning in The New York City Health Department, and Barbara Crawley, who also assisted in the development of that information. To the many health officials in Canada, England, Wales, France, and the Netherlands who allowed us to study their available data, we express our thanks. Finally, the data collection resources of The Perinatal Clinical Research Center of The Division of Research Resources, Grant No. 5M01- RR-00210, were used to obtain information for this review. Mortimer G. Rosen, M.D. SECTION I - INTRODUCTION This represents an introduction to the cesarean birth rate problem. It is extensive and is divided into six chapters in order to provide all readers with a broad base of information important to understanding the problems Task Force. Chapter Chapter Chapter Chapter Chapter Chapter II 111 IV VI being addressed and the activities of the - An Overview to the Task Force Report on Cesarean Childbirth - A Description of the Cesarean Operations - Cesarean Births: A Historical Overview - Fetal Considerations - Other Methods for Studying the Changing Trends in Cesarean Birth Rates - An Overview of the Additional Issues to be Presented Chapter I - An Overview to the Task Force Report on Cesarean Childbirth AN OVERVIEW OF THE PROBLEM Described more completely in Section II - Epidemiology, but noted here at the beginning of this report, cesarean births in the United States have increased almost threefold, from 5.5% of all deliveries (195,000 operations) in 1970 to 15.2% (510,000) in 1978. 172 This increase in operative births has come during a period of time when many forces have been at work that may have brought the change about. Improvement in infant survival and in the quality of life for the surviving neonate has been a battle cry for the fetus at least since the early 1960's. Response to the crusade to improve the outcome of pregnancy is evidenced in part by the rise in the number and availability of neonatal intensive care units, the growth in new special interest areas of Maternal and Fetal Medicine and Neonatology, and the change in technology for maternal, fetal and neonatal care. These efforts have resulted in rapidly improved survival rates and long term outcomes for both the mother and the infant at risk. Today the majority of infants survive at birth weights between 800 and 1000 grams, or 30 weeks of life. Eight years ago, 80% of those infants would have died.’ This increased infant survival, particularly of the low birth weight infant, reflects more medical interventions, including the increased use of cesarean birth. Yet the contribution of the increased use of cesarean delivery to the falling mortality rate is difficult to assess. The overall cesarean birth rate is higher than one would expect from reviewing the frequency of operative intervention in the low birth weight infant alone. ? It is apparent that the majority of cesareans are being performed on infants in normal birth weight categories. FORMATION OF THE TASK FORCE ON CESAREAN CHILDBIRTH Recently officials at the National Institute of Child Health and ‘Human Development became concerned about the rising cesarean delivery rate in the nation. Concern focused on whether data were available to explain the reasons for the rise and to support the belief that the outcome of complicated pregnancies was improved by performing cesarean rather than vaginal delivery. With an increasing proportion of women and infants undergoing cesarean delivery, with whatever attendant morbidity and cost that entailed, it was considered important that the reasons for cesarean delivery be soundly based and supportable by evidence gathered from research. Therefore the Institute decided to hold a consensus development conference on cesarean childbirth. The American College of Obstetricians and Gynecologists, likewise concerned with the rising cesarean delivery rate, strongly encouraged the Institute to hold such a conference, and promised full cooperation in the effort. The National Center for Health Care Technology, having identified cesarean delivery as a priority topic for study, also encouraged the Institute to hold such a conference, and worked with the NICHD to develop it. The National Institutes of Health (NIH) initiated the consensus development process in 1977 as one mechanism to fulfill its responsibilities for appropriate transfer of knowledge and technology developed in biomedical research to the clinical practice of medicine. The term "consensus" implies "agreement among all parties concernd about the soundness and feasibility of . . 5 ; g 3 new interventions." The development of a consensus begins with convening a group of health care professionals and other persons concerned with health care in the community to study a specific issue, and interact with other professionals who can provide value judgements in areas such as law, economics and ethics. The data gathered and their discussions and conclusions are shared with all interested health care professionals and the lay public in a public forum for comment and discussion. The process of consensus building is neither regulation, nor arbitration. The consensus development process may be invoked in assessing new technologies, or procedures already in use. Controversy may arise about the issues being studied in many areas, including the evaluation of beneficial or harmful effects, legal or moral issues, or costs. The consensus panel, after full consideration of the issue, presents areas in which there is consensus, areas in which consensus is not reached, the reasoning behind the statements, and the areas in which new information is needed. To gather and analyze data for the consensus conference and produce a set of draft conclusions and recommendations for discussion at the public meeting, the NICHD appointed a 19-member Task Force in the fall of 1979. Members were selected to provide expertise and viewpoints from the pertinent medical specialties as well as from the disciplines of law, ethics, psychology, sociology, and economics, and from public interests: The members were directed by NICHD to develop a report assessing the "state of the art" of management of childbirth by cesarean delivery. The report was to address the following questions: 1. How and why have cesarean delivery rates changed in the U.S. and elsewhere? 2. What is the evidence that cesarean delivery improves outcomes of various complications of pregnancy? 3. What are the medical and psychological effects of cesarean delivery on the mother, infant, and family? 4. What economic factors are related to the rising cesarean rate? 5. What legal and ethical considerations are involved in decisions on cesarean delivery? 6. What conclusions can be reached at present regarding (1) situations in which cesarean delivery generally produces a better outcome of pregnancy, and (2) ways to conduct cesarean delivery so that its medical and psychological risks are minimized? 7. What research is needed to clarify issues to provide a firmer basis for medical decision-making in the future? SOURCES OF INFORMATION » order to explore thoroughly the issues of importance underlying the change in cesarean birth rates, a large body of data was collected from many sources. A complete printout of the world literature relating to cesarean births was made by the National Library of Medicine and provided to the Task Force (and weighed more than ten pounds). Review of this literature, as well as some yet unpublished studies made available to the panel, constituted the major source of information for this report. In addition, the National Center for Health Statistics provided national data on cesarean births. The Public Health Service, Indian Health Service, and the military services all provided data on their cesarean delivery rates. The Commission on Professional and Hospital Activities, under a contract funded by The National Center for Health Care Technology, provided data from the Professional Activity Survey on the method of delivery employed when various complications of pregnancy were diagnosed in the years 1970, 1974, and 1978. Data on all births in New York City from 1968-1977 were reviewed to assess changes in obstetric practices regarding cesarean deliveries and changes in perinatal mortality. Data from The Obstetrics Statistical Cooperative were obtained to provide an assessment of maternal morbidity associated with cesarean birth. A report prepared for the Assistant Secretary for Planning and Evaluation (Health) of the Department of Health, Education, and Welfare by Helen Marieskind, Dr. P.H., served as a valuable reference and information source. These and many other data sources are cited in the references of the report. During 1979 and 1980 the Task Force reviewed the literature, obtained data from these new and previously unavailable sources, and finally debated the issues, not only from the physician's point of view, but also from the patient's perspective, and the health care needs of the country in general. This draft report represents the preliminary findings, conclusions, and recommendations resulting from these investigations and discussions. A final revised version of the report will be prepared after the September 22-23 Consensus Development Conference, incorporating additional material presented at that time and reflecting the final consensus of the Task Force. 1. 10 BIBLIOGRAPHY Petitti,, D., Olson, R.0., and Williams, R.L.: Cesarean section in California - 1960 through 1975. Am. J. Obstet. Gynecol. 133:391-, 397, 1979. Obstetrical practices in the United States, 1978. Hearing before the Subcommittee on Health and Scientific Research of the Committee on Human Resources, United States Senate, Washington, D.C. Govern- ment Printing Office, 1978. Kwong, Melinda: Cleveland Metropolitan General Hospital, Cleveland, Ohio. Unpublished data. Manniello, R.L. and Farrell, P.M.: Analysis of United States neonatal mortality statistics from 1968 to 1974, with specific reference to changing trends in major causalities. Am. J. Obstet.. Gynecol. 129: 667-74, 1977. Perry, Seymour: The Biomedical Research Community: Its place in consensus development. JAMA 239, 485-488, 1978. Chapter II - A Description of the Cesarean Operations 13 THE UTERINE INCISION The cesarean birth is not a single operative procedure. It is described here in order to avoid confusion in terminology and for a basis for understanding some of the technical operative terms used later in this text. The cesarean birth refers to delivery of a fetus weighing 500 grams or more, by surgery that requires an incision through the uterus. Below fetal weight of 500 grams, the procedure, although similar, is referred to as an abdominal hysterotomy. The cesarean operation is differentiated by the location and direction of the uterine incisions. Uterine incisions are divided into two major types - (1) Cervical - a transverse (Monroe-Kerr) incision or a vertical (Kronig-Selheim) incision in the lower uterine segment (above the cervix and behind the bladder). (2) Classical - a longitudinal or vertical incision in the uterine corpus (body of the uterus). When possible today, the Monroe-Kerr or low transverse incision is the most common and most preferred method for abdominal delivery. This incision is more frequently used because it has the lowest incidence of hemorrhage at the time of surgery and the lowest incidence of rupture in subsequent pregnancies. The low transverse incision requires that the urinary bladder peritoneum, and the bladder itself, be mobilized and displaced downward in order to expose the lower uterine segment. This type of incision may be covered by peritoneum at the end of the procedure and it is thought that because of this reperitonealization the incidence of intra-abdominal 14 infections or adhesions is decreased. At times, because of fetal problems such as size (very large or very small), or position (transverse or breech), or lack of space, or other maternal problems, a low vertical cesarean may be performed rather than a low transverse incision. As before, the surgeon attempts to place the incision in the lower portion of the uterus (which is less vascular) and beneath the bladder (which allows for it to be reperitonealized later). The incision is generally thought to be associated with more morbidity than the low transverse technique, but is still preferred to the classical cesarean. In the classical operation a vertical incision is made in the body of the uterus rather than in the lower portion of the uterus as described in the two previous operations. The incision allows a greater length for the surgical opening and more room for delivery of the fetus. It may be used in problems relating to the mother (e.g. the placenta covers the lower uterine segment) or, more often, problems relating to the size and the position of the fetus (e.g. a transverse fetal lie). This incision is associated with more bleeding at time of surgery and more intra-abdominal infections following surgery. All uterine incisions may rupture prior to or during labor (see Chapter X - Maternal Mortality and Morbidity and Chapter XIV - Repeat Cesarean Birth). By virtue of its location and lack of peritoneal coverings, rupture of the classical incision at any time is more likely to occur and more likely to result in morbidity for mother and fetus than the cervical incision. 15 THE ABDOMINAL INCISIONS In general there are two kinds of abdominal wall incisions. They should not be confused with the terminology relating to the uterine incisions. The abdominal incisions may be vertical in the skin and extend from umbilicus almost to pubis. All the underlying tissues are incised in the same vertical manner. In the second case, the incision may be transverse in the skin above the pubis and between the iliac crests. Depending on the kind of incision used beneath the skin, the rectus muscles may be separated and the fascia and peritoneum are incised vertically (similar to the vertical skin incision) or the rectus muscles, fascia and peritoneum divided transversely. Factors in choosing between procedures include rapidity and ease of performance (the vertical is faster), improvement in healing (still debated), diminished blood loss (vertical incision is generally less), and cosmetic reasons (the transverse incision generally heals with less obvious skin scarring, dehiscence and eviscera- tion). There are medical indications, such as maternal obesity and fetal size and position, that may also influence this choice. THE ACTUAL OPERATION In this instance the procedure described is the low transverse cesarean operation. Careful positioning of the patient on the operating table is impor- tant to prevent sudden hypotension which may occur from pressure on the abdominal aorta and the inferior vena cava. The abdomen is opened, as described, in layers and in a relatively rapid fashion. The abdominal cavity is inspected to note the degree of rotation of the uterus. 16 Laparotomy pads may be placed on either side of the uterus to reduce peritoneal soilage. The surgeon identifies the fold of peritoneum between the serosa of the uterus and the serosa of the urinary bladder. This portion of the peritoneum is elevated in the midline and incised. This allows entrance into the space between the bladder and the lower uterine segment. The bladder is then mobilized and displaced downward by blunt and sharp dissection of the peritoneum and sub-peritoneal tissues between the two organs. A small margin of peritoneum can be freed from the serosa of the uterus in the superior portion of the incision which will aid in the closure of the peritoneum following closure of the uterine incision. Now a transverse uterine incision is made with a scalpel into the muscle of the lower uterine segment. The fetal amniotic membranes may bulge into the uterine incision. The operator then inserts a finger between the membranes and the overlying wall of the uterus. Using a finger as a guide, the surgeon may use sharp dissection (insert the lower blade of the bandage scissors into the uterine wound) or blunt dissection (lateral traction with two fingers) and extend the incision laterally in a general upward curve. Once this incision has been com- pleted the uterus is open. The surgeon next inserts one hand beneath the lower edge of the uterine wound and under the fetal head. The head (vertex) can be flexed and brought through the uterine incision. The amniotic membranes may already have been, or may now be ruptured. As the vertex is brought through the incision, the assisting surgeon can exert uterine fundal pressure over the area of the fetal buttocks to assist in delivering 17 the fetal head through the incision. Once the head has been delivered, the newborn's mouth and nose may be suctioned with a bulb suction device as the delivery is completed. The fetal shoulders are delivered with gentle traction on the fetal head in a manner similar to that used for vaginal delivery, followed by delivery of the buttocks and legs. The infant is held in a head-down position to improve drainage of the mouth and nose and to reduce the chances of aspirating amniotic fluid or blood with his/her first breath of air. The mouth and nares are suctioned and the cord is clamped and divided. The infant is handed to a person in attendance. The surgeon now removes the placenta and membranes by manually separating them from the uterine wall. Oxytocin is added to the patient's intravenous infusion in order to stimulate contraction of the uterine wall, which assists in reducing blood loss. The cut edges of the uterine wall can be grasped with clamps for traction and compression of venous sinuses. The first layer of the uterine closure is usually with an 0 or #1 chromic catgut in a continuous locked stitch anchored securely at the angle of the uterine incision. In the second layer of closures another 0 or #1 chromic catgut in a continuous non-locked suture is placed in a manner as to completely cover the first layer of closure. In general, the more rapid the uterine closure, the less the blood lost during the operation. Average blood loss following cesarean birth is felt to be about 1000 cc's, about twice that of a vaginal birth. The bladder flap peritoneum is then reapproximated using a continuous 0 or 2-0 chromic catgut suture. The uterus and visceral peritoneum 18 having been approximated, the packs are removed from the abdominal cavity and any residual blood or amniotic fluid is removed by irrigation and suction. The ovaries, tubes and posterior wall of the uterus are inspected. The abdomen is then closed in layers. Post-operative management of the patient is similar to that of any patient who has undergone major surgery. Chapter III - Cesarean Births: A Historical Overview 21 The cesarean birth has been the concern of religions, nations and people from antiquity to the present. As early as 3000 B.C. in Egypt, and later in 1500 B.C. in India, national laws mandated surgical abdominal delivery of the fetus at the time of the death of its mother (post-mortem cesarean). Many myths relate to this kind of birth. For example, Asclepius (Greek God of Sleep) was said to have been "cut" from the body of his dying mother by his father Apollo. References are made to cesarean births in the Talmud, a book of Hebraic Law compiled between 100 and 500 A.D. In the Persian epic, Shah-Nama, written in the 10th and 11th centuries, obstructed labor is described, followed by operative births. In recorded Roman history, at the end of the last century before Christ, the cesarean birth was referred to as "a caeso matris utero" or literally for an infant to be cut from its mother's womb. While Julius Caesar was said to have been born by surgery, this is unlikely. At that time (100-44 B.C.), no maternal survivals were recorded following the cesarean birth, and since Julia, Caesar's mother, lived on long after his birth, this episode is assumed to be another of the many myths which have evolved around the operation. | Numa Pompilius codified Roman Law in 715 B.C. This Lex Regia (Roman Law called Lex Caesare or Caesarean Law) made it mandatory that in advanced pregnancy, in the event of maternal death, the child should be removed from the mother, so that even if the child did not survive, it could be buried separately. | According to Pliny, the name Caesar 22 was derived from caedere (to cut) and commemorated a birth by surgery. Thus, the Latin equivalents for cesarean (caesaru), as noted above, and section (seco) both imply cutting and their combined use today is redundant. Transition to the terminology cesarean birth, rather than cesarean section, may be more appropriate.* In more recent history, in 1317, Robert the II of Scotland was said to have been born by this operation. His mother fell from her horse, broke her neck and died. Post-mortem, Robert was delivered by a hunter who was present at the time. Although scarred by this surgery (corneal and scleral injury), Robert lived and was later called "King Bleary" because of his scarred appearance. Somewhat later, in England in 1537, as Jane Seymour lay dying, Edward the VI was delivered by cesarean. In the 1500's, cesarean birth still remained a matter of last resort, and was performed only for survival of the infant after maternal death (post-mortem cesarean). During this period surgery for birth was tantamount to maternal death. However, not everyone may have died from the operation. It was reputed that Jacob Nufer, a Swiss sow gelder, delivered his wife by cesarean during an obstructed labor. ! This may not only represent the first cesarean delivery with a mother surviving, but since Mrs. Nufer delivered four more children (presumably vaginally), these later births may mark the beginning of the controversy, "once a cesarean, always a cesarean". * Cesarean birth has been used where appropriate to replace the term cesarean section throughout this report. This change in use reflects a change not only as suggested by the Latin derivation of the terms, but also is in response to the usage of the term cesarean childbirth by childbirth educators. 23 This latter term was to be made prominent by E.B. Craigin as reported in the New York Medical Journal in 1916.2 In the Middle Ages, religion was involved in pregnancy decision making, and at times dictated obstetrical practices. For example, the Roman Church barred abortions, craniotomy or fetal dismemberment as techniques for delivery of the child to save the life of the mother. The Church advocated cesarean birth to save the soul of the child.” In the United States, during the Franciscan Mission Period (1769-1833), as recorded in Alta California and recounted by Valle? the operation became the mandated charge of the missionary priest attending at the death of a mother. The post-mortem operation is clearly described, including the detailing of instruments which should be available for the surgery, as well as maternal anatomy, and technical descriptions to assist in the use of the proper incisions. With a living mother, in the 1800's four other forms of manipulative delivery, including (1) version and extraction (Pare), (2) use of obstetrical forceps (Chamberlain), (3) early induction of labor to prevent excessive fetal growth, and (4) fetal destruction, seemed to hold sway, rather than resorting to the cesarean birth which still was associated with a 75% maternal mortality rate. The first successful cesarean birth in the United States may have taken place in 1794, in a log cabin in Edom, Kanawha Valley, Virginia (other authors suggest an alternate "rirat™). Dr. Bennett operated on his wife, but refused to report the procedure, since he felt that 24 no one would believe that both mother and child survived.® In 1817, Sir Richard Croft characterized physician attitudes at that time by his actions in attending the labor of Princess Charlotte. Sir Richard allowed an obstructed labor to continue, rather than intervene and dismember the next King of England (since that was the only way vaginal birth could proceed). If operative birth were resorted to, Sir Richard correctly feared the princess might die following the cesarean. Thus, Sir Richard did nothing, and in the morbid events that followed, the Princess died, the infant died, and later poor Sir Richard shot himself, probably in remorse over his failures. | Writing in 1878 and summarizing the then current status of the operation, Harris, an American medical historian, observed that a pregnant woman in labor had a 50% chance of survival post-cesarean if she performed her own surgery, or if gored by a bull, compared to a 10% reported survival rate if attended to by a New York surgeon.’ *? At the end of the 19th century, major patient care landmarks affecting operative acceptance commenced with Lister's use of antisepsis. Understanding the origins of postoperative sepsis, along with the use of antiseptic techniques and the administration of anesthesia for pain, allowed the surgery to be per formed more frequently, and ultimately the increased experiences led to improvement in surgical techniques. With more reasonable operative success rates, physician attitudes changed toward the cesarean delivery, and although still considered as a failure in vaginal birth technique, the operation became more acceptable. 25 Porro (1876) performed cesarean birth followed by a subtotal . hysterectomy and marsupialization of the surgical stump into the abdominal incision (the Porro section). Sanger (1881) replaced the sterilizing Porro technique with suture of the uterus in layers (the classical cesarean section). Prior to this, uterine suturing was performed only to control bleeding vessels in the line of the incision. The incision itself often was not closed’ and vertical incisions in the uterine fundus predominated (classical cesarean). Extraperitoneal surgical procedures in the lower uterine segment were first advocated by Frank in 1906, soon followed by modifications by Latzko and Selheim, finally leading to Walters' work in 1930 which generated interest in the use of the extraperitoneal cesarean operation in order to avoid intraperitoneal contamination.’ With Konig's technique, peritoneal flaps were developed and the uterine segment was incised in vertical fashion. More subtle innovations in operative technique were taught by Beck (1919) and DeLee (1925). It is noted that Kehrer (1881) should be credited with the transverse lower uterine segment incision later popularized by Munro Kerr in 1926.10 The terms and the techniques presently used in cesarean birth are described in more detail in Chapter II - A Description of the Cesarean Operations. Nicholas J. Eastman, who in 1932 was considered the dean of obstetricians, and whose interests later were to lead to The Collaborative Perinatal Study, was dedicated to finding the causes of cerebral palsy. Responding to a question as to how obstetrics had advanced in the preceding 26 five years, Dr. Eastman stated that the cesarean operation had "spared maternal and infant lives in the millions and prevented countless cases of cerebral palsy and other birth injuries of the newborn, and myriads of maternal genital fistulas". Although increased in use and acceptable as an alternative operative procedure, the cesarean birth still remained a procedure less frequently used than the midforceps delivery and less often performed than vaginal delivery in the case of breech births. For example, in 1939, cesarean birth rates for New York City and in Massachusetts remained less than 3% of all deliveries, In 1950, Dieckman 2 noted a maternal operative mortality rate of 0.24% in 4497 cesarean births. Textbooks at that time suggested that operative death rates following cesarean birth should be less than 1%. In recent reports, as described later in this report in Chapter X - Maternal Mortality and Morbidity, the order of magnitude decrease in maternal mortality has been from one death per hundred, to 41 deaths per 100,000 cesarean births. Shortly after World War II, for reasons still hard to define, New York City cesarean birth rates were reported to have risen from 2.4% in 1939 to 4.5% in 1949. At that time, it was noted that with the rising incidence of cesarean births, the procedure itself was becoming an important consideration among factors associated with mortality rates. As reported by the Medical Society of the County of Kings in New York, infection, anesthesia and hemorrhage were the three most commonly reported causes of death following surgery. Anesthetic risk was responsible 27 for about one in five maternal deaths. Yet even in the late 1940's, we find both concern with rising cesarean birth rates, and wide variation in rates from institution to institution. McCormack, in discussing a paper at the American Gynecologic Society in 1948, quoted cesarean birth rates in two university departments as varying between 0.17% in one and 7.06% in another. 12 In reviewing the evolution of the operative changes, we see two important themes. First, the very much improved and lowered maternal mortality rates in association with cesarean births become important in allowing more freedom of choice for the procedure. Second, the differences in operative rates between different hospitals are not new, but have been present for many years. 28 BIBLIOGRAPHY 10. 11. 12. 13. 14. Brian, V.A.: The deepest cut of all. Nursing Mirror, pp. 68-70, September 30, 1976. Craigin, E.B.: Once a cesarean section always a cesarean section - conservatism in obstetrics. New York Med. J. 104:1-3, 1916. Marieskind, H.I. (Dr. P.H.): As quoted from An Evaluation of Cesarean Sections in the United States Final report submitted to Department of Health, Education and Welfare, Office of the Assistant Secretary for Planning and Evaluation/Health, pp. 8-9, June 1979. Young, J.H.: Cesarean Section: The History and Development of the Operation from Earliest Times. H. L. Lewis and Co., London, 1944. King, A.G.: America's first cesarean section. Obstet. Gynecol. 37: 797-802, 1970. Cianfrani, T.: A Short History of Obstetrics and Gynecology. Charles Thomas, Springfield, Illinois, 1960. Harris, R.P.: Remarks on the cesarean operation. Am. J. Obstet., N.Y. 11:620-626, 1879. Harris, R.P.: Cattle-horn lacerations of the abdomen and uterus in pregnant women. Am. J. Obstet., N.Y 20:673-685, 1033, 1887. Porro, E.: Della amputazione utero-ovarica come complemento di Taglio Cesareo. Ann. Univ. Med. Chir. 237:289-351, 1876 as quoted in Williams Obstetrics, Seventh Edition, D. Appleton-Century Company, New York, pp. 596-598. Sanger, E.: Der kaiserschnitt bei uterusmyomen, etc., Leipzig, 1882. As quoted in Williams Obstetrics, Seventh Edition, D. Appleton-Century Company, New York, pp. 596-598. Douglas, R.G.: Operative Obstetrics, Third Edition, New York. Appleton-Century-Crofts, 1976. Speert, H.: Cesarean Section, Chapter 14, pp. 150-157, as quoted in Obstetrics and Gynecology in America, A History. Waverly Press, Inc., Maryland. Dieckman, W.J. and Seski, A.G.: Cesarean section at the Chicago Lying-In Hospital, 1931-1949. Surg. Gynecol. and Obstet. 90:443- 450, 1950. Hibbard, L.: Changing trends in cesarean section. Am. J. Obstet. Gynecol., 125:798-804, 1976. Jones, 0.: Cesarean section in present-day obstetrics. President- ial address. Am. J. Obstet. Gynecol. 126:521, 1976. Chapter 1y - Fetal Considerations 31 CHANGING OBSTETRICAL INDICATIONS Until the post-World War II period there was interest, but far less emphasis, in fetal and perinatal death rates. Maternal mortality commit- tees prevailed; fetal and neonatal mortality committees were nonexistent. Pressure from these maternal obstetrical committees, in the relatively recent past, fostered the described notable fall in maternal mortality. The altered medical practices associated with this improvement included (1) availability and use of improved anesthetic techniques; (2) more reliable and available parenteral fluids, blood and blood products; (3) the use of therapeutic antibiotics for sepsis and the wider choice of antibiotics in treatment of infection; and (4) better medical control of maternal illnesses such as diabetes, hypertension and heart disease. Perhaps beginning in the mid-1950's, but certainly in the 1960's, increasing emphasis was placed on the health of the fetus. There were renewed societal demands for prevention of death of the fetus and neonate, and for improvement in the quality of life of the survivors. With maternal mortality from cesarean birth having become a rare occurrence, cesarean delivery was one approach employed to try to improve fetal outcome. Today reasons for cesarean births involve many changes in decision making by the obstetrician. These changes, as reported in the obstetric literature, reflect the weighing of the risks and outcomes for both patients, and are identified by diagnostic category in Tables I and II. The complete explanation of the construction of this table is presented in Appendix A, at the end of this chapter. This information is presented here only as an introduction or perhaps as a foreshadowing of the far more abundant data reviewed in the body of this text. 32 In this synthesis of the reported series, the repeat cesarean birth is the most common factor associated with the rise in the total cesarean rate, followed by indications such as cephalopelvic disproportion, uterine inertia, malpresentation, and fetal distress. There is a general increase in the trend to resort to the cesarean route for birth in almost all diagnoses except placenta previa and abruption, which remains constant. Additional data relevant to this issue will be elaborated upon more completely in the body of this report. THE PROBLEM OF STUDYING BRAIN DAMAGE IN RELATION T0 THE CHANGING CESAREAN BIRTH RATE Included among the neurological sequelae that can follow abnormal pregnancy, labor and delivery are sensorineural hearing loss, acquired hydrocephalus, and psychomotor retardation, as well as that collection of symptoms rather loosely grouped under the title of "cerebral palsy" (ataxia, choreoathetosis, spasticity, seizures and global mental retardation).’ While the pathogenesis of many of these outcomes is often obscure, sufficient pathological information and clinical correlations have nonetheless accrued to permit a broad grouping of lesions into those associated with hemorrhage, hypoxia and ischemia.” Reducing the neurological sequelae thus requires obstetric management focused on minimizing these three events. The large subdural hematoma seen classically in the full-term, abnormally presenting product of a difficult delivery, caused by head trauma and hemorrhage, 9,10 is now a comparative rarity. Modern obstetrics has more strongly favored the safer surgical relief of those brow, face, transverse (and, now, breech) 33 presentations that used to require "difficult forceps" or other manipulative delivery. Unanticipated intrapartum episodes of asphyxia due to nuchal, knotted or prolapsed cords may still occur, but are more quickly detected during labor by electronic fetal monitoring, so that more informed judgments are now possible regarding the timing, mode and necessity for appropriate interventions. However, the improved prevention and management of these accidents of delivery has not yet been matched by a similar amelioration of other "accidents" of pregnancy, especially prematurity. 11-14 The premature fetus of less than 1500 grams birth weight may be easily compromised by prolonged labors (dystocia), breech or other abnormal presentations and, having suffered such perinatal stress (with presumed hypoxia), is at high risk of developing primary (i.e., nontraumatic) subarachnoid, intraventricular or intracerebral hemorrhage for several hours or days after delivery. Hypoxia without hemorrhage may be associated with specific neuronal necrosis, leading to any of the various clinical forms of cerebral palsy, while gross ischemia of whole sections of brain can lead to global motor and intellectual deficits. In the premature such ischemia of immature cerebral vasculature is thought responsible for the "periventricular leukomalacia" often associated with spastic diplegia. A number of retrospective studies of cerebral palsied populations have confirmed this synergism of marked prematurity, abnormal presentation 12,13, %4 Indeed, current (especially by the breech) and perinatal asphyxia. neurological outcomes among this group (less than 800 grams) are such as to counsel interventional cestraint, In addition, maternal bleeding, 34 multiple pregnancy and intrauterine growth retardation (especially that associated with toxemia) are now identified as risk factors for brain 1412413414436, 17 Thus surgical delivery has the potential to damage. eliminate only a fraction of the brain damage associated with prenatal complications. Another complicating factor in assessing the effect of cesarean delivery on brain damage is the lack of complete correlation of the infant's status at birth with eventual neurologic status. Even complete perinatal cardiac arrest can be followed by normal neurological development when the heartbeat has returned within 5 minutes, and spontaneous respiration within 30 minutes, of the asphyxial —— Infants with perinatal signs of severe "cerebral shock" at term can undergo spectacular improvement over 7, 8,13,16,19 Attempts to relate the first two or so years of life. delivery method and newborn condition to eventual intellectual quotient are complicated by the many confounding variables in an infant's developmental background and home environment and uncertainty as to how these influence ultimate functional status. Assessing the role of cesarean birth in preventing brain damage is also made extremely difficult by the need to separate the effects of the surgical procedure from the effects of its indications. To the extent that such separation is possible, the well-conducted operative procedure does not appear to contribute to cerebral damage. To the extent that cesarean birth may relieve or avoid those situations arising during labor that are known to increase the risk of brain damage, the operation may well be essential to 35 securing a healthy outcome. Those hard-core and pre-existing phenomena now chiefly associated with brain damage --- maternal bleeding, intrauterine growth retardation, multiple pregnancy, immaturity, prolonged intrauterine asphyxia --- are unlikely to have a surgical solution. No evidence is at hand that their adverse effects are worsened by cesarean birth, but evidence that cesarean delivery lessens their adverse effects is difficult to obtain and assess. The risk of later morbidity due to brain damage closely correlates with decreasing birth weight. The incidence of low birth weight infants is not changing, but the number of infants surviving at lower birth weights is increasing as improved perinatal care becomes available for the high risk pregnancy. The use of cesarean for the very low birth weight population is increasing, and the need to avoid physical and biochemical trauma at all birth weights focuses attention even more closely on the very low birth weight infant. Important to this latter consideration 1s the increased incidence of abnormal fetal presentations among the lowest birth weight categories. This will be discussed in Chapter XV - Breech Presentation. The most advantageous method for delivery of the very low birth weight infant, with respect to perinatal mortality and brain damage, is not yet known, and these considerations become increasingly complex as smaller and less mature infants become salvageable. Low birth weight (< 2000 gram) infants represent about 8% of the term birth population, and those of high birth weight (> 4000 gram) represent 1% of that. population. Normal birth weight infants at term are, of course, the largest and potentially healthiest group of infants seen during labor. Management of labor in this group has recently changed, 36 as will be discussed in Chapters VIII and IX - Epidemiology, and Chapter XIII - Dystocia. As noted above, the major cause of brain damage in this population, subdural hemorrhage resulting from birth trauma, has diminished as the more difficult manipulative obstetrical procedures have been abandoned in favor of cesarean birth. Yet, as will be noted in this report, the diagnosis of dystocia during labor is not easily defined and, while obstetrical diagnoses such as "dystocia" or "asphyxia" are more frequently made today (see Chapters VIII and IX - Epidemiology, and Chapter XVI - Fetal Distress), their direct relationship to fetal brain damage is in most cases uncertain, because the identification of brain damage at birth, or early during the neonatal period, is made in only a very few of the large number of infants born in these two obstetrical situations. Accurate figures are readily available from the Collaborative Perinatal Study concerning the number of term infants (1.5/1000 live births) who die during labor. However, neurological morbidity without death in asphyxiated infants is difficult to evaluate immediately after birth. The crude evaluating procedures that purport to predict developmental outcome are remarkably inadequate. One must accordingly wait until many intervening years have passed and additional confounding variables have appeared before the several clinical neurological entities may be accurately classified. Figures for conditions such as severe mental retardation, 3.5 per 1000 children at about 10 years of age, may be oot inated from large population studies throughout the world, but are impossible to relate accurately to circumstances of birth. Thus, a most difficult question for this Task Force will be the relation, if any, of the increase in cesarean birth to the decrease in incidence of brain damaged children. This problem will be discussed throughout this report. 37 TABLE I CHANGING IMPORTANCE FOR OBSTETRICAL INDICATIONS IN CESAREAN BIRTH RATES Mean Mean Mean Indication 1931-1949 1950-1968 1969-1975 Total Cesarean Rate 4.10 5.26 9.50 Repeat Cesarean 1.18 2.11 3.50 Cephalopelvic Disproportion 1.52 1.06 2.30 Inertia .26 +23 «97 Malpresentation .09 34 1.16 Fetal Distress .04 .38 1.32 Placental Abruption .26 v2] 24 Placenta Previa .28 +25 .30 Toxemia 43 .09 .67 Diabetes .02 .08 +29 Other .50 .61 .61 TABLE II. CESAREAN BIRTH RATES BY INDICATION, 1969-1975 Lee and Lee and Haddad -Cabert and AUTHOR(S) Jones Hughey Baggish Hibbard Baggish and Lundy Hughey Stenchever Hibbard YEAR(S) STUDIED 1962-1975 1968-1971 1969-1971 1970 1072-1974 1472 .1275 1972-1975 1973-1075 1974 RLTERESCE aU. (2) (3) (4) (68) (4) (5) (3) (6) (1) Total Cesarean Rate 6.0 6.17 7.28 9.49 10.40 12.3 9.43 13.33 9.11 Repeat Cesarean Rate 1.74 2:9 3.84 3.21 3,12 4.0 3.52 6.11 3.95 Cephalopelvic Disproportion 2.94 1.37 2.61 .84 2.86 3.97 2.77 2.22 .63 Inertia .27 -— .28 2.45 1.19 — - + 22 1.43 Malpresentation .38 «35 .56 1.37 1.90 1:32 1.30 .79 2.26 Fetal Distress .62 yaa 46 «33 2.38 1.45 «85 3.61 1.12 Placental Abruption «23 — .23 «15 «26 42 -— -— +13 Placenta Previa .28 -— 23 .38 +26 «27 -- -- .38 Toxemia .14 - .09 — 2.38 #21 - .51 -— Diabetes .18 -— .28 -- .43 .09 -— +47 -— Other — .90 -— .15 mn +57 .99 95 .10 Comment 2 1,2 1,2 8¢ Comments: 1. The rates for abruptio placenta and placenta previa have each been assumed to be one-half of the rate calculated for hemorrhage, which is the indication for surgery listed in this series. +2. The sum of rates for each indication is somewhat greater than the total cesarean birth rate in this series. It appears that occasionally more than one indication for surgery has been listed. 39 APPENDIX A A GUIDE TO THE USE OF TABLES I AND II Lack of Standard Terminology Institutions report indications for cesarean birth using different terminologies and formats. Terminology may also change over time within a single institution. Some series are similar enough to allow reasonable comparisons. Multiple Indications Most studies list only the primary indication for surgery. In actual clinical practice many considerations are frequently involved in the decision to perform cesarean birth. Rates All rates listed are in number of cesarean births per 100 deliveries. The rates listed must be considered approximate, since, as noted above, many have been calculated from data presented in different formats or with different terminology. Cephalopelvic disproportion Other indications that have been listed under this category include: a) fetopelvic disproportion b) contracted pelvis c) large fetus d) failed forceps e) failed vacuum extraction Uterine inertia The indications included in this category include: a) uterine inertia b) dysfunctional labor c) dystocia (when cephalopelvic disproportion is listed separately) Malpresentation This includes breech birth and all other non-vertex presentations. Fetal Distress The diagnosis of fetal distress is not the same to each author, and that the diagnosis changed over the time periods studied. Other This includes many rare or infrequent medical diagnoses and patient management problems. 40 BIBLIOGRAPHY 1. 10. 11. 12. 13. Hibbard, L.: Changing trends in cesarean section. Am. J. Obstet. Gynecol., 125:798-804, 1976. Jones, 0.: Cesarean section in present-day obstetrics. President- ial address. Am. J. Obstet. Gynecol. 126:521, 1976. Hughey, M., LaPata, R., McElin, T. and Lussky, R.: The effects of fetal monitoring on the incidence of cesarean section. Obstet. Gynecol. 49:513, 1977. Lee, W.K. and Baggish, M.S.: The effect of unselected intrapartum fetal monitoring. Obstet. Gynecol. 47:516-520, 1976. Haddad, H. and Lundy, L.: Changing indications for cesarean section. A 38-year experience at a community hospital. Obstet. Gynecol. 51:133, 1978. Gabert, H. and Stenchever, M.: The results of a five-year study of continuous fetal monitoring on an obstetric service. Obstet. Gynecol. 50:275, 1977. Volpe, J.J.: Perinatal hypoxic-ischemic brain injury. Ped. Clin., N. Amer. 23:383-397, 1976. Volpe, J.J.: Neonatal intracranial hemorrhage-pathophysiology, neurophysiology and clinical features. Clinics Perinatol. 4:77- 102, 1977. Fredrick J. and Butler, N.R.: Certain causes of neonatal death. II. Intraventricular hemorrhage. Biol. Neonat. 15:257-290, 1970. Fredrick, J. and Butler, N.R.: Certain causes of neonatal death. V. Cerebral birth trauma. Biol. Neonat. 18:321-329, 1971. ~ Friedman, E.A., Sachtleben, M.R., Bresky, P.A.: Dysfunctional labor. XII. Long-term efects on infants. Am. J. Obstet. Gynecol. 127:779-783, 1977. Hagberg, G., Hagberg, B. and Olow, I.: The changing panorama of cerebral palsy in Sweden 1954-1970. III. The importance of foetal deprivation of supply. Acta Paed. Scand. 65:403-408, 1976. Sabel, K.G., Olegard, R. and Victorin, L.: Remaining sequelae with modern perinatal care. Pediatrics 57:652-658, 1976. 14. 15. 16. 17. 18. 19. 20. 21. 22. 41 McBride, W.G., Black, B.P., Brown, C.J., Dolby, R.M., Murray, A.D. and Thomas, D.B.: Method of delivery and developmental outcome at five years of age. Med. J. Australia 1:301, 1979. Bennett-Britton, S., and Fitzhardinge, P.M.: Is intensive care justified for infants weighing less than 801 grams at birth? Abstract in Ped. Res. V 14:590, 1980. Buck, C., Gregg, R., Stavraky, K., Subrahamanian, K. and Brown, J.: The effect of single prenatal and natal complications upon the development of children of mature birth weight. Pediatrics 43: 942-955, 1969. Robbins, P.G., Gorbach, A.G. and Reid, D.E.: Neurologic abnormal- ities at one year in infants delivered after late pregnancy hemor- rhage. Obstet. Gynecol. 29:358-361, 1967. Steiner, H. and Neligan, G.: Perinatal cardiac arrest: quality of the survivors. Arch. Dis. Child. 50:696-702, 1975. DeSeriza, S.W. and Richards, B.: Neurological sequelae in newborn babies after perinatal asphyxia. Arch. Dis. Child. 53:564-569, 1978: Niswander, K.R., Gordon, M. and Drage, J.S.: The effect of intra- uterine hypoxia on the child surviving to 4 years. Am. J. Obstet. Gynecol. 121:892-899, 1975. Thomson, A.J., Searle, M. and Russell, G.: Quality of survival after severe birth asphyxia. Arch. Dis. Child. 52:620-626, 1977. Antenatal Diagnosis. Part III Predictors of Intrapartum Fetal Distress. NIH Publication No. 79-1973, April,1979. Chapter V - Other Methods for Studying the Changing Trends in Cesarean Birth Rates 45 During the 1970's, neonatal intensive care units, staffed by pediatricians specializing in neonatology, became well established. The importance of maternal transport systems and more centralized care for the medically-at-risk mother and fetus was recognized. Similarly, and in response to a recognized need, in the early 1970's a decision was implemented by The American Board of Obstetrics and Gynecology to formalize education in the growing subspecialty area of medical treatment for the high risk mother and fetus. Thus criteria for training programs in Maternal and Fetal Medicine were established and accreditation for individuals and for centers of training in Maternal and Fetal Medicine evolved. In 1973, the first physicians were boarded in the new subspecialty of Maternal and Fetal Medicine. In October of 1979, in gathering information for this report, a questionnaire was sent to 40 of the accredited training programs in Maternal and Fetal Medicine. The teaching centers were surveyed with the idea that what was being taught in the educational centers would reflect not only the medical care at that time, but also the predictable trends in medical practices in this field for years to come. For it is evident that what the obstetrical resident in training, or the fellow in Maternal and Fetal Medicine, sees and learns will be reflected in that individual's patterns of obstetrical practice for many years to come. The questionnaire is presented in Table I. In order to encourage replies, the questions were formed to encourage simple and brief responses. 46 It is only presented as an example of medical practices today and is neither complete enough nor extensive enough in detail to be a definitive report on obstetrical education or medical practice today. However, if used in a general way, and as an introduction to data which will be presented in later sections of this report, this information will allow further insight into the questions being asked by this Task Force. As the replies were returned, it became apparent that questions 6, 7 and 8 were not constructed in a manner to allow them to be easily answered, or answered in an informative manner. For example, all reporting program directors considered their hospitals tertiary level obstetrical care centers*. And in fact, almost by definition, if approved by the American Board of Obstetrics and Gynecology as a subspecialty training program in Maternal and Fetal Medicine, the program must have a patient flow to include adequate numbers of medically more complicated or high risk mothers in order to provide for their trainees a proper educational experience. In general, the directors of all the programs stated that they did receive referrals of patients from less sophisticated medical care areas (question 6). The percentage of referral patients was generally an estimate (question 7), and as noted earlier these numbers should be looked at as speculations. Few program directors reported exact numbers in answering this question. * Although there are other definitions as to what a tertiary level center is, for the purposes of this report, it is a referral center for high risk patients, functioning at the highest level of care. 47 In a similar manner almost all centers stated their patient popu- ulations were high risk (question 8). However, there was no uniformity in scoring systems which document high risk patients, or any other method of defining the patient population or how much risk is involved. Thus, there are limits to which the data presented in Table II can be assessed. Except for one year (1977), all reports were for 1978 or 1979. The number of patients delivered varied from very small (1,365) to very large (13,238). The cesarean birth rates extended from a low of 10% to a much higher rate of 23%. The distribution of the cesarean birth rates is recorded in Table II. There is more than a doubling of the rates between the very low and the very high reported rates. In addition, there does not seem to be any orderly clustering of the numbers. As noted, it is not easy to extrapolate from these numbers to the degree of risk populations in each hospital. For example, do high cesarean birth rates reflect methods of patient care, or the higher numbers of high risk patients being referred to that hospital? The reporting hospitals vary from large to small, from primarily serving a medically indigent population to that of a primarily private hospital. Most report they serve both patient populations. The ratio of primary cesarean births to repeat operations is also variable and extends from a ratio as high as 1:1 to 3:1. Most appear to cluster between two and three primary cesareans for each repeat cesarean birth. In summary, these numbers suggest that what exists in the general 48 patient care areas for all obstetricians (Chapters VII, VIII, IX), is also parallelled in the teaching centers. There is a wide range of medical practices, as reflected by the wide range of cesarean birth rates reported. Although the characteristics of the individual popu- lations cannot be discerned, there is no suggestion of a clustering of cesarean birth rate numbers. There is no way to look at these numbers and state one rate is too high, another too low, and a third is correct. This variance in birth rates will be discussed in greater depth in Section II--Epidemiology. CESAREAN BIRTH RATES WITHIN A GEOGRAPHIC REGION In Cleveland, Ohio, a Regional Perinatal Network* has been in existence for four years. During this time, a data collection system has been instituted and while not all hospitals in the region were yet on line or reporting completely, the data, although incomplete, does provide useful background information as part of this introductory portion of the report .** In 1978, eight hospitals were functioning within the network system. For this review these hospitals were divided into two general categories of hospital size, over 2000 deliveries (LARGE) and under 2000 deliveries (SMALL). In addition, two of the reporting hospitals were tertiary level obstetrical centers that received referral patients from the entire community. These hospitals were not identified sepa- rately, but it is noted that their cesarean birth rates were within the general range of the other reporting hospitals. Approximately 75% of the * Supported by the Robert Wood Johnson Foundation, Inc. ** Supplied by Dr. Irwin Merkatz 49 deliveries for the entire network region of 22 hospitals were reported. The cesarean birth rates during 1978 are listed in Table IV. The cesarean birth rates vary from a low of 13% to a high of 18%. In general, the smaller hospitals tend to have somewhat lower operative birth rates than the larger institutions. Their high risk patients, in part, are referred to the two centers. The information gathered suggests that within this region, perhaps influenced by the network educational program, or the physicians' train- ing, or for reasons unknown, there is some homogeneity of practice. When compared with the materials reported earlier from teaching centers throughout the United States, the narrower distribution of the cesarean birth rates is a contrast. This also contrasts with information presented in a recent textbook of Obstetrics and Gynecology, which noted wide variation in cesarean birth rates in medical centers throughout the United States. No attempt is made to discuss this information in detail with respect to birth weight distributions or diagnostic indications. This is more adequately discussed in Chapter IX - The New York City Experience. The data is presented as an overview to obstetrical practices within a region where an attempt, albeit yet incomplete, has been made to coordi- nate medical care for mother, fetus and neonate. CESAREAN BIRTH RATES WITH RESPECT TO INFANT WEIGHTS At Cleveland Metropolitan General Hospital a uniform data base record keeping system has been in use since 1973.* During a 25-month period, between January 1, 1977 and January 30, 1979, 6072 deliveries * Unpublished data supplied by Dr. Robert Sokol 50 were reviewed for specific birth weight and cesarean birth rate char- acteristics. This information, as much of the information in the introductory sections, is presented as a background upon which the more formidable data sets for larger regions have been scrutinized. In this case the model is the association of neonatal birth weights with the present cesarean birth rates. Percentage of C-Birth Rate* % of Total Weight (grams) Number Deliveries for this Weight C-Birth Rate < 2000 90 4.9% 30.5% 15.4% > 4000 37 5.0% 9.6% 6.3% Total Primary C-Birth 585 * All Primary C-Births We may note that the lowest birth weight category (< 2000 grams) has the highest cesarean birth rate (30.5%). Yet despite this high operative birth rate, because it is a small part of the entire birth population (4.9%), birth weights below 2000 grams contribute only 15.4% of the primary cesarean birth rate. The largest number of cesarean births come from the 2000-4000 gram birth weight population. If we add in the largest birth weights (> 4000 gram) with the smallest birth weights (1000-1999 grams), we see that the 10% of these extremes in birth weight contribute to 22% of all the primary cesarean births. BIBLIOGRAPHY 1s Williams Obstetrics, 15th ed. Pritchard, J.A., MacDonald, P.C., eds., New York, Appleton-Century-Crofts, 1976 bl TABLE I - THE QUESTIONNAIRE SENT TO DIRECTORS OF MATERNAL AND FETAL TRAINING PROGRAMS The following information should relate to the year 1979. However, if this is not easily available, rather than delay, information as close to this past year as possible would be helpful. 1. The total number of deliveries at your institution. 2. The total number of cesarean sections at your institution. 3. The total cesarean section rate. 4. The number of primary cesarean sections. 5. The number of repeat cesarean sections. 6. Is your hospital a tertiary level facility and/or does it receive referred patients from other sources. 7+ What percentages of your patients are referred from other geographic areas as compared to the number who are normally your hospital patients (percentages will be fine). 8. Do you risk score your hospital population? Can you give me some crude estimate (or specific estimate) of the risk characteristics, by whatever system you use, of your hospital delivery population. TABLE IT Reporting Number No. c/s Ratio of Tertiary % Patients Estimate of Risk No. Year Deliveries c/s Rate* Primary/Repeat Level Referred in Population 1 1979 3116 455 157 3:1 Yes Not answered 2 1979 6065 1399 237 2:1 Yes 10% Not answered 3 1977 5712 924 16% 241 Yes 1-27 Not answered 4 1979 2302 426 197% 1.5:1 Yes 18% Not answered 5 1979 13238 1624 127 2:53:11 Yes Uncertain 607% 6 1978 2562 317 127% 271 Yes 16-17% Not answered 7 1978 1365 351 23% 2:1 Yes 107% 33% 8 1979 3040 402 13% 2:1 Yes 87% Not answered 9 1979 1959 226 12% 271 Yes 5-107% Low to moderate 10 1978 2607 468 20% 3:1 Yes 5-10% 807% ti} 1979 3351 760 23% 2:1 Yes: 5-7% 23% 32 1979 2814 535 15% 2.5:1 Yes 47 Not answered 13 1979 1713 309 18% = Yes 10% Not answered 1 1979 13212 2021 157% 2:1 Yes 107% 30% 15 1979 2119 379 187% 231 Yes 157% 70% 16 1979 1913 350 18% 2:1 Yes 107% Not answered 17 1979 3138 481 15% 1.5:1 Yes 13% Not answered 18 1979 5245 584 11% 1:1 Yes No Answer Assuming a high risk score of 15- Low/Low =- 21% Low/High - 257% High/Low - 297% High/High- 25% 19 1979 2507 357 14% 2.5:1 Yes 12% 607% High Risk 20% Intermediate 20% Low 20 1979 1782 465 197% 2.5:1 Yes 200 annually Not answered 1979 2676 600 23% 2:1 21 1978 2733 271 10% 2:1 Yes 5% Jz 2Z 1979 4230 697 i72 3% Yes 15% 20-25% 23 1978/1979 2722 379 14% Yes 12% 217 24 1979 3114 381 127 1:1 Yes 25-30% 60-707 23 1978 3605 544 15% 1.53) Yes 9.4% 26%% 1979 3264 698 21% 2:1 5% 27 1978 3593 488 14% 2:1 Yes Small 7% Not answered 28 1979 2455 497 20% 2:1 Yes 1.5% Not answered 29 1979 3102 406 15% 2%1 Yes 10-15% Not answered 30 1979 7166 1181 16% 2:1 Yes 5% Indigent - 97% * All numbers rounded off to nearest whole number ** A six-month figure 2s 53 TABLE III DISTRIBUTION OF CESAREAN BIRTH RATES IN MATERNAL AND FETAL MEDICINE TRAINING PROGRAMS Percentage Number Reported of Hospitals 10% 1 11% 1 12% 4 13% 1 14% 3 15% 5 16% 2 17% 1 18% 2 19% 3 20% 2 21% 1 22% - 23% 4 54 TABLE IV CLEVELAND PERINATAL NETWORK Size Percentage LARGE 14% LARGE 18% LARGE 16% ALL LARGE ALL 16% SMALL 16% SMALL 13% SMALL 13% SMALL 13% ALL SMALL ALL 14% ALL 14% # numbers rounded off Chapter VI - An Overview of the Additional Issues to be Presented 57 THE QUESTION OF VARIATIONS IN SURGICAL OR OPERATIVE RATES The variation in surgical rates for many operative procedures has long been a concern. It is not intrinsic to the cesarean birth alone. An example of this concern in another operative procedure is the vonat i iovtany and adenoidectomy. Roos, et al,’ reported on these _ procedures. The authors set guidelines for standards of acceptable medical care (i.e. by consensus). These guidelines included the minimum indications for the surgery. That standard was used to analyze retrospectively the actual medical practices in the region. These authors found that only 14% of the procedures performed met strict adherence to the guidelines for surgery. In addition, there was no correlation between adherence to these standards and the actual surgical rates in a region. They found that in geographic regions where operative rates were low, there was no more 1iklighood that the operative guidelines would be met than in regions having higher operative rates. In addition, the surgical rates for tonsillectomy and adenoidectomy did not correlate with physician age, or place of training. In an editorial commenting on this report, LoGer fo? discussed elective surgical care and the variations in operative surgical rates, and noted that these variations may occur between countries, or medical care groups, and that although surgery is potentially beneficial, it is difficult to place a value on high (or low) surgical rates. 58 Discussing similar surgical situations in Seattle, in a prepaid health care plan, LoGerfo noted that in the tonsillectomy and adenoidectomy, and in the hysterectomy, surgery may be needed, but is often performed on an elective basis. The theoretical problem is one of striking a balance between the risks of unnecessary surgery, as compared with the alter- native risks of reduction in surgical rates and deprivation of a beneficial alternative. Throughout this report the reader will often find the Task Force expressing difficulty in assessing risk, benefit, or cost, and in measuring benefits of intervention as compared with no intervention. The definitions of the words risks, benefits, and costs for surgical interventions are not easily defined and assessed in medical terms or in economic terms. Simple answers in the above noted examples were not easily forthcoming. Do high surgical rates reflect philosophies of the surgeon? Do differences in the payment system, differences in education, or differences in understanding alter the aperahive rate? These same questions are posed and answers are sought in this report on cesarean births. But the questions pervade medical care in a far more general manner. THE ISSUE OF PATIENT RIGHTS We have passed through a period of time when medical information remained exclusively in the domain of the physician. Today medical information is available to the entire public in newspapers, journals, magazines and books. In the practice of medicine, information exchange between patient and physician is not a privilege, it is a right. The 59 patient today is often far better informed. This improved exchange of information is alluded to in Chapter XXI - Medico-Legal Concerns, and Chapter XX - Ethical Concerns. The impact of this knowledge on the interactions between people is not easily measured, but may influence medical care. At all times the patient has the right to understand her illness. The same complexities that exist for treating one patient exist in pregnancy for two patients (mother and fetus). It is clear that with two individuals involved, the decision making process becomes more complex, although the ethical principles do not change. Decisions cannot easily be made for the benefit of only one of the two involved patients. Risks and benefits to each patient may often have to be weighed. What is the relative risk to one as compared with the relative benefit to the other? For example, if a hypertensive crisis threatens the life of the mother, the answer is straightforward. If the mother dies, the fetus will also die. Therefore there is no alternative solution but to deliver the fetus as quickly as possible. That treatment benefits the mother by removing the cause for the hypertensive crisis. On the other hand, a lesser risk of severe hypertension in a mother, possibly leading to serious and permanent illness, but not to immediate death, must at that moment in pregnancy be balanced against the viability of a fetus and the potential benefit of one or two weeks of continued fetal development in utero. Two weeks of maturation between the 26th and 28th week of fetal life may mean survival for that fetus. 60 The principle of medical health self-determination has been laid out in the courts as the concept that every human being of adult years and sound mind has a right to determine what shall be done with his own body. Yet even for the educated, mature adult, the manner and materials by which informed consent is obtained in the surgical situation may be extremely confusing. In obstetrics, despite a long prenatal period when education can be given, the critical decisions may have to be made while the mother is undergoing stresses, such as pain and anxieties, and may be sedated. At times these decisions need to be made with speed. Finally, exchange of information in obtaining informed consent often takes place between individuals with differing educations and from different cultures. The meaning of the words used by a physician may be different to the patient and the physician. Even under the best of circumstances, a patient's memory of the information given during stress may not be accurate when the patient is questioned after the events. This same decision making for a pregnant patient is even more complex. Any failure in infant outcome as manifested by death or infant morbidity later in life leaves the questions of - "Why did it happen?" - "Who is to blame?" - "Was it my fault?" The mother and father make decisions knowing that they have to be responsible for that child forever. Thus, while we may describe the ethics of decision making and informed consent as similar to the situation of the single patient, there are differences. 61 MODERN TECHNOLOGY AND CESAREAN BIRTH RATES Technology as a term should not be too narrowly defined. For example, modern obstetric technology includes electronic fetal monitoring, but not that alone. The term technology as used here refers to a wide range of changes in patient care techniques which have allowed, or have been associated with, changes in patterns of medical care. For example, in the historical portion of this introduction, it was noted that until cesarean births became a safe and acceptable alternative method for childbirth, the operation was rarely used. Thus, technology refers also to improvement in drugs and anesthetic techniques so that the operation could be performed. In addition, technology reflects understanding and improvement in antiseptic techniques, the introduction of antibiotics, blood transfusions, and other parenteral infusions. The cesarean birth rates are also influenced by the rapidly changing technological advances within neonatal intensive care units. Infant respirator techniques, feeding, fluid balance and diagnostic devices have evolved and continue to change at an incredibly rapid pace. This improvement in knowledge and in technical care allows for the cesarean birth to be periorned at earlier stages of gestation when it may be a life-saving operation. As already described in this report, the confluence of all these advances in medical science and technology have made the cesarean birth a safe alternative to vaginal birth when needed. That is not to say or suggest that it should be used as a "natural birth." Rather, we may note that mortality rates attributed to the operation are extremely low. 62 This fact, in turn, allows for more choices as to how the physician may respond when faced with a pathophysiologic derangement in the two- patient system. That response, as reflected by rising cesarean birth rates, is reviewed in the entire workings of this Task Force. Among the "new technologies" are electronic fetal monitoring, and fetal scalp blood sampling. Two questions have been raised about them in relation to cesarean delivery: (1) Does electronic fetal monitoring discern fetal distress? (2) How does electronic fetal monitoring contribute to cesarean birth rates? The first question is not the subject for study by this Task Force. A previous consensus Task Force studied this issue. Their report, Antenatal Diagnosis: III: Predictors of Fetal Distress, was presented in Washington, D.C. in March of 1979.° The contribution and the limita- tions of electronic fetal monitoring are appropriately reviewed in that publication and cannot either be presented or summarized here and still retain the quality of that entire report. However, the second question noted above and reflecting the use of the technique and the change in operative rate is appropriate for review. It has already been alluded to earlier in this introduction and will be covered more completely in Chapter XVI - Fetal Distress. The issue of maternal risk has been touched upon in many parts of this introduction. We have noted the transition of the operative procedure from an extremely hazardous one to an extremely safe birth alternative. Risks still remain and morbidity and mortality 63 (Chapter X), as well as behavioral risks (Chapters XVIII and XIX), will be presented later in this report. But, as we have seen, the rising cesarean birth rates have been influenced by a concern for the fetus. Perinatal mortality rates have long been a concern of the involved physician. Morbidity rates, the avoidance of brain damage and the quality of life of the survivors are the themes of modern perinatal care. This concern is presented briefly in this introduction and developed more completely in several areas of the text. CONCERN FOR IATROGENIC PRETERM DELIVERY Many concerns, both of a practical and a theoretical nature, have been raised concerning the effects of cesarean birth on the fetus. A most important threat of the scheduled cesarean birth is the possibility that preterm delivery may occur because of an error in estimation of fetal gestational age. Under those circumstances, an infant who would have otherwise had an entirely normal outcome if allowed to deliver at term may develop the many problems of prematurity, including the respiratory distress syndrome, because of the early delivery. Although it is theoretically possible to prevent iatrogenic prematurity by accurate antenatal assessment of gestational age and antenatal fetal maturity testing, it seems unlikely, given recent experience, that this complication will be avoided entirely. Intermixed with the problem of iatrogenic prematurity is a second difficulty which must be understood. All normal pregnant women experience uterine contractions prior to labor onset. These generally become more apparent after the 24th week of gestation. These uterine contractions, 64 when more severe, must be separated from premature labor. In the case of false labor, no intervention is needed. In the case of premature labor, depending on the duration of gestation at that time, labor prevention or cesarean birth may be considered. This clinical situation may be compounded by the patient's complaints of abdominal pain at any time during pregnancy, or during the period of labor or labor-like uterine contractions. At this time, the physician must consider the balance between true labor, premature birth, and the more morbid threat of placental separation or uterine rupture. While the incidence of the latter two situations is low (see Chapter XIV - Repeat Cesarean Birth and Chapter X - Maternal Mortality and Morbidity), they are potential threats to the life of mother and fetus and the physician must make a clinical decision. Thus the premature delivery of a fetus in a subsequent cesarean birth is not always a simple error in dating of that pregnancy. It also may represent real and sometimes difficult clinical diagnosis in potentially life threatening situations. CONCERN FOR PROLONGED HOSPITAL STAY The problems of prematurity are discussed in Chapters XI and XII. The pathophysiologic problems of the premature infant include pulmonary immaturity (resulting in the respiratory distress syndrome or hyaline membrane disease), wet lung diseases (transient tachypnea of the newborn), intracranial hemorrhage, patent ductus arteriosis, and feeding problems because of an immature gastrointestinal tract. 65 In addition, premature birth prolongs the hospital stay for that neonate, with implications on the cost of medical care as well as on the separation of infant and family (Chapters XVIII, XIX, and XXII). CONCERN FOR THE EFFECT OF ANESTHESIA ON MOTHER AND FETUS Cesarean delivery always requires the use of anesthetic agents of some kind. Concern as to the possible effects of these drugs on the fetus is real. Complications in the use of anesthesia may lead to maternal and fetal mortality and morbidity. Mothers with inadequate oxygenation (esophageal intubation, gastric content aspiration, errors in oxygen mixture, etc.) might be maintained in such a situation over a time period long enough to lead to fetal hypoxemia that would be either incompatible with life or with intact survival. There may also be fetal difficulties secondary to maternal hypotension following conduction anesthesia. If this problem is not recognized promptly, compromises in uterine blood flow might also lead to fetal hypoxemia and acidosis. This is discussed in Chapter XI. Concern has been expressed about the possible depressant effects of maternal analgesia, sedatives, and anesthetics on the newborn immedi- ately after birth and for an undetermined period of time thereafter. Also of concern are the possible effects of such drugs on maternal-infant interactions and attachment behavior. These are discussed in Chapters XI, XVIII and XIX. That drugs given to the mother reach the fetus is clear. Whether they produce neurobehavioral effects during the early days or weeks of life is 66 less clear, with marked inconsistencies in test methods and results. Thus at this time it is unclear whether the use of maternal medication, regardless of its indication or necessity, has deleterious effects on subsequent infant behavior and maternal-infant interaction. This information is discussed in Chapter XIX. A third general area of concern relating to the adverse effects of cesarean birth on the fetus relates to the separation of the infant from the mother, which, in most hospital settings, is required for a period of time after the surgical procedure. Even in those situations where the cesarean is performed under local (rare) or conduction anesthesia (common), the conditions under which initial maternal-infant interaction normally takes place are altered. The baby is often taken from the mother and placed in the nursery during the mother's immediate post-operative course. The periods of time that the baby does spend with the mother are somewhat limited as compared to the time that the baby might be able to spend if a vaginal delivery had taken place. This issue is discussed in Chapters XVIII and XIX. CONCERN FOR THE INCREASED COST OF THE HIGHER CESAREAN BIRTH RATES This issue has been referred to in several areas of the introduction and will be more completely discussed in Chapter XXII. The problem is approached in several ways. Included in the discussion are information on what hospital charges are, how these charges relate to actual procedural and hospital stay costs, and the problems inherent in attempting to assess the costs and benefits of cesarean delivery. 67 THE CONCERN FOR THE EFFECT OF MALPRACTICE SUITS ON CHANGING CESAREAN BIRTH RATES It is evident that there has been a recent rise in medically related lawsuits. Obstetricians, physicians as a group, and other professionals are faced with an increased number of litigations. Whether this situation has contributed to the rise in cesarean birth rates is uncertain. The current state of the law with respect to cesarean delivery and the rights of patients to participate in decision making is discussed in Chapter XXI, Medicolegal Concerns. BIBLIOGRAPHY 1. Roos, N.P., Roos, L. and Heneleft, P.D.: Elective Surgical Rates Do high rates mean lower standards? Tonsillectomy and Adenoidectomy in Manitoba. The New Eng. J. of Med., Vol. 297, No. 7:360-64, August 18, 1977. 2s LoGerfo, J.P.: An Editorial. The New Eng. J. of Med., Vol. 297, No. 7:387-88, August 18, 1977. 3. Antenatal Diagnosis. Part III. Predictors of Fetal Distress. U.S. Dept. of Health, Education and Welfare, Public Health Service, National Institutes of Health. NIH Publication No. 79-1973, April, 1979. 69 SECTION II - EPIDEMIOLOGIC INFORMATION RELATING T0 CESAREAN BIRTH In the next three chapters, data from already published studies, as well as newly obtained information, is reviewed. The study of cesarean birth rates encompasses information from different countries, different medical systems, and different sections within the United States, and a single large population center studied in depth. The following issues have been addressed: (1) The extent to which the increase in rates of cesarean birth reflects a broad change in the management of the delivery that has affected all subgroups of pregnant women. The converse questions are whether important determinants of the changes are related to: (a) demographic characteristics and source of care at delivery; (b) particular complications of labor and delivery. (2) The relationship of the increased cesarean birth rate to pregnancy outcome. Specifically, the measures that are examined include rates of low birth weight, neonatal, fetal and perinatal mortality. Detailed measures of morbidity among the newborn on health status, growth, and development in childhood are not available from the sources used. Apgar scores are included, but major restrictions 70 exist in their interpretation as indicators of acute and long term effects, particularly when derived from routine reports from a great variety of hospitals rather than from special studies that attempt to standardize the observations. Chapter VII presents cross national trends from Canada and Western Europe. Multiple sources are listed in the text. Chapter VIII presents data on national and regional trends in the cesarean birth rate. The sources are tabulations of informa- tion collected by the Professional Activities Study (PAS) of the Commission on Professional and Hospital Activities (CPHA) and tabulations from the National Hospital Discharge Survey of the National Center for Health Statistics. Maternal mortality information derived from the CPHA source is discussed in the chapter on this subject. Chapter IX considers changes in the cesarean birth rate and in the outcome measures of birth weight and neonatal and perinatal mortality based on data from New York City. Chapter VII - Canadian and Western European Experience Chapter VIII - The National Experience Chapter IX - The New York City Experience Chapter VII - Canadian and Western European Experience op Em ge EE a 2d . = - - - - f } 2 AW saad es am SN adh. uF = ES a Eng v EV w= een a 73 INTRODUCTION Although the United States is the first nation to sponsor a task force consideration of cesarean birth rates, rising rates are a matter of public and professional interest in nations with comparable medical resources and health needs. | For purposes of this report, information on delivery procedures was requested from several European nations and Canada. Canada, France, the Netherlands and Great Britain responded in most detail. The information received* reflects the extraction of facts about cesarean births from general statistics on maternal and child health.2 The United States leads Canada, France, England and Wales, Norway, and the Netherlands in the current rate of cesarean births. Other than an increase in Norway between 1975 and 1978, the United States has experienced the sharpest increases. This trend of rising cesarean birth rates is occurring under different national health care systems. All of the countries have had increased percentages of hospital versus home births, increased use of medical technical resources, and a trend towards use of obstetric specialists, rather than general practitioners. The birth rate in each country has declined while infant and maternal mortality rates indicate improved chances for survival.’ Other demographic changes are underway. The population of "quest workers" in Western Europe has been growing and these groups have a characteristically high birth rate and a greater number of obstetric problems, not unlike the morbidity and mortality risks associated with lower socioeconomic groups in North America. * This chapter is derived from a substantially larger set of data, the analysis of which is still underway. 74 By virtue of population size and a unified system of coverage, nations like France, the Netherlands, and England can approach the problem of maximizing obstetric and perinatal care as a policy issue and promote standard services nationwide. The provincial governments in Canada, with general medical care directions set in Ottawa, are in a similar position. This is so whether the decision is to foster hospitalization and professional management, as in Canada over the last two decades, or to maintain a high rate of home deliveries, as in the Netherlands. In the United States, comparable implementation of health policy goals relating to maternal and child health have been subject to coordination problems at the federal level and wide diversi- fication at the state and local levels. The United States' investment in physician education and hospital technology and facilities is large. In the field of maternity care, the number of obstetricians in training is increasing. ® The centralization and scope of perinatal services has been greatly augmented in the last decade. In response to the declining birth rate, numbers of maternity beds in hospitals have decreased. ’ The relation of national health care systems and policy to medical outcome is subject to wide variations. Measured in the gross terms of infant, perinatal, neonatal, and maternal mortality rates (Tables I, II, III and IV), the general trend in industrialized nations is towards reduced levels. The identification of cause and effect factors that link cesarean births to outcome is no clearer in these countries than in the United States. However, Canada, France, the Netherlands, and 75 Great Britain will be taken as case examples by which major influences on increasing cesarean rates can be assessed. Despite a lack of uniformity in the data available, three general descriptive areas can be addressed. The first is the characteristics of mothers and infants which might bear on cesarean birth rates or have been found associated with the procedure. The second is the division of obstetric responsibilities among specialists, general practitioners and midwives. The third area includes the avail- ability of medical facilities which permit surgical intervention in childbirth. “THE CANADIAN EXPERIENCE Despite the common border shared by the United States and Canada, the recognition of political and sociodemographic differences tempers any comparison of health and medical statistics. The political autonomy of the provinces in Canada is considerable and has been augmented by legis- lation in recent years. This autonomy is reflected in the administration of health insurance plans which, while based on nationally defined goals, are designed to serve distinct provincial populations. In maternity services, the level of cross utilization between populations is minimal, allowing statistics from each province to reflect conditions within that political area. At the same time, variations in population density and levels of urbanization among provinces tend to greater extremes than in the United States. The urbanization of greater Montreal is comparable with that of the mid-Atlantic United States. The sparsity of settlement over much of the Canadian north and west is much less than our own southwest. The population density of Canada is 2 persons per square mile and the population density in the United States is 23. 76 The rise in cesarean birth rates varies greatly among provinces (Table V). The sharpest increase occurred in Newfoundland where the rate went from 4% in 1969 to 14% in 1976. Similarly, Prince Edward Island cesarean birth rates (representing small numbers) rose from % to 16%. Nova Scotia showed an apparent gain from 5% to 11%. In contrast, the neighboring province, New Brunswick, shows an increase of only four percentage points during the same time period. In the most populous and urbanized provinces, Quebec and Ontario, the rates increased from 5% and 6% respectively to relatively modest levels of 10% and 11%. In the western provinces, British Columbia, the region's most heavily settled and urbanized province, exhibited a rate increase from 6% to 13% with a comparable rate gain in Alberta and much sharper gains in the more rural provinces of Saskatchewan and Manitoba. MATERNAL CHARACTERISTICS Nationally there has been a shift away from women over thirty-five having cesareans and a commensurate increase in women in the 15-19 years category and most strikingly, in the 25-29 years category. Table VI shows distributions by three sets of provinces: Ontario and Quebec which follow the national trend; British Columbia and Alberta which demonstrate a shift to even younger age brackets among women having cesareans; and New Brunswick and Newfoundland which evidence an even younger median age for mothers. The differences parallel fertility trends in the three areas over the same time period. While fertility rates have been declining for all age groups, the 77 steepest decline has been in older age groups. In the western provinces, fertility rates for ages 20-29 increased; in the Maritimes this increase extends to the 15-19 age bracket. If age itself is taken as a predictor of increased likelihood of cesarean delivery, the reduction in numbers of older women would have diminished the overall rate of cesareans. In most populous provinces, including British Columbia and Alberta, the increase in the 25-29 years age category more than compensates for any reductions in the older age category. The increase in cesareans in the under twenty population in the Maritimes suggests compensation from that direction. A most important deficit here is the lack of information on parity, repeat cesareans, and medical complications, as well as social class variables, as a means of identifying the population accountable for the total rate increase. PHYSICIAN PRACTICE AND HOSPITAL RESOURCES Detailed information for Canada as a whole on diagnoses leading to cesarean delivery has yet to be compiled and analyzed. Data available from the province of Alberta does indicate the importance of repeat cesareans, fetopelvic disproportion (type unspecified), breech presen- tation, and fetal distress, in that order, in accounting for about two-thirds of cesarean births in 1976 and 1977 (Table VII). This generally coincides with observable trends in the United States. The distribution of obstetricians by province generally follows rates and rate changes for cesarean deliveries. Research linking changes in medical professional services to cesarean rate increases in Canada has not yet been done. However, in 78 other research on surgical procedures in Canada, particularly that of Stockwell and Vayda, © both numbers of practicing obstetricians and available maternity beds in hospitals would predict rate changes. The Canadian example, offering a variety of accommodations to physicians, makes it difficult to characterize professional autonomy and antenatal care. We do know that government promotion of medical education has been heavily weighed towards physicians rather than paraprofessionals, such as midwives, and that the provinces have not been receptive to midwifery even as a solution to rural access problems. As in the United States, the role of the teaching hospital in the rise of cesarean rates remains largely unexamined. In Ontario, which is the subject of the Stockwell and Vayda study, data for 1976 through 1978 indicates that the percentage of all cesareans being performed in teaching hospitals has been decreasing. Of the total number of cesareans per formed in 1976, 42% were done in teaching hospitals, whereas in 1978, the teaching hospitals accounted for 30%. The remaining cesareans were almost entirely in other public hospitals; private hospitals account for less than 1% of the cesarean births. If we look at information from Manitoba, the teaching hospital accounts for a larger proportion of the cesareans than in Ontario, and has remained at 52%. Similarly, in Alberta, for 1976 and 1977, teaching hospitals accounted for 56% of all cesareans per formed. 79 Nevertheless the influence of the teaching center is large. Further, their roles may be more influential in developing areas such as Newfoundland, Manitoba, and British Columbia, rather than the more established provinces of Ontario and Quebec. On the cesarean procedures themselves, national data over the last decade demonstrates a preference for the low transverse cervical incision, a reduced incidence of classical cesareans, and the virtual elimination of the extraperitoneal procedure. This parallels changes seen in most countries. THE FRENCH EXPERIENCE Since the end of World War II, in a programmatic effort to rebuild the national population, the French government has made a considerable investment in preventive programs in maternal and infant health. The demographic obstacles to this effort have been less acute in the urbanized northeast and east than in western regions which have been depopulated by migration, particularly to Paris and the east,’ Relative to the rest of Western Europe, the population density of France is low (97) as compared to 229 in Great Britain and 329 in the Netherlands. The greater part of France's fifty-four million population is located in the area west of a straight line which can be drawn between Provence and Haute-Normandie. Even within this area, the Paris region claims one-fifth of the national population with other centers in Lorraine, Alsace, Franche-Compte', Rhone Alpes and Provence-Cote D'Asur. While the French birth rate has been declining, the number of foreign workers, predominantly from North Africa, Southern Europe and Turkey, has been increasing. The present proportion of "guestworkers" is 80 about 8% of the national population and they have tended to concentrate y 10 in urban areas. THE FRENCH NATIONAL STUDY ON PREGNANCY AND CHILDBIRTH Due to a recently completed national study on pregnancy and child- birth, details of the medical context of cesarean deliveries are more available for France than for Canada or other nations reviewed in this report. Characteristic clinical facts, such as Apgar scores, rates of fetal monitoring, prenatal visits, and choice of physician have been reported along with socioeconomic information. For the most part this data has not been correlated with changes in cesarean birth rates. Nonetheless, there are discernible trends within regions which allow for speculation on the general rise in cesarean rates in France. The National Inquiry is based on a sample of 11,171 births in 1972 and of 4,685 in 1974-1976, selected from thirteen regions, each averaging approximately 75,000 births annually. The cesarean birth rate recorded in this study rose from 6.1% to 8.5%. From the National Inquiry and other studies on maternal health, maternal professional and upper class status are negatively associated with morbidity and mortality of mother and newer. 2 Migrant status and medical history of previous stillbirths, low birthweight infant, and parity of three or more effectively predicted perinatal mortalily. In an independent study of the relationship between maternal occupation and cesarean births, a significant association was found to exist between a woman's professional status and cesarean delivery. Limitation of the research to public hospitals may have resulted in differential 81 selectivity among various categories of women, thereby imposing restrictions on the interpretation of this Finding. 1’ Nationally the proportion of immigrants increased from 8.7% in 1973 to 11.6% in 1976. In the national inquiry sample the percentage of immigrant mothers increased from 14.8% in 1972 to 17.7% in 1976. At the same time, the distribution of the age of French mothers shifted away from both those under 20 years and over 30 years of age to women in their 20's (Table IX). The number of women in France having their obligatory four prenatal visits has increased significantly. In 1972, some 15.3% of the sample population had less than four visits; in 1975-76, this had decreased to 10.6% (p < 0.01). Concurrently, the recorded incidence of pathology during pregnancy increased. Diabetes, hypertension, vaginal and urinary infections increased. As for infant health, the proportion of low birthweight remained the same, but the percent of newborns with Apgars of less than 7 increased (24.1% in 1972 to 34.3% in 1975-76, p < 0.01) as did the percent who failed to cry immediately (16.7% to 23.2%, p < 0.01). These figures exclude infants born by cesarean. Statistically significant increases were also noted for all infants in cardiac, respiratory, and nervous disorders as well as infection and anemia. MEDICAL PRACTICE AND HOSPITAL RESOURCES The rise in cesarean birth rates coincides with a general trend towards increases in professional management of labor and delivery. National fetal monitoring rates have increased in the four year period 82 (1972-1976) from 6.4'percent to 31.percent. Instrumental deliveries in general have also increased from 11% to 14%. This is in contrast to the data reported in the New York City experience in Chapter IX. National trends in physician care show a decline in use of the general practitioner (from 11.9 to 6.5 percent), with the sharpest decline among those mothers under twenty years of age (10.9 percent to 4.7 percent) and those with a previous history of stillbirth or low weight infants (16.2 to 4.5 percent). Relative to the United States, and Canada, the French midwife plays an important role in prenatal care, surveillance of labor, and responsibility for delivery. The role of physicians in the hospital context is nonetheless dominant and, since the number of home births in France is minimal, the authority of the midwife has to be looked at from the perspective of medical teamwork in larger facilities or shared responsibilities in small clinics. The general trend has been for increasing numbers of pregnant women to seek out the services of a physician and, among physicians, to prefer obstetricians. General practitioners tend to be consulted more frequently in the first trimester. By the third trimester, however, 67.5 percent of the pregnant women in the National Inquiry had seen an obstetrician. In addition, working class and rural populations tend to rely on the services of a general practitioner, while educated, professional parents use the services of obstetricians. Even with working class and rural women as patients, the general practitioner is becoming less involved in obstetric 83 care as the demand for obstetricians increases. In the time period of the national study the percent of women in the care of general practi- tioners declined from 27.1 to 19.4 (p < 0.01). The trend in hospital utilization has been towards public and larger hospital facilities, although 55.4 percent of deliveries still take place in private hospitals and clinics. Since 1972, 34.2 percent of public maternity units with less than fifteen beds and 42.9 percent of private maternity units with less than fifteen beds have closed. For all maternity units the percentage of closings of private facilities has been twice that of public. Nonetheless, the percentage that are small units remains high: 31.3 percent of public facilities and 35.5 percent of private; but larger units (over 25 beds) claim the largest proportion of deliveries (68.2 percent in 1976, up from 46.6 percent in 1972). As in the United States and Canada, the investment in neonatal intensive care is recent and considerable. The percentage of newborns transferred to neonatal intensive care rose from 5.9 percent in 1972 to 8.6 percent in 1976. This fact may reflect the new availability of such treatment, primarily in the larger hospital setting. 7 REGIONAL CHANGES IN CESAREAN BIRTH RATES Regional changes in cesarean birth rates were investigated in the national study and are represented in Table VIII. Nine regions underwent changes at a statistically significant level. Aquitaine, Auvergne, Centre, Champagne, Franche-Compte', Lorraine, Grande Couronne, and Rhone-Alpes increased their cesarean birth rates. In the Midi-Pyrenees 84 region, cesarean birth rates decreased by sixty per cent. Although limited numbers of cases does not permit a high level of statistical certainty about the rate changes in Limousin and in Haute-Normandie, each is of interest in the extremes they demonstrate. The Limousin rates rose from 4.4 percent in 1972 to 18.2 percent in 1976. In contrast, rates in Haute-Normandie during the same time dropped from 4.5 percent to 3.7 percent. Turning to perinatal mortality figures, the trend to decreasing rates has been consistent for all regions, although further statistical analysis might reveal a connection between increased medical intervention and sharp reductions. In Alsace and fFrance-Compte, for example, a dramatic drop in perinatal mortality rates was accompanied by an equally dramatic rise in cesarean-birth rates. However, a nearly identical reduction in mortality took place in Picardie and Corse without a great investment in cesareans. The most problematic stillbirth rates endure in the western and most populated half of France and improvements which have occurred, as in Limousin and Midi-Pyrenees, seem to have done so regardless of cesarean birth rate changes. As noted elsewhere in this text, stillbirths are not easily related to cesarean birth rates, since when present, a vaginal mode of delivery is generally chosen. This information with respect to stillbirth and perinatal mortality rates is presented as another example of the complexity of the problem of cesarean birth rates. The material is too complex to be examined in depth in this report. 85 PHYSICIAN PRACTICE To put the rise in cesarean birth rates in the context of other changes in modes of delivery illustrates once again the point that medical management in general has increased. The Midi-Pyrenees, with its low rate of cesarean births, has about the same percent of spontaneous deliveries as Limousin with the highest cesarean rate. In the former region there is an increase in inductions and use of episiotomies. Nationally, spontaneous delivery has dropped from 85 per cent in 1972 to 80 percent in 1976 paralleling the trend in the United States. Another trend which gives an indirect measure of changes in obstetric care is the proportion of deliveries performed by generalists as opposed to specialists (Table X). The one region in which cesarean rates have recently decreased, Midi-Pyrenees, is the only one in which the proportion of generalists has not changed importantly (18.6 percent and 20.0 percent in 1972 and 1976 respectively). Otherwise, the majority of regions with increased cesarean rates also show a decrease in the percent of generalists in charge of deliveries. While this is far from conclusive evidence, it seems reasonable to assume that an increase in the use of specialists will affect the choice for increased intervention in the process of delivery. The recent decision of the French government to decrease physician numbers while also encouraging family practitioners via changes in educational policy should provide new insights to the effect of policy on specialist vs. generalist involvement in maternal and infant — 86 THE NETHERLANDS EXPERIENCE Maternal and infant care programs in the Netherlands are supervised by an administratively decentralized system aimed at meeting the needs of some fourteen million people living in the most densely populated nation in the world. Three-quarters of the population lives in urban areas. The cesarean birth rates in the Netherlands have been among the lowest of industrialized countries, with an equally low rate of increase. Hoogen- doen reported that between 1968 and 1975, the cesarean delivery rate increased from 1.8 percent to 2.8 percent. In more recent years, the rate of increase has accelerated. Still the Netherlands presents a profile of both low cesarean rates and low maternal and infant mortality rates which distinguishes it from other industrialized nations considered in detail in this report. While not researched in great detail, the influx of migrant workers to the Netherlands has been cited as a special problem in obstetric —— Migrants, largely from the East Indies and Turkey, account for 6 per cent of all births and have a birthrate of 30 per thousand, as opposed to the Dutch rate of 12.6. MATERNAL HEALTH The emphasis in maternal health care in the Netherlands is on the early identification of high risk mothers. The average number of prenatal visits is twelve. All mothers are reported as seeing their physician or midwife in the third TL The average maternal age is twenty-six. Primiparity proportion has increased with the decrease in family size. 87 The rate of vacuum extractions, forceps and cesarean deliveries by maternal age is indicated in Table XI. The highest rates of procedures apply to primiparous women, especially those over thirty. This is more true for vacuum extraction and forceps delivery than for cesarean birth. In the latter, the overall rate per 1000 births tends to equalize between primiparae and multiparae. The frequency of these three procedures by parity from 1968 to 1975 is presented in Table XII. In each case, the primiparae receive the most treatment, yet the gap between treatment rates for each group narrows somewhat over the years by virtue of a proportionally greater rate increase. Since primiparity and multiparity are numerically equal in the Netherlands, the shift is a significant one. In 1979 percentages for these same three procedures reveal roughly the same pattern. Of all primiparae, 4.8 percent had vacuum extractions, 2.3 percent had forceps deliveries, and 2.7 percent had cesarean births. Of all multiparae, only 1.0 percent had vacuum extractions, 0.4 percent had forceps deliveries, and 2.3 percent had cesareans., MEDICAL PROFESSIONALS AND HOME BIRTH Unlike other industralized countries, the Netherlands has made the support of home births a matter of government policy and thus avoided the nearly 100 percent hospitalization rate for delivery which prevails in the United States, Canada and Western Europe. The home birth rate is currently at 38 percent. This represents a decline from 42 percent in 1977 and from 63 percent in 1969.17 88 The shift to hospitalization for childbirth is accompanied by a diminishing reliance on the general practitioner, who now handles about 20 percent of all obstetric cases. The work of the specialist has increased to 40 percent of all births. A third professional, the midwife, handles the remaining 40 percent. Maternity aids (trained nurses) are another category of health professionals whose function is to assist at home births and provide postnatal care and domestic help. The declining birth rate in the Netherlands has particularly affected general practitioners, although the tendency towards group practice and government initiative in equalizing salaries between generalists and specialists is expected to offset the declining role of the general practitioner. Midwives, too, have been affected. Their work is or can be centralized. However, often several midwives will run maternity homes of about twenty beds or less for women who prefer not to deliver at home but do not want or need hospitalization.2! The advantages of reimbursement go to midwives whose services are covered. In order for the services of a consultant physician to be reimbursed, certified proof of medical conditions has to be shown. FACILITIES FOR CHILDBIRTH Rather than the contrast implied in home versus hospital births, a range of facilities for delivery is available in the Netherlands. The maternity home is equivalent to home birth in the deemphasis of technology. 89 No surgical services, anesthesia or, in most cases, forceps deliveries are provided for. A second equally small category of facility known as the polyclinic is available. Here technology is minimal, but the polyclinic is associated with a hospital or directly within it. Most hospitals are without large obstetric wards. The average number of deliveries per hospital in a year is 500. 2] There are sufficient numbers of hospitals for the claim to be made that no one is more than one half hour from one. Further, the government has invested in an ambulance service which virtually guarantees the transport of expectant mothers under the supervision of a nurse and a driver trained in resuscitation. The pattern of hospital confinement is as follows: 38 percent give birth at home or in a maternity home, 35 percent are referred to a hospital before delivery on the basis of possible medical risk, and the remaining 27 per cent opt for hospitalization despite the financial penalty levied against those for whom hospitalization is not medically indicated. The unreimbursed portion of the bill for one hospital day roughly equals the total cost for ten days of maternity home care. Approximately 30 per cent of those hospitalized (and presumably those in the best health) stay only one or two days, considerably less than the ten days allotted to lying in under national insurance. Some 15 per cent of those in maternity homes de the same. An increase has also been noted in reliance on the services of maternity aides among both those hospitalized and those giving birth at home and in maternity homes. |? The trend in 90 hospitalization indicated here is a precautionary one, rather than one based on patient choice. Anesthesia is given for spontaneous delivery. On the other hand, an obstetrician supervises all at-risk deliveries. The medical management of delivery has, as in France, shown signs of increasing with vacuum extractions more frequent than cesareans. THE EXPERIENCE IN GREAT BRITAIN Specific information on cesarean births in Great Britain is not readily available, but nonetheless can be placed in the context of health systems and population changes which have affected Western Europe. In general Government sponsorship of maternal and child health programs is longstanding. 20 The present centralized administration serves a population of 56 million, 76.9 percent of whom live in urban areas. The immigrant population reached 9 percent in 1977; the great majority of these are working class , live in cities and have emigrated from former British colonies in Asia, Africa, and the Caribbean.?’ MATERNAL AND INFANT MORTALITY FIGURES Between 1964 and 1975 the total number of births in England and Wales dropped from 890,518 to 609,740, while the rate of cesarean deliveries rose from 3.2 percent to 5.7 percent. In the same period of time, with increased hospitalization for delivery, maternal mortality rates following cesareans have decreased from 1.3 per thousand to 0.7 per thousand. If we look at the overall maternal mortality rates for 1964 to 1975, the decrease measured from 20 per 100,000 to 11 per 100,000.22 91 The differences between general maternal mortality rates and those connected with cesarean deliveries are diminished when the distinction is drawn, inasmuch as it can be, between avoidable factors having to do with the choice and implementation of a cesarean, and other unavoidable condi- tions, such as the mother's prior state of health (see Table XIII). In the Report on Confidential Enquiries into Maternal Deaths, the 81 deaths following cesarean birth occurring in 1973-75 were analyzed, with 61 designated as true maternal deaths and 20 as caused by an associated disease. This report is described in more detail in Chapter X. As Chalmers and Richards? have interpreted the figures on maternal mortality, there was a 54 percent improvement in the chances of post- cesarean survival between 1954 and 1972. However, because of the increase in numbers of cesareans being performed, there was only a 19 percent reduction in the overall risk associated with the operation. A rise in the proportion of women who have severe disease incidental to their pregnancies is cited as an influence on maternal mortality rates associ- ated with cesareans. The authors cite also the increasing importance of pulmonary embolism and complications of anesthesia in accounting for maternal deaths. With regard to general statistics on stillbirths, perinatal and neonatal mortality (not specified as related to cesareans), changes have generally followed those reported by Koosterman for the Netherlands.2 Conditions susceptible to prenatal care, toxemia, antepartum infections, placental insufficiency, and hemolytic disease account for most stillbirths. 92 Congenital anomalies continue to make up a large proportion, approximately twenty percent, of the current (1977) rate of 9.4 deaths per 1000. This is about the proportion which held in 1972 through 1976, with some variation. PHYSICIAN PRACTICE AND HOSPITAL SERVICES Increased medical management of labor and delivery, found in the French National Inquiry, would also seem to apply in England. Cesarean and forceps births and induction rates have each increased as a percentage of all deliveries in England and Wales. Induction in particular was the source of controversy and investigation, with rates in some hospitals reported at 70 percent. As a surgical procedure, cesarean births may affect a relatively small and hot expanding population of patients because of the limited licensure prevailing in England. With virtually no increase in hospital beds in decades and with restrictions on the numbers of surgeons assignable to hospitals, the ratio of surgeons was reported in 1968-69 as 19.0 per 100,000, as compared to 27.3 in Canada and the United States.28 Presumably, the same disparity exists today and is not necessarily contradicted by the fact that hospital physician staff grew by 50 percent between 1963 and 1974.27 Competition between specialists and general practitioners and between physicians and midwives in England has been represented as less than in The Netherlands. 28 State investment in domiciliary health services has provided an expansion of midwife services for therapy and education. The midwives are integrated into the hierarchy of hospital personnel, although more at the level of the French midwife than their 93 Dutch counterpart. The general practitioner, being without surgical license, demurs to the obstetrician in cesarean cases. An obstetrician routinely screens virtually all women at some time during pregnancy. Provided good transportation is available to a central hospital, ventures in rural areas involving maternity clinics staffed only by general practitioners have been successful in terms of perinatal and maternity mortality rates. 2? Despite a programmatic emphasis on home care, the British Ministry of Health reported that home births, at 33 percent in 1961, had rapidly given way to hospital deliveries,” and by 1970, only 5 percent were home births.>0 Another trend has been the closing of small hospitals and the centralization of medical resources in larger facilities. In 1977, 2 percent of all births took place at home (10,940 of a total of 574,664 live and still births). In contrast to The Netherlands, the stillbirth rate for home births (11.2 per 1000) did not compare favorably with hospital deliveries. Hospitals and homes under the National Health Service with maternity facilities (non-surgical) enjoyed a rate of 2.8 per 1000. The remainder of NHS hospitals had a rate of 9.9 per 1000, while maternity homes not under NHS had a rate of 5.7. A fifth category of confinement includes psychiatric institutions, homes for unmarried mothers, remand homes, reception centers and private houses other than the mothers' usual place of residence; in this category the stillbirth rate was 40.6 per 1000.°" Implied here is a selection of difficult cases to hospitals with obstetric facilities, as well as a combined selection by pathology and social class to other institutions unlikely to be equipped with specialized technology or surgeons. 94 The great majority of deliveries (approximately 80 percent) take place in the second category of hospital rather than in general practice maternity hospitals. In 1977 the latter hospitals were responsible for less than ten percent of all deliveries in England and Wales, indicating that the relatively high rate of mortality in hospitals with consultant obstetricians is the result of a mixture of high risk and low risk patients. 1. SUMMARY The increased use of specialist services in labor and delivery emerges as an important cross national trend. In the United States, the percent of pregnancies delivered by an obstetrician went from 68 percent in 1968 to 81 per cent in 1977.2 Similar trends, but with lower percentages, occurred in other countries surveyed. Increases in cesarean rates are influenced by availability of physician and hospital services and these, in turn, are subject to influence by government policy and incentives. When the impetus for medical development is strong, as it has been in developing regions of Canada and France, the cesarean rate increase appears to rise in association with investments in specialist services and hospital technology. With conservative government policy, of which the Netherlands is the best example, access to surgically equipped facilities and obstetricians is controlled by insurance reimburse- ment and programmatic early identification of high-risk mothers. Public preference for specialist services and, by inference, for the reduction of risk which expertise and technology promises, is evident in all areas. 85 The presence of the specialist in the United States and Canada may be contrasted with the integration of midwives and other auxiliary personnel into hospital and home care for pregnant women in some countries in Western Europe. The use of obstetricians' services roughly correlates with rates of cesarean births in the United States, Canada, France, England, and The Netherlands, in descending order of frequency of cesarean birth rates. 96 TABLE I. INFANT MORTALITY RATES - SELECTED YEARS PER 1,000 LIVE BIRTHS United States Canada France Great Britain and Wales Netherlands Norway Source: Data from 1969, 1974-75 from the World Health Statistics 1969 1974 1975 1976 1977 20.7 16.7 16.1 15.2 14.0% 19.3 15.0 14.3 13.5 12.4 19.6 14.7 13.8 12.5 11.4%+ 18.0 16.3 16.0 14.0 13.7% 13.2 11.3 10.6 10.7 2.5 13.8 10.5 11.1 10.5 9.2 Annual volumes for 1976-77 from United Nations Demographic Yearbook, 1978. * Provisional + Excluding deaths of infants dying before registration of birth 97 TABLE II - PERINATAL MORTALITY RATES - SELECTED YEARS PER 1,000 LIVE BIRTHS 1969 1974 1915 United States 24.2 22.2 20.7 Canada 22.5 16.6 -- France 25.4 19.5 18.3 Great Britain and Wales 23.7 20.6 19.9 Netherlands 19.8 16.9 14.0 Norway 20.7 15.7 14.2 Source: World Health Statistics Annual Volumes 98 TABLE III - NEONATAL MORTALITY RATES - SELECTED YEARS PER 1,000 LIVE BIRTHS 199 1974 1975 United States 15.6 12.3 11.6 Canada 13.9 10.0 9.7 France 13.7 2.9 9 Great Britain and Wales 12.0 11.0 10.7 Netherlands 10.0 8.0 7.6 Norway 10.5 7.4 po Source: World Health Statistics Annual Volumes 99 TABLE IV. - MATERNAL MORTALITY RATES - 1968-69 AND 1975-76 PER 1,000 BIRTHS 1968-69 1975-76 United States 24.35 12.55 Canada 25.45 9.3 France 22.05 -- Great Britain and Wales 19.5 71.5 Nether lands* 19.45 7.9 Norway* 14.1 3.15 * Based on fewer than 30 cases per year Source: Demographic Yearbook, United Nations, 1978 100 TABLE V. - CANADA - CESAREAN BIRTH RATE CHANGE BY PROVINCE - 1969-1976 Canada Nova Scotia New Brunswick Prince Edward I. Newfoundland Quebec Ontario Saskatchewan Alberta British Columbia Manitoba 5 5 (719) (553) (113) (537) (4699) (7648) (786) (1401) (2079) (704) 1969 (%) 1" 9 16 14 10 11 10 10 13 1976 (%) (1435) (1059) (306) (1581) (9364) (13,432) (1526) (3240) (4692) (1684) % Rate Change 120 80 161 250 100 83 150 100 117 175 TABLE VI - % AGE DISTRIBUTION OF CESAREAN BIRTHS BY PROVINCES (SELECTED) 1976, 1976 Canada Ontario Quebec British Columbia Alberta New Brunswick Newfoundland 101 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45+ 1969 .009 07 .30 .28 .18 .12 .05 .0044 1976 .0011 .09 .30 .36 +77 .06 .016 .0012 1969 .001 .07 «29 «29 19 .11 .04 .004 1976 .001 .08 .30 +37 «17 .06 .02 .001 1969 .002 .05 .28 .30 .19 .14 .05 .004 1976 .001 .05 .28 .39 .20 .06 .02 .001 1969 .005 .07 «3 .30 “17 «11 .04 .004 1976 .002 .08 .30 .38 «17 .06 .01 .001 1969 .002 .07 .33 .28 «17 .10 04 .004 1976 .001 «10 «32 «35 15 .06 .02 .001 1969 .10 .38 +29 .18 .09 .06 011 1976 .001 .16 «37 .30 «12 .05 .008 1969 004 «12 «32 22 .15 .10 .07 .011 1976 .001 .18 .36 «26 .06 .05 .02 .001 102 TABLE VII - DIAGNOSIS OF CESAREAN SECTION PATIENTS TREATED IN PUBLIC AND FEDERAL GENERAL HOSPITALS RANKED IN DESCENDING ORDER BY FREQUENCY OF OCCURRENCE, ALBERTA, 1976 TO 1977 H-ICDA-2 SEPARATIONS PERCENTAGE SEPARATIONS PERCENTAGE DIAGNOSTIC Primary Diagnosis CODE OF TOTAL OF TOTAL Previous cesarean section 664.4 895 29.7 1,081 29.4 Fetopelvic disproprotion- type unspecified 655.9 539 17:5 630 17.1 Breech presentation 656.0 272 8.9 330 9.0 Fetal distress 664.7 221 7+2 267 7:3 Prolonged labor - not otherwise specified 657.9 138 4.5 145 3.9 Complication of delivery- unspecified 664.9 74 2.4 104 2.8 Prolonged first stage of labor-unspecified 657.3 72 2.3 101 27 Placenta previa, partial 651.0 64 2.1 91 2.5 Persistent occiput posterior 656.5 62 2.0 83 2.3 Prolonged pregnancy 664.6 59 1.9 77 2.1 Premature separation of placenta, partial 651.2 51 1.7 68 1.9 Premature labor 664.3 50 1.6 63 1.7 Abnormality of bony pelvis- type unspecified 654.9 48 1.6 56 1.5 Premature rupture of membranes 664.0 45 1.5 52 1.4 Transverse presentation 656.1 42 1.4 42 1.1 Excessive size of fetus 655.0 40 1.3 40 1.7 Prolonged rupture of membranes 664.1 38 1.2 38 1.0 Multiple pregnancy-unspecified 662.9 35 1.1 38 1.0 Placenta previa,complete 651.1 30 1.0 32 W.' Transverse arrest-fetal head 656.6 26 +9 32 9 103 TABLE VIII - FRANCE - CESAREAN BIRTH RATE CHANGES BY REGIONS 1972-1975-6 1972 1975-6 % France 6.1 8.5 39 p < 0.001 Alsace 4.8 7.8 63 NS Aquitaine 4.9 1.1 127 p < 0.01 Aubergne 4.3 11.4 165 p < 0.01 Bourgogne 9.1 12.3 35 NS Bretagne 6.6 6.1 8 NS Centre 5.7 1127 105 p < 0.05 Champagne 1.6 5.9 269 p < 0.05 Franche-Comte 2.5 8.2 228 p < 1.05 Languedoc-R 8.6 14.7 71 NS Limousin 4.4 18.2 314 NS Lorraine 2.6 8.1 212 p < 0.01 Midi-Pyreness 9.1 3.6 60 p < 0.05 Nord-Pas-DC 3.8 4.8 26 NS B- Normandie 5.8 9.8 69 NS H- Normandie 4.5 3.7 18 NS Pays de la Loire 9.5 11.8 24 NS Picardie 2.6 6.1 69 NS Poitou-Ch. 5.2 6.0 15 NS Prov. + Corse 1.2 7.3 35 NS Paris 9.2 9.4 2 NS Petite Couronne 72.5 2.9 32 NS Grande Couronne 4.6 13.3 189 p < 0.001 Rhone-Alpes 4.6 7.5 63 p < 0.05 TABLE IX - FRANCE - CHANGES IN MATERNAL AGE DISTRIBUTION 1972 and 1975-1976 Age - mother < 20 years 21-29 years > 30 years 1972 16. 61. 22. 3 104 1975-1976 14.5 ) 66.9 ) 18.6 ) p > 0.001 105 TABLE X - FRANCE - CHANGES IN THE FREQUENCY OF DELIVERIES PERFORMED BY GENERAL PRACTITIONERS, 1972 and 1975-76 Regions 1972 1975-1976 France 11.2 6.5 p < 0.001 Alsace 0.2 0.0 NS Aquitaine 13.5 4.0 p < 0.001 Auvergnee 15.3 3.8 p < 0.001 Bourgogne 8.2 745 NS Bretagne 29.6 7.7 p < 0.001 Centre 14.5 2.8 p < 0.001 Champagne 0.6 0.6 NS Franche-Comte 5.9 2.3 NS Languedoc-Roussillon 18.5 5.9 p < 0.01 Limousin 36.9 4.6 p < 0.01 Lorraine 1.8 0.0 NS Midi-Pyrenees 18.6 20.0 NS Nord-Pas-de-Calais 14.0 7.8 p < 0.01 Basse-Normandie 36.6 18.6 p < 0.001 Haute-Normandie 12.8 7142 p < 0.05 Pays de la Loire 19.4 16.8 NS Picardie 6.6 12.2 NS Poitou-Charentes 29.1 13.0 p < 0.001 Provence + Corse 20.2 14.6 p < 0.05 Paris 0.2 0.0 NS Petite-Coiuronne 2.2 149 NS Grande-Couronne 2.8 0.3 p < 0.01 Rhone-Alpes 7.6 5.3 NS 106 TABLE XI - NETHERLANDS - FREQUENCY OF PROCEDURES BY AGE OF MOTHER AND PARITY - 1971-1975 Ages of Vacuum Extract Forceps Cesarean Mother Primi- Multi- Primi- Multi- Primi- Multi- parae parae parae parae parae parae per 1,000 births < 20 years 28 10 14 7 17 13 20-24 39 8 18 3 20 13 25-29 55 9 24 4 28 18 30-34 87 12 38 5 55 28 35-39 120 17 57 8 119 44 40+ 152 19 52 8 209 70 All ages 48 10 22 4 27 23 107 TABLE XII - NETHERLANDS - FREQUENCY OF PROCEDURE BY PARITY 1968-1975 Vacuum Extract Forceps Cesarean Primi- Multi- Primi- Multi- Primi- Multi- parae parae parae parae parae parae per 1,000 births 1968 32.5 5.3 17.8 2.9 21.1 14.6 1969 8.7 6.5 16.8 2.5 25.9 16.0 1970 43.7 7.5 17.0 2.5 25.2 16.4 1971 48.8 8.6 21.5 3.7 25.5 17.0 1972 44.4 8.6 21.6 4.1 25.6 19.7 1973 48.6 9.6 22.3 4.7 27.8 22.5 1974 53.6 11.8 24.1 4.4 29.7 24.9 1975 58.7 12.8 24.7 4.9 32.2 24.3 108 TABLE XIII - GREAT BRITAIN DISTRIBUTION OF IMMEDIATE CAUSE OF DEATH AMONGST CESAREAN SECTION DEATHS - 1973-75 Number of Number of All Deaths deaths with deaths with Number Percentage of no avoidable avoidable total deaths Immediate Cause factor factor Haemorrhage 1 7 8 9.9 ’ Pulmonary embolism 4 2 6 7.4 Sepsis and paralytic ileus 1 7 8 2.9 Hypertensive diseases of pregnancy 4 8 12 14.8 Anesthesia 1 16 17 21.0 Other true causes 5 S 10 12.3 Associated diseases 16 4 20 24.7 Total 32 49 81 100.0 109 BIBLIOGRAPHY Ts See, for example, . Johnell, H.E., Ostberg, H., and Wahlstrand, T.: Increasing Cesarean Section Rate. Acta Obstetricia et Gynecologica Scandinavica, Vol. 55, 1976, pp. 95-100. Frankenburg, H.W.: Die Wandlung der Kaiserschnitt-Indikationen. Changes in the Indications for Cesarean Sections. Geburtshilfe und Frauenheilkunde, Vol. 35, 1975, pp. 265-72. Albrecht, H.: Kritische Analyse einer hohen Kaiserschnittfrequenz unter besonderer Berucksichtigung der Kindlichen Morbiditat. Critical Analysis of a High Percentage of Cesarean Section, Particu- larly with Regard to Infantile Morbidity. Zeitschrift fur Geburt- shilfe and Perinatologie, Vol. 179, 1975, pp. 206-14. Unless otherwise noted, descriptive information on maternal and child health care in Canada, France, The Netherlands, and Great Britain and Wales is from government documents received in response to Task Force inquiries and cited in detail below, In addition to the information compiled in Tables I-IV, see specific studies cited in case discussions as well as the following conference proceedings: World Health Organization, Conference on New Trends in Maternal and Child Health, Moscow 1974; Copenhagen 1975; Rooth Gosta and Lars-Eric Bratteby, eds, Perinatal Medicine Fifth European Congress of Perinatal Medicine, Uppsala, Sweden, 1976, Stockholm, Almgrist & Wiksell International, 1976. For further information on mortality trends, see Shapiro, Sam: A Perspective on Infant and Fetal Mortality in the Developed Countries. World Health Organization Bulletin, 1975, pp. 96-116 and Kessner, D.M., et al. Infant Death: an analysis by maternal risk and health care. Washington, D.C., Institute of Medicine, National Academy of Sciences, 1973. Bamford, F.N.: Immigrant mother and her child. British Medical Journal, 1, 1971, pp. 276-280; Barron, S. L. and M.P. Vessey. Immigration - a new social factor in obstetrics. British Medical Journal, 1, 1966, pp. 1189-1194; Berger, C., J. Laugier, and J. Soutoul, Caracteristiques de 1'accouchement et du nouveau-ne de migrante. Journal of Gynecology, Obstetrics and Biological Repro- duction, 3, 1974, pp. 1227-1234; Antonovsky, A. and J. Bernstein. Social class and infant mortality. Social Science and Medicine, 11, 1977, pp. 453-70; Brooks, C.H. The changing relationship between 110 socio-economic status and infant mortality: An analysis of state characertistics. Journal of Health and Social Behavior, 16, 1975, pp. 291-303; Ventura, Stephanie J., Selma M. Taffel and Ernell Spratley. Selected Vital and Health Statistics in Poverty and Nonpoverty Areas of 19 Large Cities, United States, 1969-71. Vital and Health Statistics Publications Series 21, No. 26, DHEW Publ. No. (HRA) 76-1904., Washington, D.C., U.S. Government Printing Office, 1975. Davis, Karen and Cathy Schoen: Health and the War on Poverty. Brookings Institution, 1978, pp. 120-160; HEW, Maternal and Child Health Service, Promoting the Health of Mothers and Children, Fiscal Year 1973, DHEW (HSA) 74-5002; Steiner, Gilbert Y., The Children's Cause, Brookings Institution, 1976. Spellacy, William N., and Sharon A. Birk, and William C. Buhi: A National Survey of Medical School Obstetrics and Gynecology Departments, 1965 to 1975. Journal of Medical Education, 52:11, 1977, pp. 901-905; Gough, H.G.: Specialty Preferences of Physicians and Medical Students Journal of Medical Education 50:4, 1975, pp. 581-587; DHEW, Interim Report of the Graduate Medical Education National Advisory Committee, Washington: Public Health Service, H.R.A. Publication No. 79-633, 1973, pp. 83-92; Giacalone, Joseph J. and James I. Hudson, Primary Care Education Trends in U.S. Medical Schools and Teaching Hospitals, Journal of Medical Education, 52:12, 1977, pp. 971-981, documents the declining numbers of nurse-midwies in the U.S.; Miller, C.A.: What Technology Breeds - A Review of Recent U.S. Experience with Cesarean Sections. The John Sundwall Memorial, School of Public Health, Ann Arbor, University of Michigan, 1978, review physician and hospital trends. Guillemin, Jeanne: Canadian National Health Insurance: An Overview. Office report for the Hon. Tim Lee Carter, U.S. House of Representatives, Health and Environment Subcommittee of the Interstate and Foreign Commerce Committee, Washington, D.C., 1973. see also: Roemer, Ruth and Milton I. Roemer: Health Manpower Policy under National Health Insurance - The Canadian Experience, DHEW (HRA) Publication No. 77-37, 1977, p. 12; Andreopoulos, S., ed., National Health Insurance Can We Learn From Canada? New York; Wiley, 1975, and Stone, Leroy and Claude Marceau. Canadian Population Trends and Public Policy through the 1980's. Montreal, McGill-Queen's University Press, 1977. 8. 10. 11. 12. 13. 14. 15. 16. 17. 18. 111 Stockwell, Heather and Eugee Vayda: Variations in Surgery in Ontario, Medical care 17.4, 1979, pp. 390-396; Vayda, Eugene, M. Morison, and G.D. Anderson: Surgical Rates in the Canadian Provinces, 1968-1972 -- a five year analysis. Canadian Journal of Surgery 10, 1976, pp. 235-237; Dycle, Frank, et al. Effect of Surveillance on the number of hysterectomies in the province of Saskatchewan. New England Journal of Medicine 296, 1977, p. 1326- 1328; Hastings, J.E.F., et al: An interim report on the Sault Ste. Marie study: A comparison of personal health services utilization. Canadian Journal of Public Health 61, 1970:289. Dyer, Colin: Population and Society in Twentieth Century France, Dunton Green, England: Hodder and Stoughton, Ltd. 1978. Beullac, M. Christian, Ministre du Travail, Septieme Rapport sur la Situation Demographique de la France. Paris, 1978, pp. 19-21. Rumeau-Rouguette, C et al. Naitre en France. Enguetes Nationales sur la grossesse et 1'accouchement. Paris, Institut National de la Sante et de la Rocherche Medicale, 1979. Kaminski, M. et al. Issue de la grossesse et surveillance prenatale chez les femmes migrantes. Enguete sur un chantillon representif des naissances en France en 1972. Revue Epidemologique et Sante Publique, 26, 1978, pp. 29-46. Saurel-Cubizolles, M. Influence de l'activite professionnelle de la femme enceinte sur le deroulement et 1'issue de la grossesse. Master's thesis in sociology, Paris, Universite Rene Descartes, 1973. Glaser, W. Paying the Doctor, Baltimore: John Hopkins Press, 1970, pp. 125 ff. Mensh, Ivan Norman. French Medical Education: Years of Change. Journal of Medical Education 53:9, 1978 pp. 608-618. Hoogendoorn, D. De stijgende frequentie van enkele kunstrerlossingen. Nederlands Tijdschrift voor Geneeskunde 121, 1977,pp. 1250-1252. Phaff, J.M.L. The organization of obstetrics in The Netherlands. Geneva World Health Organization Perinatal Study Group 1973 (mimeo), pp. 1-2; Moodie, Margaret The Pattern of Maternity Services in the Netherlands, London, Department of Health and Social Security, 1977 (mimeo) also reports on maternal health in The Netherlands. Phaff, op. cit., p. 5. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 112 Kloosterman, G.J.: Organization of Obstetric Care in The Netherlands. Amsterdam, University of Amsterdam, Department of Obstetrics and Gynecology, mimeo, 1979, p. 13 ff. See Moodie, op. cit. World Health Organization, Special Issue on Migrants. Geneva, 1978, pp. 306-307. Office of Population Censuses and Surveys. Mortality Statistics. Childhood and Maternity. Review of the Registrar General on deaths in England and Wales, 1977. London, H.M.S.0., 1979. Personal communication; see also. Chalmers,I. and M. Richards: Intervention and Causal Inference in Obstetric Practice. In Benefits and Hazards of the New Obstetrics. T. Char and M. Richards, tds., Philadelphia, J.B. Lippincott, 1977. Op. cit., pp. 13-16. Richards, M.P.: Innovation in medical practice: obstetricians and the induction of labor in Britain. Social Science and Medicine 9:11- 12, 1975. Bunker, J.P.: Surgical Manpower: a comparison of operations and surgeons in the United States and in England and Wales. New England Journal of Medicine 282, 1970, pp. 135-144. Maynard, Alain: The Containment of Health Care Costs in the United Kingdom. In Stuart 0. Schweitzer, Ed., Policies for the Containment of Health Care Costs and Expenditures, Washington, DHEW (NIH), 1976, pp. 167-180. Moodie, op. cit. pp. 3-4, See, however, D. Mechanic's account of friction between general practitioners and specialists in Great Britain in General Practice in England and Wales: Results of a Survey of a National Sample of General Practitioners, Medical Care 6:3, 1968. Barron, S.L., A.M. Thomson, and P.R. Philips. Home and Hospital Confinement in New Castle-upon-Tyne, 1960-1969. British Journal of Obstetrics and Gynecology 84, 1977, pp. 401-411. Two additional studies document the retreat of general practitioners from obstetric service: Lloyd, G.: The general practitioner and changes in obstetric practice. British Medical Journal 1, 1975, pp. 79-82; Oldershaw, K. L., and J.M. Brudenell: Use by general practitioners of obstetric beds in a consultant unit: a further report. British Medical Journal 1, 1975, pp. 139-142. 30. 31. 32, 113 Peel Report. Domiciliary Midwifery and Maternity Bed Needs. Report of the Subcommittee of the Standing Maternity and Midwifery Advisory Committee, London, H.M.S.0., 1970. Mortality Statistics, 1977, op. cit., p. 101. American College of Obstetricians and Gynecologists, personal communication. Chapter VIII - The National Experience 117 AN ANALYSIS OF DATA FROM THE COMMISSION ON PROFESSIONAL AND HOSPITAL ACTIVITIES INTRODUCTION This section represents an analysis of the data from the Commission on Professional and Hospital Activities (CPHA). The Professional Activities Study (PAS) collects information on hospital discharges from a large number of United States short-stay hospitals.* For this analysis, information was taken from these records on all admissions in 1970, 1974, and 1978 for childbirth. In each of these three years, there were over one million births available for analysis (see Table I) Information was obtained separately from the 654 hospitals that were members of CPHA in all three years, and for the larger group of all member hospitals. The distributions of complications and cesarean delivery rates were virtually identical for the hospitals that were members in all three years and for the larger group. Thus, this analysis is based on the larger group. CPHA member hospitals are distributed throughout the United States, are a wide range of sizes and include non-teaching institutions as well as those with a major and minor teaching component. Appendix A gives the number of hospitals used in this analysis by geographic location, bed size, and teaching status. In addition, for reference, the detailed * Basic data for the use in this study were supplied by the Commission on Professional and Hospital Activities (CPHA), Ann Arbor, Michigan. In these data, the identities of the individual hospitals were not revealed in any way. Any analysis, interpretation, or conclusion based on these data is solely that of the NICHD, and CPHA specifically disclaims responsibility for any analysis, interpretation, or conclusion. 118 delivery information on which this analysis is based is provided in Appendix B. For the three years, the number of member hospitals, the total number of births used in this analysis, the number of cesarean and vaginal births, and the cesarean delivery rate are shown in Table I. The cesarean birth rate (cesarean births per 100 total births) increased from 5.7 in 1970 to 14.7 in 1978. In the National Hospital Discharge Survey, described elsewhere in this report, the rate for the U.S. as a whole increased from 5.5 in 1970 to 15.2 in 1978. The PAS rates are quite similar to the national rates, and it is reasonable to assume that trends in cesarean delivery rates by compli- cation, in distribution of complications and in maternal mortality ratios in these hospitals are broadly representative of national trends. For 1970 and 1978, cesarean delivery rates by complication and the percent of all births with the given complication are displayed in Table II. In this table, the complications have been grouped for ease of interpretation. The more detailed data on specific complications are presented in Appendix A. A direct comparison of the two years is made more difficult by a change in the coding system in about 1972. Prolonged rupture of membranes, prolonged pregnancy, fetal distress, and multiple births did not appear as complications in the 1970 International Classification of Diseases, Adapted (ICDA). In order, therefore, to examine changes in these complications over time, it is necessary to compare 1974 with 1978. This is done later in this report. 119 AN OVERVIEW OF THE DATA There are several important points about data in this table. First, cesarean birth rates have increased for virtually all compli- cations. The largest increase in the cesarean delivery rate, both as a difference in rates between the two years and as a proportion of the 1970 rate, is for breech delivery. In 1970, the cesarean delivery rate for breech was 11.6 and by 1978 it had increased 417% to 60.1. The second largest increase in cesarean delivery rate from 1970 to 1978 was for other fetal complications. It increased from 6.3 to 25.5, or 305%. Most of this increase, however, was due to cesarean delivery for fetal compli- cations that could not have been listed in 1970 since they were not part of the ICDA. For premature rupture of the membranes and premature labor, the two fetal complications that were listed in both the 1970 and the 1978 ICDA, the increase in cesarean delivery rates was from 6.3 to 14.7, or 133.1%. In both 1970 and 1978, virtually all women (98%) with a previous cesarean delivery were delivered by cesarean. THE INCREASE IN PROPORTIONS OF DELIVERY COMPLICATIONS As striking as the increase in complication specific cesarean delivery rates is, the increase in the proportion of all deliveries that had complications is even more impressive. In 1970, 69.9% of all deliveries had no mention of complications. In 1978 only 54.4% had no mention of complications. Only for malpresentation (breech, persistent occiput posterior, other) and other "maternal" complications (antepartum hemorrhage, prior gynecological surgery) was the percentage of births with that complication approximately the same in 1978 as in 1970. The 120 increase in the percentage of births with a given complication was not, furthermore, restricted to complications with high cesarean delivery rates. For example, the percentage of deliveries complicated by lacerations, with a cesarean delivery rate of 0.0 in 1970, increased from 9.8% in 1970 to 11.8% in 1978. Both changes in complication-specific cesarean delivery and in the percentage of births with complications will contribute to changes in the cesarean delivery rate. That this is the case is seen most clearly with the diagnosis of previous cesarean. Here, the cesarean delivery rate in 1970 was 98.3 and 2.1% of all births had this complication. In 1978, the cesarean delivery rate was almost the same, 98.9, but the percentage of all deliveries with this complication had increased to 4.6%. It is easy to see that this increase in the percentage of women with previous cesarean contributed 2.5 percentage points to the overall rise in the cesarean delivery rate in this interval. For other complications for which there were changes in both the cesarean delivery rate and in the percentage of all births with the complication, it is possible to calcu- late the approximate contribution of each to the overall increase in the cesarean delivery rate from 1970 to 1978. This is done by an adjustment technique detailed in Appendix C. The results of these calculations are shown in Table III. For each complication, the table shows the contribution to the overall rise in the cesarean delivery rate from 1970 to 1978. It breaks down this contribution into two components, that due to an increase in the complication-specific cesarean delivery rate and that due to the change in the proportion of births 121 with that complication. The contributions are shown both in percentage points and as a percent of the total rise. Dystocia contributed 29.2% of the overall rise in cesarean delivery rate, previous cesarean 27.0%, breech 15.7%, and "other fetal'"* 20.2%. Together, these four complications account for 92.1% of the rise in the cesarean delivery rate from 1970 to 1978. For each of the four complications, it is important to examine the separate contributions to the overall rise of changes in the complication-specific cesarean delivery rate and changes in the percent with complications. As shown in Table III, for previous cesarean, virtually all of its 27.0% contribution to the increase is due to the increase in the percentage of women with the complication rather than to any change in obstetric practice. Conversely, for breech virtually all of its 15.7% contribution to the increase is a result of the increase in the cesarean delivery rate for this complication, since the percentage of all births with this complication was almost unchanged from 1970 to 1978. Dystocia and fetal indications had important contributions from both the change in complication-specific cesarean delivery rates and from changes in the percentage of all births with the complication. For both, however, changes in the percentages with the complication were two to three times those of changes in the complication-specific cesarean delivery rate. Overall, 32.5% of the increase in the cesarean delivery rate was contributed by changes in the complication-specific cesarean delivery rate and 67.7% by changes in the percentage of births with complications. * premature ROM, premature labor, multiple pregnancy, prolonged ROM, prolonged pregnancy, fetal distress. 122 The results of an analysis identical to the above except that it excludes the contribution of changes in previous cesarean are shown in Table IV. After excluding this, dystocia contributes 40.0% of the overall rise in cesarean delivery rates from 1970 to 1978. Of the rise exclusive of previous cesarean, 30.8% is contributed by the increase in the percentage of deliveries with dystocia, and 9.2% by changes in the cesarean delivery rate for dystocia. "Other fetal" complications contri- bute 27.7% of the rise exclusive of previous cesarean; most, 20.0%, is contributed by the increase in the percentage of deliveries with these "fetal" complications. 21.5% of the rise exclusive of previous cesarean is due to breech and, as before, all of it is due to the increase in the cesarean delivery rate for breech and none to the change in the percent- age of breeches. Overall, exclusive of previous cesarean, 44.5% of the rise is contributed by changes in complication-specific cesarean delivery rates and 55.5% by changes in the percentage of births with complications. THE CONTRIBUTION OF FETAL MONITORING Fetal monitoring has been frequently cited as a contributor to rising cesarean delivery rates (see Chapter XVI). Whether or not a fetal monitor was used is not included in the CPHA data obtained and this question cannot be examined directly. It is possible to examine fetal distress as a contributor to the increase. To the extent that the effect of fetal monitoring on cesarean delivery rates is mediated through increases in recognition of fetal distress, this will measure the effect of fetal monitoring. However, as mentioned previously, fetal distress was not a codable complication in 1970. Therefore, we must compare 1974 and 1978. 123 For 1974 and 1978, the cesarean delivery rate and the percentage of all deliveries with fetal distress as a primary complication and as a secondary complication accompanying any other complication is shown in Table V. As either a primary or accompaning complication, fetal distress is associated with a high cesarean delivery rate (60.0) which changed little from 1974 to 1978. The percentage of deliveries with fetal distress as a primary complication, however, more than doubled, increas- ing from 0.6% in 1974 to 1.4% in 1978. As a secondary complication, fetal distress increased from 0.5% to 1.1%. The overall increase in the cesarean delivery rate from 1974 to 1978 was 5.6. The adjustment procedure described in Appendix B was used to assess the contribution of fetal distress to the increase in this period. Since the cesarean delivery rate for fetal distress virtually did not change in this period, all of the contribution is due to the change in the percentage of deliveries with fetal distress. The percentages of deliveries with fetal distress are shown in Table VI. From 1974 to 1978, fetal distress as a primary complication contributed 0.5 percentage points or 8.9% of the overall rise. As an accompanying diagnosis, fetal distress contributed 0.3 percentage points or 5.4% of the overall rise. If fetal distress as either a primary or secondary diagnosis is considered as "the reason" for cesarean delivery, then 0.8 percentage points or 14.3% of the rise in the cesarean delivery rate from 1974 to 1978 is contributed by fetal distress. 124 TABLE I NUMBER OF MEMBER HOSPITALS, NUMBER OF CESAREAN AND VAGINAL BIRTHS, AND CESAREAN BIRTH RATE CPHA. 1970, 1974 ALL HOSPITALS Number of hospitals Number of births Vaginal Cesarean Cesarean Birth Rate (1) (1) Cesarean deliveries per 100 and 1978 YEAR 1970 1974 1978 97 1435 1425 1,062,078 1,255,812 1,199,215 1,001,426 1,141,406 1,023,381 60,652 114,406 175,834 5.7 9.1 14.7 total deliveries 125 TABLE II CESAREAN DELIVERY RATE AND % ALL BIRTHS, 1970 AND 1978, CPHA ALL HOSPITALS Cesarean Delivery Rate¥* % All Deliveries Complication 1970 1978 1970 1978 No ment ion 0.2 0.2 69.9 54.4 Lacerations 0.0 0.1 9.53 11.8 Previous cesarean 98.3 98.9 2.1 4.6 Dystocia (1) 50.6 67.0 %.8 6.7 Breech 11.6 60.1 2.9 2.8 Persistent occiput posterior 3.5 10.3 1.4 1.2 Other malpresentations 30.5 37.2 0.8 1.0 Other "maternal" (2) 38.2 50.5 1.4 1.2 Other "fetal" (3) 6.3 25.5 2.8 8.0 Other fetal - both years (4) 643 14.7 2.8 4.6 Other fetal - other NR 40.4 NR 3.4 Other, unspecified 6.1 7.0 5.2 8.3 All 5.7 14.7 100.00 100.00 *® Cesarean deliveries per 100 total deliveries. (1) Fetopelvic disproportion, abnormal pelvis, prolonged labor. (2) Antepartum hemorrhage, prior gyn surgery. (3) Premature ROM, premature labor, multiple, prolonged ROM, prolonged pregnancy, fetal distress. (4) Premature ROM, premature labor. NR Not reported (see text). CONTRIBUTION TO RISE IN CESAREAN DELIVERY RATES FROM 1970 TO 1978 OF CHANGES IN 126 TABLE III CESAREAN DELIVERY RATES AND PERCENT WITH COMPLICATIONS Contribution to Rise % Contribution to Rise (1) Fetopelvic disproportion, abnormal pelvis, prolonged labor. (2) Antepartum hemorrhage, prior gyn surgery. (3) Premature ROM, premature labor, multiple, prolonged ROM, prolonged pregnancy, fetal distress. (4) Premature ROM, premature labor. (5) Percents may not equal 100.00 due to rounding. Complication CDR* 7% Total CDR* 7% Total No mention 0.0 0.0 0.0 0.0 0.0 0.0 Lacerations 0.0 0.1 0.1 0.0 1+ 1.1 Previous cesarean 0.0 2.4 2.49 0.0 27.0 27.0 Dystocia (1) 0.6 2.0 2.6 6.7 22.9 29.2 Breech 1.4 0.0 1.4 15.7 0.0 15.7 Persistent occiput posterior 0.1 0.0 0.1 1.1 0.0 Pi Other malpresentations 0.1 0.1 0.2 1.1 1.1 2.2 Other "maternal" (2) 0.2 -0.1 0.1 2.3 -1.1 1.2 Other "fetal" (3) 0.5 1.3 1.8 5.6 14.6 20.2 Other fetal - both years(4) 0.5 0.2 0.7 Seb 2.3 7.9 Other fetal - other 1.1 1.1 12.4 12.4 Other, unspecified 0.0 0.2 0.2 0.0 2.3 2.3 All 2.9 6.0 8.9 32.5 67.5 100.00(5) %* Cesarean delivery rate, cesarean deliveries per 100 deliveries. 127 TABLE IV CONTRIBUTION TO RISE IN CESAREAN DELIVERY RATES FROM 1970 TO 1978 OF CHANGES IN CESAREAN DELIVERY RATES AND PERCENT DELIVERIES WITH COMPLICATIONS, EXCLUSIVE OF PREVIOUS CESAREAN DELIVERY % Contribution to Rise+ Complication CDR* % Total No mention 0.0 0.0 0.0 Lacerations 0.0 1.5 1.5 Dystocia (1) * 9.2 30.8 40.0 Breech 21.5 0.0 21.5 Persistent occiput posterior 1.5 0.0 1.5 Other malpresentations 1-3 1.5 3.0 Other "maternal" (2) 3.1 -1.5 1.6 Other "fetal" (3) 7.3 20.0 2747 Other fetal - both years (4) 7.7 Ze] 10.8 Other fetal - other NR 16.9 16.9 Other, unspecified 0.0 3.1 Ze All of the above 44.5 555 100.00 Rise exclusive of previous cesarean delivery. Cesarean delivery rate per 100 deliveries. Fetopelvic disproportion, abnormal pelvis, prolonged labor. Antepartum hemorrhage, prior gyn surgery. Premature ROM, premature labor, multiple, prolonged ROM, prolonged pregnancy, fetal distress. Premature ROM, premature labor. Not reported. 128 TABLE V FETAL DISTRESS AS A PRIMARY DIAGNOSIS AND AS ANY ACCOMPANYING DIAGNOSIS 1974 AND 1978, CPHA, ALL HOSPITALS CDR % All Deliveries Complication 1974 1978 1974 1978 Fetal distress, primary 60.1 59.0 0.6 1.4 Fetal distress, accompanying 57.9 60.0 0.5 Yel All fetal distress 59.1 59.4 Ye 245 All births 2.1 14.7 100.0 100.0 129 TABLE VI CONTRIBUTION TO RISE AND % CONTRIBUTION TO RISE IN CESAREAN DELIVERY RATES FOR FETAL DISTRESS, 1974 T0 1978 ,CPHA, ALL HOSPITALS Complication Fetal distress, primary Fetal distress, accompanying All fetal distress All births Contribution 0.5 0.3 0.8 5.6 0/ /0 Contribution 8.9 5.4 14.3 100.0 130 VARIATIONS AND TIME TRENDS IN CESAREAN DELIVERY RATES BY REGIONS OF THE COUNTRY AND BY SELECTED HOSPITAL, MATERNAL AND INFANT CHARACTERISTICS INTRODUCTION Examination of time trends and variations in cesarean delivery rates is important because it provides clues to the reasons for the rise in rates. National information on cesarean delivery rates is available from the Hospital Discharge Survey (HDS) and from the Professional Activity Study (PAS) of the Commission on Professional and Hospital Activities.Z The HDS is conducted by the National Center for Health Statistics. Each year information from the face sheets of .a sample of in-patient dis- charges from non-Federal, general and special short-stay hospitals is collected. About 200,000 records are examined. The sample is constructed to be representative of all United States hospital discharges and the data provide national estimates of trends. The PAS collects information on hospital discharges from about 1500 of the approximately 6000 short-stay hospitals in the United States. No attempt be: ade to insure the representativeness of these hospitals. In addition, member hospitals may vary from year to year. This limits the validity of national estimates derived from this source although, because of the large number of participating institutions, the data are useful. Unfortunately, neither of these sources of national information links the maternity record to that of the infant. Therefore, only hospital and maternal characteristics can be studied. For information on 131 cesarean delivery rates in relation to infant characteristics, we must rely on other sources. The National Natality Survey, a follow back study of a 1 in 500 sample of live births in the United States is one source. The most recent survey was in 1972, however, and predates the rapid increase in cesarean delivery ates. New York City and California have vital statistics systems which allow examination of cesarean delivery rates in relation to infants' characteristics. Although these are not necessarily representative of national trends, the data again are useful. REGIONS OF THE COUNTRY Information on time trends and variations in the cesarean delivery rates is available both from HDS and PAS. 2 The HDS data on trends from 1965 through 1978 in cesarean delivery rates by regions of the country is shown in Figure I. The rates in 1965 were similar in all regions except the West, which was somewhat higher (6.4%) than the U.S. as a whole (4.4%). By 1978, the rate in the Northeast had risen to 17.6%, whereas for the West and North Central regions the rates were only 14.6 and 13.9, respectively. The percent increase in cesarean delivery rates for the period was 291.1 in the Northeast, 322.2 in the South, 239.1 in the North Central, and 128.1 in the West. PAS? also studied time trends and variations in cesarean delivery rates by region of the country. The period of study was 1967 through 1974. They also found that cesarean delivery rates were higher in the later years in the East than in other regions. In contrast with HDS, the 132 percent increase in cesarean delivery rates was similar in all regions. Both studies indicate that the rise in cesarean delivery rates is a national trend and that factors that have contributed to this rise are pervasive. Information by region on variations in implementation of technology and of differential distribution of other possible contributors to the rising cesarean delivery rates is not available. The reason for the difference in the HDS rates of rise of cesarean delivery rates by region of the country is, therefore, difficult to interpret. It seems unlikely, however, that urbanization accounts for the difference, since the highest rate increases are found in the Northeast and the South, regions which differ greatly in these two factors. HOSPITAL SIZE HDS data for 1970 and 1978 on cesarean delivery by hospital size are seen in Table VII. Cesarean delivery rates are directly related to hospital size in both years. The rate of increase in cesarean delivery rates, also shown in Table VII is less in small hospitals than in medium and large hospitals. PAS findings, also shown in Table VII , are similar. Again, the data suggest that factors influencing the rise in cesarean delivery rates are pervasive, operating in hospitals of all sizes. INSURANCE COVERAGE, METHOD OF PHYSICIAN AND HOSPITAL REIMBURSEMENT Monetary considerations, especially higher reimbursement for cesarean delivery, have been cited as a contributor to rising cesarean delivery rates.” If important, cesarean delivery rates might be different in women with insurance and in women with a substantial differential in reimbursement 133 for cesarean compared with vaginal delivery. Cesarean delivery rates might also be lower in hospitals without monetary incentives to operative delivery, such as HMOs and other prepaid health plans, than in fee-for- service hospitals. Very little information on cesarean delivery rates according to insurance coverage is available. Furthermore, what is available must be interpreted with caution, since there are differences other than insurance between women who have different health insurance coverages. Cynamon and Placek’ found that, in the 1972 National Natality Survey, the cesarean delivery rate for women with insurance coverage for prenatal care was slightly higher (7.4%) than for women without coverage (7.2%). The cesarean delivery rate for women with insurance coverage for the hospital bill was also slightly higher (7.4%) than for those without (7.1%). The difference in the cesarean delivery rate for women with and without insurance coverage for the physician fee was greater than for those with and without prenatal and hospital coverage, 7.7% for women with it, compared with 6.7% for those without. Since information on age, parity, and other factors related to cesarean delivery is not presented, however, the interpretation of these differences is difficult. Were the differences large, they might support speculation on possible monetary incentives for cesarean delivery. The data suggest that monetary incentives are not a major factor contributing to increases in cesarean delivery rates. This is not, however, a direct examination of the issue of monetary incentives. Furthermore, these data are from 1972 and predate the rapid national rise in cesarean delivery rates (see 134 Figure I). The 1980 National Natality Survey is now in progress and may shed further light on this question. Another source of information on cesarean delivery rates in relation to reimbursement is a California Department of Health Services Study.” In it, cesarean delivery rates in California Medicaid recipients were examined using information from their paid claims file. For the period 1977 through February 1978, the cesarean delivery rate in Medicaid recipients was 10.4% whereas for the entire state in 1977 it was 15.4%. The authors point out the method for identifying mode of delivery tended to misclassify cesarean deliveries as vaginal. In order to account for the large differences in cesarean delivery rates between Medicaid recipients and the rest of the state, however, almost one-third of deliveries would have to be misclassified. This seems unlikely. Thus, in California, the cesarean delivery rate in 1977 in Medicaid recipients was probably lower than in the rest of the state. However, factors other than payment source may account for this difference. Comparison of the age distribution of Medicaid recipients giving birth in the period of study with the age distribution of all women giving birth in 1977 shows that 59.8% of Medicaid recipients were less than 24 years of age compared with 49.7% of all women giving birth. Cesarean delivery rates in California in 1977 were lower in younger women, ’ and the difference in age distribution could account for much of the difference in cesarean delivery rates between Medicaid recipients and other women. This emphasizes the methodologic problems inherent in comparing cesarean delivery rates by insurance coverage without concomitant 135 examination of other possible factors associated with both cesarean delivery and insurance coverage. Similar problems are encountered in interpreting differences in cesarean delivery rates between HMOs and other prepaid health plans and fee-for-service and other hospitals. The populations served are likely to be very different. In addition, general preventive medical care and a high degree of early and frequent prenatal care may reduce the incidence of pregnancy complications requiring cesarean delivery. This has been done by several authors, however, and attempts have been made to control for differences in the characteristics of the populations. Williams and Hawes? studied cesarean delivery rates in 323 California hospitals. They found that Kaiser-Permanente Medical Care Plan ownership, indicating prepaid medical care, was significantly negatively correlated with cesarean delivery rate. They attempted to control for possible differences in the populations served by these hospitals by using multiple linear regression and several variables that described the population served, such as percent of its deliveries which were to white women. In this multivariate analysis, Kaiser-Permanente ownership main- tained a statistically significant, independent negative association with cesarean delivery rate. The authors suggest that prepayment has an "independent attenuating impact on the rate of surgical intervention." In a study of pregnancy outcomes in members of a Boston Health Maintenance Organization (HMO), Wilner, et a1? found that the primary cesarean delivery rate was 11.4% in members of the HMO compared with 14.3% in fee-for-service patients delivered at the same hospital. 136 This difference, although not statistically significant (p = .06) is in the same direction as that in the Williams and Hawes study.B Cesarean delivery rates in military and other federally-funded hospitals for the period 1970 to 1978 are shown in Table VIII. These hospitals are like the Kaiser-Permanente Medical Care Plan and other HMOs in being non-fee-for-service practices. Thus, in Table VIII, cesarean delivery rates in Army and Indian Health Service hospitals and in CHAMPUS are lower in most years than in the U.S. as a whole. In Navy, Public Health Service and Air Force hospitals, on the other hand, cesarean delivery rates are higher in most years than in the United States as a whole. Information to adjust for possible differences in the age and parity distribution of women delivering in these hospitals and in other factors related both to cesarean delivery and participation in these plans is not available. Since the populations served are probably different from the United States as a whole, interpreting the differences is, as in the above studies, difficult. However, it appears that practice in the non-fee-for-service setting may not have a universally attenuating influence on cesarean delivery rates. TEACHING STATUS Teaching status of a hospital might be related to cesarean delivery rates if, in training institutions, cesarean deliveries were performed to allow physicians-in-training to "practice" doing them. However, like all the preceding comparisons of cesarean delivery rates by hospital characteristics, this one has factors other than teaching status that must be considered. Teaching institutions are, in general, large and 137 located in urban settings. They usually serve high risk populations. The latter factor would result in a higher cesarean delivery rate than in non-teaching institutions independent of allowing "practice" in doing cesarean deliveries. For 1967-1974, PAS2 examined the relation of teaching status to cesarean delivery rates in 124 large and medium-large hospitals. Indeed, teaching hospitals had higher cesarean delivery rates throughout the study period. The rate of increase in cesarean delivery rates in them was slightly higher than in non-teaching hospitals. By looking only at large and medium-large hospitals, this analysis controlled for this difference between teaching and non-teaching hospitals. Other factors, such as difference in risk characteristics of the population were not controlled, however. Williams and Hawes, © in the previously cited California study, found no association of teaching status with cesarean delivery rate. In this analysis, cesarean delivery rates were weighted by size of delivery service. In a previous study, 10 Williams found that size of delivery service, teaching status, and cesarean delivery were highly intercorrelated. The adjustment made by weighting the later analysis by size of delivery service may account for the absence of an association of teaching status with cesarean delivery rate. This is, however, itself an important result. It implies that relation of teaching status with cesarean delivery rate may not be independent. HOSPITAL OWNERSHIP Reasons to be concerned about cesarean delivery rates according to 138 hospital ownership are the same as for differences by insurance coverage and method of reimbursement. That is, proprietary hospitals might have higher rates because there are incentives to perform procedures which lengthen hospital stay and increase utilization of high capital investment facilities, such as operating rooms. HDs! and Williams examined the relation of hospital ownership to cesarean delivery rates. The HDS data is shown in Table IX. Proprietary hospitals had slightly higher cesarean delivery rates in 1965 and 1978 than hospitals of other ownerships. The rate of increase in cesarean delivery rates, however, was greatest in voluntary non-profit hospitals. Will iams® and Hawes found a significant positive association of non-profit ownership with cesarean delivery rate as well as previously discussed negative association with Kaiser-Permanente ownership. They found no association of cesarean delivery rates with proprietary ownership. The relation of cesarean delivery rates with hospital ownership is very weak. It is doubtful that it is an important determinant of cesarean delivery rates. ETHNICITY, MARITAL STATUS AND AGE OF MOTHER HDs! examined cesarean delivery rates by ethnicity, marital status and age of mother. Results by ethnicity and marital status are shown in Table X. Cesarean delivery rates in women of all ethnicities were very similar. Rates of increase in the cesarean delivery rates were also almost identical in women of all ethnicities. Factors affecting cesarean delivery rates are, therefore, operating uniformly in women of all ethnicities. Examination of rates by marital status yields a similar conclusion. 139 Figure II shows cesarean delivery rates by age of mother in 1965, 1970 and 1978. In all three years, cesarean delivery rates increased approximately linearly with age up to 40 years. The rate of increase of cesarean delivery rates was higher, however, in women less than 20 years than in older women. Other studies 0 have shown that cesarean delivery rates and their rates of increase are also related to parity. Information on parity is not available from the HDS. BIRTH WEIGHT OF INFANT The 1972 National Natality Survey” presented data showing the relation of birth weight to mode of delivery for a 1 in 500 probability sample of United States live births. The data showed that 11.6% of babies weighing less than 2500 grams and only 7.0% of babies weighing over 2500 grams were delivered by cesarean birth. There is no later period with which to compare this data in order to examine time trends. To do this, local sources must be relied upon. Unfortunately, in data from the two largest sources, New York City and California, birth weight categories are not uniform, nor is data from exactly the same years available. There are, however, important consistencies in the findings from the two sources. They are presented here to illustrate those consistencies. Cesarean delivery rates'by birth weight in two similar periods for California and New York City are shown in Table XI. In both periods in both places, cesarean delivery rates were higher in babies weighing 1501 to 2500 grams than in babies weighing more than 2500 grams. In the 140 earlier periods, in contrast, cesarean delivery rates for babies weighing 1500 grams or less were lower than for those weighing 2501 grams or more. In the later period, the cesarean delivery rate for infants weighing less than 1501 grams approached that of infants weighing 1500 to 2500 grams. The larger rate of increase in the cesarean delivery rate of infants weighing less than 1501 grams reflects this difference. This indicates that factors influencing management by cesarean delivery of infants weighing less than 1501 grams may be different from those influ- encing management of infants of other weights. Despite the high cesarean delivery rate of infants weighing less than 1501 grams, because they comprise less than one percent of all deliveries, the contribution of differences in the rate of increase in cesarean delivery rate among them to the overall increase in cesarean delivery rates is extremely small. SUMMARY 1. The cesarean birth rate in the United States has increased about threefold over the past decade to reach 15.2 per 100 total births in 1978. This rise reflects a change in obstetric practice which is not limited to any area of the country, to hospitals of one size or teaching status, or to women with particular characteristics, such as age, race, or marital status. There is suggestive evidence that in non-fee-for-service settings the level of the cesarean birth rate is not quite as high as in the country as a whole. However, this problem cannot be addressed since there are differences besides monetary considerations between fee-for-service and non-fee-for- service practices. 141 The largest contribution (29%) to the overall rise in the cesarean birth rates from 1970-78 has been from the diagnosis and management of dystocia (fetopelvic disproperiion, abnormal pelvis, prolonged labor). Cesarean delivery after previous cesarean has also made a substan- tial contribution (27%) to the rise in the overall cesarean birth rate; the third most important factor has been the increased recourse to cesarean birth in the case of breech presentation, which accounts for 15% of the rise in the cesarean birth rate. 142 TABLE VII CESAREAN DELIVERY RATES BY HOSPITAL SIZE 1965 AND 1978 NATIONAL HOSPITAL DISCHARGE SURVEY 1967 AND 1974, PAS HDS Cesarean % Change Delivery Rate in Rate 1965 1978 Size Small < 100 3.5 10.1 188.6 Medium 100-499 4.8 15.7 227.1 Large 500+ 4.6 17.0 269.6 PAS Cesarean % Change Delivery Rate in Rate 1967 1974 Size < 100 4.2 6.7 39.5 100-199 4.4 8.7 97.7 200-399 4.9 9.2 87.8 400+ 5.4 10.4 92.6 143 TABLE VIII CESAREAN DELIVERY RATES IN MILITARY AND PUBLIC HEALTH SERVICE HOSPITALS, IN THE INDIAN HEALTH SERVICE, AND IN THE U.S. AS A WHOLE 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 u.s. (1) 5.5 5.8 7.0 8.0 9.2 10.4 12.1 13.7 15.2 - Army (2) NA 5.4 6.6 7.5 8.7 9.9 11.3 12.5 13.2 14.3 Navy (3) NA NA 6.8 8.6 10.2 10.9 12.1 13.8 14.7 - Air Force (4) 5.5 6.4 7.4 8.5 10.1 11.4 13.2 14.4 15.5 - USPHS (5) NA NA NA 8.5 12.2 12.0 13.2 15.7 11.2 - IHS (6) NA NA NA 549 5.5 6.9 8.5 10.0 10.6 - CHAMPUS (7) Sed 5.5 7.8 8.3 2.2 10.1 11.2 10.4 11.6 - Source (1) Hospital Discharge Survey, NCHS. (2) (3) (4) (5) (6) (7) Personal communication, Dr. Bernhard T. Mittemeyer, Director, Professional Services, Office of the Surgeon General, U.S. Army, March 1980. In-patient Data System, Naval Medical Data Services Center, November, 1979. Biometrics Division, Directorate of Health Care Support, Office of the Surgeon General, USAF, November, 1979. Personal communication, Dr. Meade Butler, Chief, Professional Disciplines Section, Division of PHS Hospitals and Clinics, Health Services Adminis- tration (one hospital only), November, 1979. In-patient Care Branch, Office of Program Statistics, Indian Health Service, November, 1979. Statistics Branch, Office of Civilian Health and Medical Program of the Uniformed Services, April, 1980. 144 TABLE IX CESAREAN DELIVERY RATES BY HOSPITAL OWNERSHIP 1965 AND 1978 NATIONAL HOSPITAL DISCHARGE SURVEY Cesarean % Change Delivery Rate in Rate 1965 1978 Ownership Proprietary 5.0 16.4 228.0 Government 4.6 13.1 184.8 Voluntary/Non-Profit 4.3 15.8 267.4 Ethnicity White Other NR 145 TABLE X CESAREAN DELIVERY RATES BY ETHNICITY AND MARITAL STATUS OF MOTHER 1965 AND 1978 NATIONAL HOSPITAL DISCHARGE SURVEY Marital Status Married Unmarried NR Cesarean Delivery Rate 1965 1978 4.4 15.6 3.9 14.6 5.4 13.8 4.6 15.5 3.0 13.3 4.7 18.1 % Change in Rate 254.5 274.4 155.6 237.0 312.1 285.1 Birth weight (grams) <1000 1001-1500 1501-2500 2500+ 146 TABLE XI CESAREAN DELIVERY RATES BY BIRTH WEIGHT IN TWO SIMILAR PERIODS CALIFORNIA (1) AND NEW YORK CITY (2) CALIFORNIA NEW YORK CITY % Change % Change 1970 1977 in Rate 1968-69 1976-77 in Rate Birth weight (grams) 4.1 10.3 751.2 9.7 24.6 153.6 <1500 6.1 15.5 154.1 10.2 20.8 103.9 1501-2000 9.4 21.6 129.8 2001-2500 8.0 16.9 11.3 6.6 14.7 122.7 2500+ 6.9 15.6 126.1 (1) California Department of Health Services, Birth Cohort Records. (2) New York City, Vital Statistics. Appendix A TABLE 1 Number o! CPHA hospitals by region, bed size and teaching status - > 1970 North East Midwest South West Major Minor Non Major Minor Non Major Minor Non Major Minor Non teaching teaching teaching All teaching teaching teaching All teaching teaching teaching All teaching teaching teaching All Bed size 0-99 0 1 15 16 0 0 85 85 0 57 57 0 0 40 40 100-199 0 4 31 35 3 8 84 95 0 4 58 62 0 1 32 33 200-399 17 21 64 102 12 12 94 118 7 51 62 3 7 42 52 400+ 28 10 5 43 29 19 41 89 19 7 14 40 9 4 5 18 All 45 36 115 196 44 39 304 387 23 18 180 22) 12 12 119 143 Total N = 947 1974 0-99 0 1 22 23 0 0 153 153 0 0 88 88 0 0 96 96 100-199 0 6 42 48 2 10 138 150 0 2 107 109 0 2 79 81 200-399 19 22 80 121 13 13 144 170 7 11 72 90 4 5 66 7S 400+ 35 10 8 53 37 21 50 108 23 11 21 55 6 S 4 15 All 54 39 152 245 52 4 485 581 30 24 288 342 10 12 245 267 Total N = 1339 1978 0-99 0 1 24 25 0 0 161 161 0 0 96 96 0 0 115 115 100-199 0 6 41 47 2 8 143 153 0 1 118 119 0 3 12 75 200-1399 19 20 73 112 12 8 138 158 S 8 78 91 3 4 50 57 400+ 35 7 8 50 33 19 39 91 21 13 21 55 8 6 6 20 All 54 34 146 234 47 35 481 563 26 22 313 361 11 13 243 267 Total N = 1425 LT Appendix B Table 1 1970, CPHA, all hospitals Cesarean Vaginal Total %X all ow? Complication N Deaths N Deaths N cort births Cesarean Vaginal No mention 1,078 5 741,402 105 742,480 0.2 69.9 463.8 14.2 Previous cesarean 22,399 4 379 1 22,778 98.3 2-1 12.9 * Lacerations, perineal 15 0 93,471 9 93,486 0.0 8.8 * 95.6 Lacerations, other 30 0 10,233 8 10,263 0.3 1.0 * 78.2 Umbilical complications 997 0 33,677 8 34,674 2.9 3.3 * 23.8 Antepartum hemorrhage 5,119 9 8,885 13 14,004 36.6 13 175.8 146.3 Postpartum hemorrhage 55 1 5,755 7 5,810 1.0 0.6 * 121.6 Prior GYN surgery 575 0 123 1 898 64.0 0.08 * * Retained placenta 65 0 6,168 3 6,233 1.0 0.6 * 48.6 Fetopelvic disproportion 15,702 12 7,762 2 23,464 66.9 2.2 76.4 25.8 Abnormal peivied 1,194 3 776 0 1,970 60.6 0.2 251.3 * Prolonged labor 2,785 6 11,618 3 14,403 19.3 1.4 215.4 25.8 Breech 3,515 4 26,704 12 30,219 11.6 2.9 113.8 44.9 Persistent occiput posterior 518 0 14,237 4 14,755 3.5 1.6 * 28.1 Other malpresentations 2,443 3 5,573 i 8,016 30.5 0.8 122.8 1.9 Precipitate labor 18 0 3,394 0 3,412 0.5 0.3 * * Premature ROM 1,575 1 19,042 3 20,617 7.6 1.9 63.5 15.8 Premature labor 313 l 9,074 11 9,387 3:3 0.88 * 121.2 Multiple pregnancy NR ree eee Prolonged ROM M— > Prolonged pregnancy N——— > Feral distress Nii immo Uterine rupture 70 2 100 5 170 41.2 0.0 * * Other complications -~-s--nBo_...s. iw so Unspecified complications 2,186 18 3,053 8 5,239 41.7 0.5 823.4 262.0 All 60,652 69 1,001,426 204 1,062,078 5.7 100.00 113.8 20.4 [a Type unspecified NR Not reported Too few births to provide stable estimate of rates Cesarean delivery rate; per 100 delivery rate; per 100 deliveries Maternal mortality ratio; per 100,000 deliveries by that route 8Y1 Appendix B Table 2 1974, CPHA, all hospitals Cesarean Vaginal Total X all MMR Complication N Deaths N Deaths N cor! births Cesarean Vaginal No mention 2,289 5 797,227 83 799,516 0.3 63.7 218.4 10.4 Previous cesarean 34,092 10 536 0 34,628 98.5 2.8 29.3 * Lacerations, perineal 18 0 109,846 12 109,864 0.0 8.8 * 10.9 Lacerations, other 67 0 17,228 3 17,295 0.4 1.4 * 17.4 Umbilical complications 1,772 0 55,086 11 56,858 3.3 4.5 * 20.0 Antepartum hemorrhage 6,554 15 9,074 9 15,628 41.9 1.2 228.9 99.2 Postpartum hemorrhage 48 0 5,910 ? 5,958 0.8 0.5 * 118.4 Prior GYN surgery 796 0 151 0 947 84.7 0.1 * Retained placenta 83 0 8,198 6 8,281 1.0 0.7 * 73:2 Fetopelvic disproportion 33,734 10 12,211 2 45,585 73.2 3.6 29.6 16.4 Abnormal pelvis’ 2,123 0 925 0 3,048 69.7 0.2 * * Prolonged labor 5,314 2 14,766 1 20,080 26.5 1.6 37.6 6.8 Breech 9,090 6 24,951 5 34,041 26.8 2.7 66.0 20.0 Persistent occiput posterior 719 0 12,384 0 13,103 5.5 1.0 * * Other malpresentations 3,683 8 10,915 3 14,598 25.2 1.2 135.8 21.5 Precipitate labor 25 0 3,905 0 3,930 0.6 0.3 * * Premature ROM 3,039 0 23,676 7 26,715 11.4 2.1 * 29.6 Premature labor 881 ) 16,519 10 17,400 5.1 1.4 113.5 60.5 Multiple pregnancy 635 1 5,053 0 5,688 11.2 0.5 157.5 * Prolonged ROM 1,405 2 3,409 2 4,814 29.2 0.4 142.3 58.7 Prolonged pregnancy 851 0 2,894 2 3,745 22.7 0.3 * 69.1 Fetal distress 4,308 6 2,860 0 7,168 60.1 0.6 139.3 * Uterine rupture 99 0 81 5 180 55.0 0.0 * * Other complications 11 1 35 1 46 23.9 0.0 * * Unspecified complications 2,770 8 3,566 5 6,336 43.9 0.5 289.5 141.3 All 114,406 72 1,141,406 174 1,255,812 10.0 100.0 62.9 15.2 Too few births to provide stable estimate of rates Cesarean delivery rate, per 100 deliveries Maternal mortality ratio, per 100,000 deliveries by that route WON =» Type unspecified 6v1 Appendia B Table 3 1978, CPHA, all hospitals _ Cesarean Vaginal Total X all MMR? __ Complication _N Deaths N Deaths N cor! births Cesarean Vaginal No mention 1,475 0 650,339 32 651,814 0.2 54.4 * 4.9 Previous cesarean 54,218 10 624 0 54,842 98.9 4.6 18.4 * Lacerations, perineal 32 0 121,140 7 121,172 0.0 10.1 * 5.8 Lacerations, other 68 0 20,304 1 20,372 0.3 1.7 * 4.9 Umbilical complications 1,846 0 66,735 8 68,581 2.7 5.7 * 12.0 Antepartum hemorrhage 6,534 8 7,039 9 13,573 48.1 1.1 122.4 127.9 Postpartum hemorrhage 52 0 5,513 3 5,565 0.9 0.5 * 54.4 Prior CYN surgery 780 0 128 0 908 85.9 0.) * * Retained placenta 82 0 7,205 3 7,287 1a 0.6 * 41.6 Fetopelvic disproportion 44,036 17 10,029 0 54,065 81.5 4.5 38.6 0.0 Abnormal pelvis? 1,113 0 612 0 2,325 73.2 0.1 * * Prolonged labor 9,189 6 16,428 3 25,617 35.9 2.1 65.3 18.3 Breech 20,405 2 13,527 10 33,932 60.1 2.8 9.8 23.9 Persistent occiput posterior 1,486 0 12,948 1 14,434 10.3 1.2 * 7:7 Other malpresentations 4,611 3 7,797 2 12,408 37.2 1.0 65.1 25.7 Precipitate labor 57 0 5,783 1 5,840 1.0 0:5 * 17.3 Premature ROM 5,971 0 28,683 4 34,654 17.2 2.9 0.0 14.0 Premature labor 2,158 5 18,621 6 20,779 10.4 1.7 231.7 32.2 Multiple pregnancy 1,656 4 5,150 2 6,806 24.3 1.6 241.5 38.8 Prolonged ROM 2,738 0 4,568 1 7,306 37.5 0.6 * 21.9 Prolonged pregnancy 2,271 3 7,684 0 9,955 22.9 0.8 44.0 * Fetal distress 9,646 5 6,696 0 16,342 59.0 1.4 51.8 * Uterine rupture 69 0 38 | 107 64.5 0.0 * * Other complications 73 0 29 2 102 71.6 0.0 * * Unspecified complications 4,697 11 5,761 4 10,458 44.9 0.9 234.2 69.5 All 175,834 72 1,023,381 100 1,199,215 14.7 100.0 41.0 9.8 * Too few births to provide stable estimate or rates Cesarean delivery rate, per 100 deliveries Maternal mortality ratio, per 100,000 deliveries by that route w Ne Type unspecified 0ST Appendix B 1978, CPHA, selected hospitals (hospitals with continuous membership) Table 4 Cesarean Vaginal Total Xx all war? Complication N Deaths N Deaths N cor! births Cesarean Vaginal No mention 642 0 324,134 15 324,776 0.2 53.3 * 4.6 Previous cesarean 27,797 4 294 0 28,090 99.0 4.6 14.4 * Lacerations, perineal 11 0 62,186 2 62,197 0.0 10.2 * 3.2 Lacerations, other 30 0 10,522 1 10,552 0.28 1.7 * 9.5 Umbilical complications 944 0 35,889 5 36,833 2.6 6.1 * 13.9 Antepartum hemorrhage 3,312 5 3,579 6 6,891 48.1 1.1 151.0 167.6 Postpartum hemorrhage 31 0 2,722 0 2,753 1.1 0.5 * * Prior GYN surgery 398 0 61 0 459 86.7 0.1 * * Retained placenta 40 0 3,608 2 3,648 1.3 0.6 * 55.4 Fetepelvie disproportion 22,362 5 5,724 0 28,086 79.6 4.6 22.4 0.0 Abnormal pelvis’ 878 0 373 0 1,251 70.2 0.2 5 * Prolonged labor 4,420 3 8,726 1 13,146 33.6 2.2 67.9 11.5 Breech 10,477 1 6,923 8 17,400 60.2 2.9 9.5 115.6 Persistent occiput posterior 748 0 6,956 0 7,704 9.7 1.3 * * Other malpresentations 2,334 1 4,625 1 6,959 33.5 1:1 42.8 21.6 Precipitate labor 20 1 2,867 2 2,887 0.7 0.5 * * Premature ROM 3,143 0 15,140 1 18,283 17.2 3.0 * 6.6 Premature labor 1,152 1 9,837 2 10,989 10.5 1.8 86.8 20.3 Multiple pregnancy 781 3 2,477 1 3,258 24.0 0.5 384.1 40.4 Prolonged ROM 1,447 0 2,346 1 3,793 38.2 0.6 * 42.6 Prolonged pregnancy 1,214 0 4,272 0 5,486 22.1 0.9 * * Fetal distress 4,935 2 3,471 0 8,406 58.7 1.4 40.5 * Uterine rupture 32 0 20 } 52 61.5 0.0 * * Other complications 5 0 9 1 14 35.7 0.0 * * Unspecified complications 2,554 7 2,491 3 5,045 50.6 0.8 274.0 120.5 All 89,706 32 519,252 54 608,598 14.7 100.0 35.7 10.4 Ww oN =o» Type unspecified Cesarean delivery rate, per 100 deliveries Too few births to provide stable estimate of rates Maternal mortality ratio, per 100,000 deliveries by that route 161 APPENDIX C 152 The following formula was used to calculate the contribution to the increase in cesarean delivery rate of changes in the complication-specific rate and of the change in the proportion of births with complications. (1) contribution of change in CDR' = (1978 CDR-1970 CDR) X 1970 % (2) contribution of change in % = (1978%- 1970 %) X 1978 CDR (3) total contribution = contribution of change in CDR + contribution of change in % lcpr = cesarean delivery rate; births ty cesarean per 100 births 153 BIBLIOGRAPHY Ves 10. 11. Placek, P.J. and Taffel, S.M.: Demographic variation in cesarean delivery rates: United States, 1970-1978. In press, Health United States, U.S. Department Health and Human Services, National Center for Health Statistics, 1980. PAS Reporter 14:1-55, December, 1976. Placek, Paul: Maternal and infant health factor associated with low birth weight: Findings from the 1972 National Natality Survey. In Reed, D.M. and Stanley, F.J. (Eds): The Epidemiology of Pre- maturity. Baltimore, Urban & Schwarzenberg, 1977, pp. 197-211. Marieskind, H.I.: An evaluation of cesarean section in the United States. Report submitted to the Assistant Secretary for Planning and Evaluation, Department of Health, Education and Welfare, June, 1979. Cynamon, M.L. and Placek, P.J.: Insurance coverage for prenatal care, hospital stay and physician care: United States, 1964-1969 and 1972 National Natality Surveys. Paper presented at the American Public Health Association Poster Session, New York, 1979. Medi-Cal Deliveries. Data Matters, Topical Reports. California Center for Health Statistics. Report register number 0513-901, April, 1979. California Department of Health Services, birth cohort records, 1977, unpublished data. Williams, R.L. and Hawes, W.E.: Cesarean section, fetal monitoring, and perinatal mortality in California. Am. J. Public Health 69:864- 874, 1979, Wilner, S.I., Monson, R.R., Schoenbaum, S.C., Winickoff, R.N.: A comparison of pregnancy outcome between a health maintenance organization and fee for services practices. Paper presented at the APHA meeting, November 7, 1979, New York, New York. Williams, R.L.: Measuring the effectiveness of perinatal medical care. Report to the California Department of Health, July, 1977. Petitti, D., Olson, R.0., and Williams, R.L.: Cesarean section in California, 1960 through 1975. Am. J. Obstet. Gynecol. 133:391-397, 1979. rv m— Chapter IX - The New York City Experience 157 INTRODUCTION The material that follows concerns the situation in New York City and is derived from computer tapes made available by the New York City Department of Health. The special value of this set of tapes is that (1) except for maternal morbidity it contains a wide range of relevant variables important in understanding changes in obstetrical care; (2) the experience covers the years 1968-1977 during which large changes occurred in cesarean rates; and (3) data for infant deaths have been continuously matched with birth information, thereby providing a strong analytical base. Generalizability is restricted by the fact that the results are for a single, large, densely populated urban area with population and health systems characteristics that distinguish it in several respects from other areas. However, despite these differences, information from the Commission on Professional and Hospital Activities (CPHA) and the National Hospital Discharge Survey (HDS) discussed in the previous chapter indicate that for many variables, the trends and levels reached in cesarean birth rates are similar in New York City and nationally. Further, there is considerable consistency between CPHA data on complications of pregnancy and delivery derived from hospital record information, and corresponding data coded from entries on birth and fetal death records. Throughout the presentation, changes in cesarean birth rates are placed in the context of other changes in method of delivery, information not available from either the CPHA or HDS data sets. Mortality is also 158 examined in relation to the various methods of delivery. The analysis places major emphasis on deaths during the first 28 days following birth (the neonatal period). These neonatal deaths include those that occurred in the hospital of birth, or following infant transfer, or subsequent to discharge to the home. Fetal mortality is introduced, but the unavail- ability of information to separate antepartum from intrapartum fetal deaths seriously restricts the interpretation of the data for this pregnancy outcome. Only fetal deaths of 28 weeks or more gestation are included. To a large extent, the exclusion of fetal deaths of 20-27 weeks gestation was dictated by the apparent wide fluctuations in reporting completeness. For example, in 1968, 1977, and 1978 there were 1,628, 222, and 536 fetal deaths reported at these gestational ages. For about half of the fetal deaths in 1968 birth weight was not reported; 1977 and 1978 corresponding proportions were 14% and 46%.* Accordingly, perinatal mortality is defined in this report as including neonatal deaths and only fetal deaths of 28 weeks or more gestation, and through the first 28 days of the neonatal period. It should be noted that the inability to distinguish between antepartum and intrapartum fetal deaths also imposes restrictions on the utility of perinatal death rates for the study of cesarean births. Other issues that affect the interpretation of relationships involving a characteristic, due to reporting and classification problems, are taken up when the variable is first discussed. *¥ The proportion of fetal deaths, 20-27 weeks, with a cesarean birth was less than 1% in 1968, 4% in 1977, and 2% in 1978. 158 OVERVIEW OF TRENDS In New York City during the 10 year period, 1968-1977, the propor- tion of births by cesarean increased from 6.5% to 16.6% (Table 1A).* The upward trend continued in 1978 (the latest year of available data) to 17.3%. Thus far, the primary cesarean rate** has undergone a larger relative change than the repeat cesarean rate. However, in 1978, 5.9% of the live births were repeat cesarean births, which is as high as the primary cesarean birth rate was in 1971. Taking into account the growing proportions of women who have had a primary cesarean, this figure may be expected to increase appreciably. The change in cesarean rates is paralleled by large reductions in the use of forceps; the low forceps rate is less than half of what it was in 1968; use of high and mid-forceps, already at a low point in 1968, has dropped to about 1% of the births in more recent years. In the aggregate, operative procedures at delivery have decreased and spontaneous births have increased. Major reductions in neonatal, fetal (28 weeks or more), and peri- natal mortality have occurred in the 10 years, 1968-1977 (Tables IB-ID). The period of especially large decreases in the neonatal death rate was 1968-1971 when the rate dropped an average of 6.5% per year; since then the decrease has averaged 2.7% per year. The cesarean birth rate maintained similar average rates of increase in both periods (11-14%). * All arabic numeral tables are found at the end of this chapter. ** Except where specifically indicated, "rate" refers to the proportion of births with a cesarean, e.g., denominators for primary cesarean birth rates include births to mothers with a history of previous cesarean. 160 There is no evidence from the available data that the slower rate of decrease in neonatal mortality in the more recent period reflects a shift from fetal to infant death; between 1974 and 1977 there was, in fact, a slight increase in fetal mortality (28 weeks or more). The perinatal mortality rate, combining as it does reonatal and fetal deaths, presents a picture of large reductions in mortality in the early part of the decade under study, and lesser decreases since 1974. In contrast, the post- neonatal death rate has undergone little change throughout the decade. Mortality rates by method of delivery are strongly affected by differences in birth weight distributions, and the levels of these rates change markedly when adjustments are made for such differences (discussed below). However, within a method of delivery category, unadjusted figures indicate the dimensions of change over time. Between 1968 and 1977, neonatal mortality for both primary and repeat cesarean births decreased markedly. Spontaneous births alsc experienced decreases in neonatal mortality; rates for births with vaginal breech or forceps delivery vary considerably from year to year but at the end of the decade mortality among vaginal breech deliveries was slightly higher than previously, and mortality in the forceps group was moderately lower. The perinatal mortality rates parallel these relationships. Interpretation of the changes in mortality by method of delivery is influenced by the possibility that the increase in cesarean births involved, to some extent, shift of better risk infants from other categories into the cesarean birth group. One suggestion of this comes from the joint occurrence of increases in cesarean births and large decreases in forceps 161 deliveries. If this is indeed a major factor then it is necessary to take into account the exceptionally low mortality in the forceps group within which many of the cesarean births in 1977 would have been found in earlier years. This issue will be returned to in a later section utiliz- ing information on birth weight and other characteristics. From this point, the analysis is concerned with comparisons between 1968-69 and 1976-77 and an exploration of the situation in 1976-77 for selected subgroups. CHANGES IN CESAREAN BIRTH RATES AND RELATED FACTORS (LIVE BIRTHS) One of the principal observations from Tables 2A-2D is that the cesarean birth rate increase was general, affecting all ethnic groups, births to young and old, high and low educated women; voluntary, proprie- tary and municipal hospital births: low and normal birth weights; single and plural births. Closer examination of the changes and levels of cesarean births indicates several! important patterns for a broad range of variables. Ethnic group - cesarean birth rates show minor differences by race ethnic groups; among very small infants (£1500 gms), however, blacks have appreciably lower cesarean birth rates than whites (non-Puerto Rican and Puerto Rican), a differential that is greatly reduced at higher birth weights. Deliveries by forceps are substantially more frequent among white (non-PR) births than in the other groups, at every birth weight; vaginal breech deliveries are at the lowest rate among blacks but the gap has decreased since 1968-69. 162 Age of mother - The rate of cesarean birth increases with advancing age to reach 21% among women 30 years of age or older; this relation- ship is found at all birth weights; the dominant factor is the relatively high repeat cesarean births. Birth order (excluding prior fetal deaths) - First births have the highest cesarean rates in 1976-77 in contrast to no difference in 1968-69; at low birth weights, the differentials by birth order are now minor as compared with the situation in the earlier period, but at 2500 grams and over the differences are large. The level of the rate in 1976-77 is 17.2% for primary cesarean births among first births, 10.7% and 6.5% for repeat cesarean births among second and third or higher order births, respectively, Foreshadowing large increases in repeat cesarean births in the future under current practices for managing multiparous women with a prior cesarean birth. Education of mother - In 1976-77 the rate of primary cesarean births increases with educational attainment, an indicator of socioeconomic status. This gradient is present at all birth weights and is larger than formerly. Type of hospital - voluntary hospitals have consistently had the highest cesarean birth rates; municipal hospitals, the lowest. However, the differentials have decreased markedly at low birth weights. Proprietary hospitals have rates close to those in the voluntary hospitals. 163 Type of service - Reflecting the situation by type of hospital, births to private patients have higher cesarean rates than general service patients. Prenatal visits - In both 1976-77 and the earlier period, the cesarean birth rate rises ‘with increasing number of prenatal visits; excluding the small group of births with no reported prenatal visits (3-4%), the gradient is steeper for primary than repeat cesarean births; the relationship between primary cesarean birth rates and frequency of prenatal visits is not explained by differentials in birth weight or gravidity. Plurality - The cesarean birth rate among multiple births increased more rapidly than among single births to reach 25.9% in 1976-77. A twofold difference is found at all birth weights except the very low weights (< 1500 gms). Source of payment - Information for this variable is available only for more recent years. Almost one-half of the births (46%) were to women with insurance. Over one-third (37%) were covered by Medicaid and a small portion (15%) were self-pay. The highest primary cesarean rate is in the insured group, followed closely by the self-pay, with Medicaid patients having the lowest rate. This ranking is found at all birth weights and is consistent with the relationship found above by type of service. 164 SUMMARY In summary, for all birth weights combined, older age of mother, first birth, higher education, delivery at a voluntary hospital and as a private patient, more frequent prenatal visits, and multiple births are associated with relatively high cesarean birth rates. Ethnicity is not an important determinant of cesarean birth rates. Application of a loglinear multiple contingency table analysis to 1976-77 single births in which age, birth order, educational attainment, ethnic background, and birth weight are entered clarifies the relationship of birth weight to cesarean birth rates when these variables are jointly considered. As a rule,the trends observed in the preceding tables were found to be present by the loglinear model as well. Variability in these trends among different birthweight classes was brought out fairly sharply in a few cases. Women having some college education have higher primary cesarean birth rates than high school graduates for any birthweight, but this trend is much stronger for babies under 2500 gms than for those above this level. The cesarean birth rate for women who have not com- pleted high school depends on the other factors but would appear to be close to the high school graduates' experience. A factor in interpreting the increase in cesarean birth rates is the change in characteristics of the pregnant women; e.g., increases in the proportions of first births and births to higher educated women. Adjust- ments for these changes indicate that only a small proportion of the increase in cesarean birth rates is due to these circumstances, e.g., 165 adjusting the rate of cesarean births in 1976-77 (15.7%) to the birth order composition in 1968-69 results in a rate of 15.3%. A similar adjustment for primary cesarean births reduces the 1976-1977 rate from 10.7% to 9.9% indicating that one-eighth of the increase in primary cesarean births is due to changes in birth order, mainly the increased proportion of first births. CHANGES IN METHOD OF DELIVERY BY BIRTH WEIGHT Birth Weight. Table A summarizes the changes in method of delivery by detailed birth weight for live births. All birth weight groups, except over 4,000 grams, show primary cesarean birth rates in 1976-77 about 2 1/2 times the corresponding rates in 1968-69. For repeat cesarean births the largest ratio (2.9) is at the very low birth weights, 1,000 grams or less (this change is based on very small numbers and subject to large chance variation). The ratio drops to 1.4 in the next higher birth weight group and then increases steadily with increasing weight. Among vaginal births, the most important change in almost all birth weight groups is the decrease in forceps deliveries. Vaginal breech births change little between 1,001 and 2,500 gms; under 1,001 gms the propor- tional almost doubles and above 2,500 gms it decreases. The distribution of live births by method of delivery is shown in Table 3 for each birth weight group. In 1976-77, the cesarean birth rate at weights 1000 gms or less (8.9%) is substantially lower than in the next higher 500 gms and then rises to 24.3% at the highest weights, 4001 grams or greater. The gradient is more marked for primary cesarean birth rates than for repeats. The relationships were similar in 1968-69. 166 Cesarean birth rates are lowest in the most favorable birth weight groups, 2501-4000 grams, but because a large majority of the births (about 84%) occur at these weights, a change in this group accounts for more cesarean births than a similar relative change at low birth weights, a fact that is of considerable significance in assessing the level of the overall cesarean birth rate. CHANGES IN METHOD OF DELIVERY BY PRESENTATION The issue addressed here concerns the extent to which the management of various presentations at delivery accounts for the current level of cesarean birth rate and the degree to which changes in the management of particular presentations explain the increase in cesarean births. Several observations can be made from the data in Table B. In both time periods, normal presentations represent a large majority of the births. ROP/LOP/ ROT/LOT and breech presentations are reported for relatively small proportions, but their importance lies in the relatively high probability, particularly in 1976-77, that they will be managed by cesarean. The likelihood of a cesarean is far less for normal presentations but because of the preponderance of "normal", there are substantially more cesarean births in this group than in any other presentation category except for ROP/LOP/ROT/LOT. Of special interest, in this connection, is the fact that the proportion of all births in 1976-77 that were normal presenta- tions delivered by cesarean (4.1%) is more than twice the corresponding figure for breech presentations (1.7%). The proportions of cesarean births are appreciably higher in 1976-77 than in 1968-69 for all types of presentations. What stands out is that 167 of the 8.8 percentage point increase in the cesarean birth rate, changes in management of breech presentations are responsible for only 1.0 percentage point, a level well below the contribution of any of the other reported presentations. There is a major qualification related to the ROP/LOP/ROT/LOT and head categories. It will be noted that increases occurred over this time period in the proportions of all births with these presentations, especially head, reflecting a change in classification of some births previously reported as "normal" presentation. Breech presentations are unlikely to be subject to the same reservation. Tables 4A-4D give the distribution of births in each presentation category by method of delivery for specific birth weights. Thus, the data show that the cesarean rate for normal presentation, which had very low proportions delivered by cesarean in 1968-69, increased to 5.3% for all weights combined and in several weight groups reached nearly 9%; use of forceps decreased sharply. Cesarean births have long been common for ROP/LOP/ROT/LOT presentations but by 1976-77 they accounted for 3 out of 5 of the births with these presentations. Breech presentations also showed large increases in cesarean births. The change in management of breech presentations involved major reductions in the proportions delivered with no reported operative procedure; a substantial increase in vaginal breech deliveries for the very small infants (1000 gms or less); and increased tendency to shift from vaginal breech to cesarean as birth weight advanced above 2500 gms. In the aggregate, however, more than a third (37.2%) of the breech presentations in 1976-77 were managed by vaginal breech delivery; previously the figure was 41.3%. 168 The relationship of presentation at delivery to primary cesarean births is given in Table C (also see Tables 4A-4D). Statements made above for all cesarean births apply equally to the primary cesarean birth situation. Again, increases in cesarean births for presentations reported as normal, ROP/LOP/ROT/LOT or head outweigh the change in management of breech presentations in explaining the rise in the primary cesarean birth rate. Of the 6.9 percentage point increase in primary cesarean births, only 1.0 percentage point is attributable to the increased likelihood that a breech presentation will be managed by cesarean birth. INDICATIONS FOR SURGICAL DELIVERY Table D provides information based on what was reported on the live birth certificates regarding indication for surgical intervention. Changes in diagnosis and classification impose major restrictions on developing comparable data on the 10 year period for this variable. The increased proportions of births with reported third trimester bleeding, fetal distress and dystocia” in 1976-77 as compared with 1968-69 are undoubtedly mainly due to diagnostic changes. The small decrease in abnormal presentation may also be influenced to some degree by reporting changes rather than an alteration in underlying conditions. Nevertheless, the reported experience is informative for assessing the changes in cesarean birth rates. Only a minor part of the increase in the cesarean birth rate can be attributed to third trimester bleeding or fetal distress, in contrast to the significant role of dystocia. The latter is entirely due to the doubling in the proportion of cases diagnosed as dystocia, three out of four of which in both time periods were managed by cesarean birth. * Principal inclusions in this category are contracted pelvis, cephalo- pelvic disproportion, uterine dysfunction, and prolonged labor. 169 The important influence of the dystocia diagnosis on the increase in the primary cesarean birth rate is seen in Table E. One-third of the increase (2.3 of the 6.9 percentage points) is in this category. Another relatively large segment of the change is found in the category "none", i.e. cases in which the entry on the birth certificate was "none." With respect to repeat cesarean delivery, the overwhelming majority had "previous section" recorded as the indicator for surgical delivery in both periods; in only 7% of these births was one of the four indications shown in Table E reported on the vital record. RELATIONSHIP OF MODE OF DELIVERY TO PREGNANCY OUTCOME Thus far, the discussion has been directed at clarifying changes in cesarean birth rates over the decade, 1968-77, through an examination of a broad range of background and medical characteristics of the mother. In this and subsequent sections, the concern is with measures of pregnancy outcome. It is not possible to reach definitive conclusions about the effect of a specific change in the management of pregnancies by means of observational data such as are available for this report. However, the information does provide a reasonable basis for an exploration of possible effects and for the identification of issues that deserve close scrutiny. INCIDENCE OF LOW BIRTH WEIGHT. The importance of birth weight as a measurement of favorable or unfavorable pregnancy outcome is well established. About 3 out of 4 of all the neonatal deaths come from the small proportion of births weighing 2500 gms or less (9.4% in New York City); over half of the deaths are concentrated among the very small infants, weighing 1500 gms or less at birth, who constitute only 1.5% of all the births. From these and related 170 data, it is clear that even a modest change in the incidence of low birth weight can have a major impact on the neonatal death rate for all births combined. The question at issue in this report is whether the more frequent recourse to cesarean birth is associated with an increase in the low birth weight rate. It is necessary to bear in mind that the evidence available for this consideration is the aggregated set of data on the New York City experience. Although the data are classifiable by various charateristics they cannot throw light on the extent to which the timing of the cesarean in individual cases was appropriate or inappropriate. This issue is developed more completely in Chapter XII - Neonatal RDS. The birth weight distributions for live births by method of delivery are given in Table F. On an overall basis, the direction of the change between 1968-69 and 1976-77 is towards a moderate decrease in the propor- tion born at low birth weights. The only method of delivery category that does not show a decrease in the incidence of low birth weight is vaginal breech delivery. The size of the reduction is similar among primary cesarean births as among all births combined; it is most pronounced among repeat cesarean births. The decreases in incidence of low birth weight are not due to changes in the characteristics of the pregnant women over the decade. As illustrated by the data in Tables 5a-5B for ethnic racial groups, one of the most important variables affecting the composition of births, there is a high degree of consistency in the changes in birth weights. If the 171 births in 1976-77 had the same ethnic racial composition as those in 1968-69, the proportion of births at 2500 gms or less would be 9.1 percent, or slightly less than the observed figure 9.4 percent. A similar type of adjustment applied to primary and repeat cesarean births leaves the picture substantially unchanged. CONCLUSION It is clear that the large increase in the cesarean birth rate has not been accompanied by an increase in the incidence of low birth weight. From this, it might be argued that the question of whether significant increases in iatrogenic prematurity resulted from the more than doubling in the cesarean birth rate can be answered in the negative. However, the furthest one can go is to indicate that the data do not support an affir- mative conclusion. The reason for the caution is that it is not possible to determine whether the decline in incidence of low birth weight was slowed by the changes in mode of delivery; also, measures of maturity at birth are needed, in addition to birth weights, to answer the question definitively. MORTALITY (NEONATAL AND PERINATAL) Tables 6A-6B provide information on relative frequency and mortality (neonatal, fetal, perinatal) for a number of the variables previously discussed. Summary measures for post-neonatal and infant mortality are included. Adjustments for changes in ethnic racial composition and other charateristics of the mother or source of care at time of delivery have little effect on the relationships derived from these data. (See Table 5C for neonatal mortality rates by ethnic racial group). On the other hand, differences and changes in birth weight distribution have a major 172 effect on the levels of the mortality rates by method of delivery. Table G gives neonatal death rates, unadjusted and adjusted for birth weight differences.* Adjustment changes the magnitude of the differentials between the two time periods. In the cases of the cesarean births, the adjusted rates show a smaller decrease than the unadjusted, especially for repeat cesarean births. Also, the levels of the neonatal death rates change markedly when differences in birth weight are taken into account. The mortality risk among repeat cesarean births is no longer relatively low; the risk among vaginal breech births is sharply reduced but it is still almost 3 times the overall mortality rate; and the risk in the forceps delivery group more than doubles, although it remains the lowest among the methods of delivery. The effect of adjustment on the perinatal rates follows the same pattern as for the neonatal rates. From this point, the discussion concentrates on mortality measures in specific birth weight categories. BIRTH WEIGHT < 1,000 gms: Small decreases (11-13%) occurred in the neonatal and perinatal mortality rates; these are accompanied by a substantial increase in the risk of mortality during the rest of the first year of life (post-neonatal period) but there is still an improvement of about 11 percent for the entire first year of life. Neonatal and perinatal mortality among primary cesarean births decreased to reach a point where the chances of survival approached 50 percent, a level * Adjustment is to the 1968-69 birth weight distribution for all methods of delivery combined. An adjusted rate for a subcategory, therefore, indicates what the neonatal mortality rate would be if the birth weight composition were the same as for all births in 1968-69, combined. 173 also found in the forceps delivery group. Mortality among repeat cesarean births, accounting for only a small portion (1.9%) of the births weighing 1,000 gms or less, remained very high as did the loss among spontaneous and vaginal breech births. BIRTH WEIGHT 1001-1500 gms: A major decrease occurred in this weight group in neonatal and perinatal mortality (about one-third) between 1968-69 and 1976-77. The large changes in method of delivery were accompanied by about a 50% decrease in neonatal and perinatal mortality among primary cesarean births and more than a one-third decrease in mortality among repeat cesarean births, not far behind the drop in mortality among spontaneous births. A far smaller decrease was experienced among births delivered by forceps (about 20%). Because of the uncertainty about the selectivity of cases that accompanied the increase in use of cesarean births, the contribution made by this change in method of delivery to the reduction in neonatal mortality cannot be estimated. However, a conservative estimate of the underlying reduction in the primary cesarean births' neonatal death rate can be made. This involves adjusting the 1968-69 neonatal death rate among primary cesarean births to take into account (a) the approximate amount of the change in the rate of cesarean births attributable to shifts out of the spontaneous and forceps categories and (b) the associated neonatal mortality rates, under the assumption that the selectivity out of spontaneous and forceps birth categories is not importantly biased (it could be argued that the large reduction in neonatal mortality among spontaneous births indicates that the bias was, in fact, towards poorer risks being selected for a cesarean 174 delivery; but the small reduction in mortality among forceps deliveries would argue in the other direction). Application of the estimation procedure reduces the neonatal mortality rate among primary cesarean births from 405.6 per 1,000 to 356.5 per 1,000, moderately affecting the margin of the reduction in risk of neonatal mortality associated with primary cesarean birth. With the adjustment, the reduction is 44% which is greater than the decrease for all births combined. Repeat cesarean births also show a 44% decrease in neonatal mortality. Births by vaginal breech delivery, representing an important propor- tion of the surgical deliveries, experienced about a 30% reduction in neonatal mortality. Although fetal mortality increased, perinatal mortality showed a decrease of 27%. Changes in management of breech presentations were extensive during this period and an indication of the net effect of these changes is gained by a comparison based on mortality among all births with breech presentation. This obviates the problem of selectivity that was dealt with for primary cesarean births through the broad assump- tions discussed in the previous paragraph, and it can be stated that the changes were accompanied by a large decrease in mortality among the breech presentations (38%). BIRTH WEIGHTS 1501-2000 gms: Mortality declined even more at these birth weights than at 1001-1500 gm (neonatal mortality rate is cut almost in half; perinatal rate by over a third). All methods of delivery show marked reductions in neonatal mortality; the largest are in primary and repeat cesarean births. Application of the adjustment procedure in the previous section reduces the neonatal mortality rate for primary cesarean births to 124.2 per 1,000. This reduces the decline from an observed 62% 175 to an estimated 41%; neonatal mortality decreased among repeat cesarean births by 70%; among breech presentations the neonatal mortality rate dropped 48%. Decreases in perinatal mortality rate are large for cesarean births (40% for primary and 63% for repeat) but for breech presentations the reduction in the rate is more modest, 24%, because of lack of reduction in fetal mortality. BIRTH WEIGHTS 2001-2500 gms: Reduction in neonatal mortality is less than at weight 1501-2000 gms (33% compared with 44%); perinatal mortality decrease is modest, 19%. Primary cesarean births show an especially large decrease in mortality; repeat cesarean birth mortality is also down appreciably. Adjustment in 1968-69 neonatal mortality rate for primary cesarean births to take into account shift over time from forceps* to cesarean deliveries results in an estimated neonatal mortality rate of 32.6 per 1,000; this reduces the differential between 1968-69 and 1976-77 from 65% to 39%. Breech presentations are associated with a 30% decrease in neonatal mortality but only a marginal decrease in perinatal mortality (14%). BIRTH WEIGHTS ABOVE 2500 gms: Small changes are found in the neonatal and ser inatel mortality rates in each birth weight subgroup of Table 6B. Decreases in observed neonatal mortality rates among primary cesarean births are eliminated when adjustments are made to take into account the effect of shifts from forceps to cesarean delivery (See Table H). Repeat cesarean births show appreciable reductions at all birth weights above 2500 gms. Breech presentations experienced no change in neonatal mortality, except above 4,000 gms where the mortality increased. * For birth weights 2001-2500 gms and higher weights, the assumption is that the entire increase in the rate of primary cesarean births is due to reduction in forceps delivery. 176 CONCLUSION The New York City experience indicates that a distinction needs to be made between low birth weight infants and those weighing over 2,500 gms in assessing changes in mortality among cesarean births. The most striking observation is that at birth weights 1,001-2,500 gms, neonatal mortality among primary cesarean births decreased substantially between 1968-69 and 1976-77, even after allowance is made for possible selectivity of lower risk births into the cesarean birth category over the decade. The situation above 2,500 gms differs substantially. Adjustment for selectivity that may have occurred suggests that there was no decrease in the mortality among primary cesarean births. Mortality among repeat cesarean births is down appreciably in all birth weights, but as discussed below, the level of the repeat cesarean death rate at the low birth weights is considerably higher than the loss among all births at these weights. APGAR SCORE One minute and 5 minute Apgar scores are presented in Tables 7A and 7B by birth weight and method of delivery. Although there are important problems associated with such scores when the observations are not made under highly controlled, standardized conditions, the data obtained from the birth record may be taken as suggestive. A strong inverse relation- ship between birth weight and low Apgars appears in these data for each method of delivery. Breech deliveries have, by far, the poorest Apgars. Leaving aside births under 1,001 gm, a group that in any event has extremely high neonatal mortality, primary cesarean births consistenty 177 have lower Apgars than forceps and spontaneous births; the same holds for repeat cesarean births, but the differentials are less. The margins in 1976-77 are less for 5 minute Apgars than 1 minute scores (Table I). Apgars were more often not recorded in 1968-69 than in 1976-77, and 5 minute Apgars are so incomplete for the earlier period as to make them unusable for comparison with the situation in 1976-77. One minute Apgars in 1968-69 also have larger proportions of "not stateds" than in the more recent period, but above 1,000 gms, the data are not seriously handi- capped by this factor. CONCLUSION Caution is needed in assessing the levels and changes in low Apgar scores because of the nature of the data. Five minute Apgars are so incompletely reported in 1968-69 as to make them too questionable for comparison with scores in 1976-77. The 1 minute Apgars do suggest, however, that the proportions with low scores (under 7) remained substan- tially unchanged for primary and repeat cesarean births and for vaginal breeches. At all birth weights, low 1 minute and 5 minute scores are most common among vaginal breeches; primary cesarean births are also at a distinct disadvantage compared with total births; and repeat cesarean births are at a moderate disadvantage. SELECTED SUBGROUPS Selected for discussion in this section are several subgroups in which there is a high interest when considering the cesarean birth rate. The focus is on the situation in 1976-77. Many of the restrictions 178 previously noted are applicable; undoubtedly the most important are the inability to take into account all of the relevant medical and other factors that affect the decision to perform cesarean delivery and the unavailability of information about the condition of the newborn aside from birth weight. REPEAT CESAREAN BIRTH The large reduction in mortality that has taken place among repeat cesarean births has already been noted. The issue addressed here con- cerns the comparative level of mortality in 1976-77. As seen in Table J, despite the reduction, the neonatal mortality rate at the low birth- weights shown (under 2501 gm) is consistently higher among repeat cesarean births than among vaginal births.* At the birth weights above 2500 gm the rates are the same. The differences in perinatal mortality follow a different pattern with vaginal births either having higher rates or being closer to the repeat cesarean birth rates than seen for neonatal death rates. However, this may well reflect the greater likelihood of a vaginal delivery when the fetus is known to be dead, a consideration that applies to all of the comparisons of perinatal mortality rates involving cesarean births. BREECH PRESENTATION Information reported on indications for method of delivery shows that 3.4% of the births in 1976-77 were breech presentations. The special risk status of these births is reflected by their high propor- tions in low birth weight groups and their high mortality at every birth weight. As a result, they account for 1 out of 5 of the neonatal and perinatal deaths. Because of the substantial proportion of the breech presentations that involves plural births, the data analyses that follow have been restricted to single births. * Emphasis is placed on patterns; tests of statistical significance indicate that in most cases the difference within a specific birth weight category could be due to chance factors. 178 At birth weights 1,000 gms or less, cesarean birth is an infrequent method of delivery for breech presentations (5%). The proportion with primary cesarean births increases sharply above this weight but vaginal breech delivery remains a frequent procedure (Table K). Comparison of birth weight specific neonatal mortality rates shows no consistent pattern of difference between primary cesarean birth and vaginal breech births under 2501 gms, although there is a suggestion that under 1501 gms the risk is lower among cesarean births. Above 2500 gms, cesarean births have far lower neonatal mortality. The perinatal death rate is lower among cesarean deliveries in all birth weight groups, including low birth weights, than among vaginal breech births. However, the qualification previously referred to applies; i.e., dead fetuses are more likely to be managed through a vaginal procedure than by cesarean birth. The major differential in mortality among births over 2500 gms, with primary cesarean births having a distinctly lower risk, bears further scrutiny. At these birth weights, despite the shift toward increased recourse to primary cesarean birth between 1968-69 and 1976-77, the neonatal rate was 15.1 per 1,000 in 1968-69 compared with 16.9 per 1,000 in 1976-77 (Table K). The perinatal rates were also close in these two periods, 26.3 per 1,000 and 21.5 per 1,000 respectively. The special significance of this lack of change in mortality among breech births, mature as measured by birth weight, is that it relates to a group that accounts for about 78% of the breech presentations. At low birth weights, there was a substantial reduction in mortality over the decade, as discussed earlier for breech presentations (single and plural births combined). 180 DYSTOCIA This complication was reported in 5.6% of the births, almost all of which were over 2500 gms. About 3 out of 4 of the births with dystocia were through primary cesarean birth; the remaining births were evenly divided between spontaneous and forceps delivery. As noted in Table L the difference between primary cesarean births and vaginal births in neonatal mortality could readily be due to chance factors. The difference in perinatal mortality is statistically significant but the increased probability of a vaginal delivery for fetal deaths imposes a restriction on this relationship. (Rates are limited to births over 2500 gms because of the small numbers under this birth weight.) FETAL DISTRESS A small proportion (3.2%) of the births were reported with this complication as an indication for mode of delivery. Almost half were primary cesarean births; the remainder are almost entirely evenly divided between spontaneous and forceps delivery. The differences between primary cesarean births and vaginal births in their neonatal and perinatal mortality rates for low birth weight infants are in the direction of higher rates among vaginal births; the differences are in the opposite direction for births at 2501+ gms (Table M). Small numbers make these relationships uncertain but the perinatal rates differ significantly at 2500 gms or less, again reflecting the increased likelihood of a vaginal delivery in the case of fetal death. SUMMARY (1) The pattern in New York City, an area for which information is available on changes in the cesarean birth rate and on pregnancy outcome, is consistent in important respects with the national picture. a) b) c) d) e) 181 In this area, the cesarean birth rate increased 2 1/2 fold between 1968 and 1977 to reach 17.3 per 100 total births. The primary cesarean birth rate in 1977 was 11.2 per 100 total births and there are indications that this rate is continuing to increase. All subgroups of the population, regardless of socioeconomic or other demographic characteristics, source of care, or payment method shared in the rise in the primary cesarean birth rate, and the current level varies only moderately by characteristic. Repeat cesarean birth rates have also increased to stand at 5.4 per 100 total births in 1977. Although the rate of increase has lagged behind the change in primary cesarean birth rates, under present management practices for women with prior cesarean births, the repeat cesarean delivery rate is expected to increase markedly. The increase in primary cesarean birth rates coincides with sharp decreases in forceps deliveries. Consistent with the national data, dystocia cases made the largest contribution to the increase in primary cesarean births (33%), reflecting a doubling in the reporting of dystocia (prin- cipal inclusions: cephalopelvic disproportion, uterine dysfunction, and prolonged labor). Breech presentation and fetal distress each accounted for another 14% of the increase in the primary cesarean rate. (2) (3) (4) 182 Primary cesarean birth rates vary substantially by birth weight. Generally, low birth weights are associated with higher cesarean rates than birth weights above 2500 gms; exceptions are a very low cesarean birth rate under 1001 gms and a high rate above 4000 gms. Because of the preponderance of births at normal weights, close to 90% of the cesarean births weigh over 2500 gms. These relationships have not changed over the decade, reflecting the fact that similar increases in the cesarean birth rate occurred at almost all birth weights. The proportion of babies born at low birth weights (2500 gms or less) decreased between 1968-69 and 1976-77, from 10.2% to 9.4%. Decreases in proportions of low birth weight infants occurred among both primary and repeat births. These changes run counter to the upward trend in cesarean birth rates. Accordingly, speculation that the increased cesarean birth rate was accompanied by increases in iatrogenic prematurity, as measured by birth weight, is not support- ed by the New York City experience. However, an unknown is whether the decrease in the low birth weight rate would have been greater if not for the large increase in cesarean births. Also, a careful assessment of iatrogenic prematurity would require other measures of prematurity besides low birth weight. Major reductions in neonatal, fetal (28 weeks or more), and peri- natal mortality have occurred in the 10 years 1968-77. The decrease occurred at all birth weights, including the very low birth weight, under 1,001 gms. However, by far the largest decreases were in the birth weight groups 1,001-2,500 gms (between one-third and almost a half). (5) (6) (7) (8) 183 Comparisons of differentials in level and reduction of mortality by method of delivery place principal emphasis on neonatal mortality rates. Perinatal mortality rates, which include fetal deaths, 28 weeks or more gestation, are subject to qualification because of the greater likelihood of a vaginal delivery when the fetus is known to be dead. Birth weight is an important consideration in all of these assessments of mortality. After adjustment to take into account differences in birth weight composition, primary and repeat cesarean births have higher neonatal mortality rates than all vaginal births in 1976-77 (14.5 per 1,000 for cesarean births and 11.1 per 1,000 for vaginal births). Births by forceps delivery have the lowest mortality (9.6 per 1,000); vaginal breech births, the highest (36.2 per 1,000); spontaneous births have a rate of 12.3 per 1,000. The largest relative decreases in neonatal mortality over the decade were among cesarean births. Selectivity factors may be operating to explain partially these changes. These may consist of shifts into the primary cesarean birth group of some of the births that previously had been delivered by forceps. At the low birth weights (under 2,501 gms), large decreases in neonatal mortality were experienced by primary cesarean births even after taking into account a possible shift from forceps delivery, a group with especially low mortality, However, there were also substantial decreases among repeat cesarean births and vaginal births. These concomitant changes suggest that factors in addition to the possible increased safety of cesarean delivery for the newborn played a role; for example, neonatal intensive care. (9) (10) (11) (12) 184 Above 2,500 gms, where a small decrease in neonatal mortality occurred among all births combined, primary cesarean births showed no decrease in mortality after allowing for selectivity from the forceps delivery group. Repeat cesarean birth mortality declined at the same time. The conclusion regarding primary cesarean births is that in this rapidly increasing group there has been a lag in improving chance of survival among infants at mature birth weights. The special significance of this lies in the fact that close to 90% of all primary cesarean births weigh 2,501 gms or more. Breech presentations, which underwent major changes in management, had large reductions in neonatal mortality among low birth weight infants. No reduction occurred among births with breech presenta- tion at birth weights over 2,500 gms. Small numbers preclude examining mortality experience separately for large infants, over 4,000 gms. Apgar scores at 1 and 5 minutes are subject to major qualifications, but they suggest no change over the decade and higher proportions under 7 among cesarean births generally than all births combined; vaginal breeches have especially high proportions under 7. The current picture for selected categories of births of special interest indicates the following: a) At low birth weights, repeat cesarean births have substantially higher neonatal mortality than all births combined; at normal weights, there is no difference. b) c) d) 185 Among breech presentations, there is no consistent difference in neonatal mortality at low birth weights between primary cesarean births and vaginal breech delivery. But, at mature birth weights, there is a fivefold differential between mortality rates for these two methods of delivery in favor of primary cesarean births. The strong qualification, however, is that this is the weight group that showed no overall decrease in mortality for the total group of breech presentations. Dystocia, a diagnosis heavily concentrated among births over 2,500 gms, shows no important difference between primary cesarean births and vaginal births in neonatal mortality. This observa- tion needs to be qualified by the fact that it is based on very small numbers in the vaginal birth group. Fetal distress, a diagnosis associated with high mortality risk, cannot be explored reliably for mortality differentials because of small numbers. The observed difference at low birth weights is in the direction of improved survival among primary cesarean births; this does not apply to the mature births which account for about 90% of the infants with reported fetal distress. 186 TABLE A: Ratio between 1976-77 Proportion of Births in Specified Method of Delivery to Corresponding Proportion in 1968-69 Birth Weight Cesarean Birth Vaginal Birth Spontan- Primary Repeat Total eous Breech Forceps Birth Weight Total 2.53 1.85 0.91 1.07 0.86 0.55 < 1000 gms 2.56 2.89% 0.94 0.84 1.92 0.82% 1001-1500 gms 2.68 1.35 0.86 0.87 1.01 0.65 1501-2000 gms 2.65 1.46 0.87 0.92 0.99 0.56 2001-2500 gms 2.40 1.66 0.90 1.02 1.06 0.50 2501-4000 gms 2.56 1.86 0.91 1.09 0.78 0.51 > 4001 gms 2.12 2.32 0.85 1.03 0.75 0.48 * Based on small numbers and subject to large chance variation. 187 TABLE B: Percent of all births by presentation and cesarean birth changes - 1968-69 to 1976-77 1976-77 1968-69 Changes in Cesarean Cesarean Cesarean Birth Total Births* Total Births Percentages Presentation at delivery TOTAL 100.0 15.74 100.0 6.95 8.79 Normal 76.3 4.07 82.9 1.66 2.41 ROP/LOP/ROT/LOT 9.0 5.50 6.3 2.20 3.30 Head Ze> 2.69 23 0.90 1.79 Breech 3.4 1.68 3.6 0.67 1.01 Other 3.8 1.80 3.9 1.52 0.28 * Primary and repeat cesarean births combined. 188 TABLE C: Percent of all births (excluding repeat cesarean births, by presentation and primary cesarean birth, changes 1968-69 to 1976-77 Presentation at Delivery TOTAL Normal ROP/LOP/ROT/LOT Head Breech Other Primary Cesarean Births as percent of all births (excluding repeat 1976-77 11.24 2.65 3.94 1.84 1.54 1.27 cesarean births) 1968-69 4.34 0.87 1.43 0.51 0.54 0.99 Change in Primary cesarean birth percentage 6.90 1.78 2.51 1.33 1.00 0.28 189 TABLE D: Percent of births by indications for surgical delivery that are cesarean births, changes 1968-69 to 1976-77 Percent of all births 1976-77 1968-69 Change in Cesarean Cesarean cesarean birth Indications Total Births* Total Births* Percentages TOTAL 100.0 15.74 100.0 6.97 8.77 Third trimester bleeding 1.09 0.59 0.50 0.47 0.12 Fetal distress 2.19 1+57 1.07 0.61 0.90 Dystocia 5¢57 4.23 2.84 2.13 2.10 Abnormal presentation 2.13 0.85 2.79 0.41 0.44 Previous section 4.49 4.40 2.31 2.30 2.10 None+ 73.97 2.10 88.13 0.22 1.88 Other/not stated 9.56 2.05 2d 0.83 1.22 *¥ Includes primary and repeat cesarean births + Reported as "none" on birth certiicate 190 TABLE E: Percent of all births by indications for surgical delivery that are primary cesarean births, changes 1968-69 to 1976-77 Primary cesarean as percent of all births Changes in Primary (excluding repeat cesarean) cesarean percentages 1976-77 1968-69 Indications TOTAL 11.24 4.34 6.90 Third trimester bleeding 0.55 0.44 0.11 Fetal distress 153 0.61 0.92 Dystocia 4.22 1.96 2.26 Abnormal presentation 0.87 0.39 0.48 None* 2.01 0.05 1.96 Other/not stated 2.03 0.76 1.27 * Reported as "none" on birth certificate 191 TABLE F: Percent distribution, method of delivery by birth weight, 1976-77 and 1968-69 PERCENT DISTRIBUTION CESAREAN VAGINAL 1976-77 Total Primary Repeat Spontaneous Breech Forceps TOTAL 100.0 100.0 100.0 100.0 100.0 100.0 < 1000 grams 0.63 0.41 0.23 0.68 7.17 0.10 1001-1500 0.82 1.38 0.43 0.77 5.22 0.35 1500-2000 1.82 2.96 1.51 1.68 8.21 1.06 2001-2500 6.11 6.66 6.32 6.14 16.26 4.39 2501-4000 84.20 77.02 85.17 85.18 60.26 81.99 > 4001 6.36 11.52 6.29 5.54 2.61 6.08 (< 2500) (9,38) (11,41) (8.49) (9.26) (36.86) (5.90) 1968-69 TOTAL 100.0 100.0 100.0 100.0 100.0 100.0 < 1000 grams 0.79 0.51 0.19 1.05 3.98 0.08 1001-1500 0.80 1.26 0.58 0.92 4.32 0.29 1500-2000 1.88 2.91 1.98 2.03 7.34 1.06 2001-2500 6.74 7.74 777 7.11 14.51 5.24 2501-4000 84.40 76.17 85.19 84.01 67.08 87.61 > 4001 5415 11.15 4.07 4.69 2.41 5.56 (< 2500) (10.21) (12.42) (10.52) (11.10) (30.15) (6.67) 192 TABLE G: Neonatal mortality rates, unadjusted and adjusted for birth weight differences, by method of delivery, 1976-77 and 1968-69 Unadjusted Adjusted* Method of Percent Percent Delivery 1976-77 1968-69 decrease 1976-77 1968-69 decrease TOTAL 12.1 11.1 29.6 13.0 16.9+ 2247 Primary cesarean 14.6 28.5 48.6 14.5 25.6 43.4 Repeat cesarean 8.7 20.2 56.9 14.4 24.7 41.7 All vaginal births 11.9 16.5 27.8 11.1 16.1 31.4 Spontaneous 11.4 19.4 41.1 12.3 16.4 24.6 Breech 102.7 81.0 (26.8) 36.2 29.0 (25.0) Forceps 4.6 5:9 22.6 9.6 13.3 27.4 Note: ( ) increase; percentage change calculated from mortality rates to two decimal places. Adjustment is to birth weight distribution for all methods of delivery combined in 1968-69 (direct method). + Differs from unadjusted due to exclusion of small number of births and deaths with unknown birth weight. 193 TABLE H: Effect of adjustment on neonatal mortality rate for primary cesarean births, 1976-77 and 1968-69 Neonatal mortality rate per 1,000 Observed Adjusted 1976-77 1968-69 1968-69 2501-3000 gram 8.2 21.7 8.0 3001-4000 gram 5.6 6.9 4.0 2 4001 gram 9.1 13.5 8.5 194 TABLE I: Percent with low 1-minute and 5-minutes Apgar Scores by birth weight, cesarean births and vaginal breech births, 1976-77 1 MINUTE APGAR 5-MINUTES APGAR Vaginal Vaginal Breech Breech All Cesarean All Cesarean Births Primary Repeat Births Primary Repeat 1001-1500 < 4 22.8 31.7 28.3 41.9 10.4 13.3 4.3 20.1 4-6 30.7 32.3 19.6 36.0 17.8 18.3 34.8 24.1 1500-2000 <4 8.1 13.8 13.4 14.6 2.7 3+2 7.0 4.2 4-6 19.5 25.5 20.4 29.4 7.3 10.5 4.4 1.9 2001-2500 <4 2 8.0 4.6 6.3 0.9 1.8 1.7 1:9 4-6 8.1 16.5 10.7 26.7 2.2 5.4 3.0 3.9 2501+ <4 1.7 3.8 1.3 6.1 0.3 0.7 0.2 2.6 4-6 3 9.4 3 17.1 0.7 2:5 0.9 2.8 * Not stated Apgars are distributed among the known scores in each birth weight group 195 TABLE J: Neonatal and perinatal mortality rates for vaginal births and repeat cesarean births, by birth weight, 1976-77% Neonatal Perinatal Repeat Repeat Vaginal Cesarean Vaginal Cesarean 1001-1500 grams 238.0 260.9 331.8 346.2 1501-2000 grams 55 «6 75.5 114.4 103.7 2001-2500 grams 14.5 25.6 32.7 41.5 2501-3000 grams 5.0 5.2 9.4 6.9 3001-4000 grams 2:3 2.4 4.0 245 * Data not shown for birth weights 1000 gram or less and over 4000 gram because of small numbers in the repeat cesarean birth groups. TABLE K: 196 weight, 1976-77, single births. Percent breech presentation delivered by Total (N) Primary Cesarean Vaginal Breech Birth Neonatal mortality All Births Primary Cesarean Vaginal Breech Birth Perinatal mortality All Births Primary Cesarean Vaginal Breech Birth * Adjusted to the birth weight distributions of all breech presentations of BIRTH WEIGHTS (GRAMS) Method of delivery, neonatal and perinatal mortality, breech presentations, including repeat cesarean births, by birth Total <1000 1001-1500 1501-2000 2001-2500 2501+ (5432) (256) (190) (236) (533) (4208) 50.1 5.1 32.6 36.0 44.3 55.3 36.6 50.4 42.6 45.8 41.7 34.5 71.6 820.3 242.1 118.6 46.9 17.8 22.0% 615. 4+ 209.7 152.9 42.4 6.9 94, 2% 806.2 271.6 111.1 45.1 32.6 107.3 855.9 382.0 231.9 86.3 22.2 27.8% 666.7 209.7 208.8 50.4 9.4 142.1% 843.8 453.7 255.8 94.0 40.6 singletons, the mortality rates are: Primary cesarean Vaginal breech birth + 5-9 deaths. Neonatal Perinatal 52.5 20:7 82.0 120.6 197 TABLE L: Births with dystocia at delivery by birth weight, method of delivery, 1976-77 Primary Total Cesarean Live births with dystocia 11,492% 8,278 Percent of all births in category 5.6 31.6 Birth weight 100.0 100.0 < 2500 grams 3.8 2] 2501-4000 grams 81.6 81.0 > 4001 grams 14.5 15.8 Mortality (< 2501) Neonatal 3.35 2.99+ Perinatal 4.79 4.10++ Vaginal 2,767 4.20+ 6.85++ *¥ Includes 447 repeat cesarean births not shown separately. + Rates subject to large sampling error due to small numbers of deaths; difference between rates not statistically significant (p, very large). ++ p < .05. 198 TABLE M: Births with fetal distress by birth weight, method of delivery, 1976-77 Total Live births with fetal distress 6,585% Percent of all births in category 3.2 Distribution of births with fetal distress Total 100.0 < 2500 grams 12.0 > 2501 grams 81.1 < 4000 grams 6.9 Neonatal mortality < 2500 grams 82.2 > 2501 grams 8.3 Total 17.2 Perinatal mortality < 2500 grams 120.0 > 2501 grams 13.2 Total 26.8 * Includes 110 births not shown separately. + p, large for each pair of comparisons. ++ p < .05. Primary Cesarean 2,997 13 100. 13. 77. 64. 10. 18. 71 a0 Wn .6 0+ 8+ « B84++ 15. 23. 7+ Vaginal 3,478 2. 100. 0 10.4 84. 102. C+ 16. 163. 2+ 28. 11 _ 5+ 34+ TABLE 1: TOTAL LIVE BIRTHS BY METHOD OF DELIVERY, NEW YORK CITY, 1968-78 C-BIRTH _ _ ___ VAGINAL BIRTH High/Mid Low Total Total Primary Repeat Total Spontaneous Breech Forceps Forceps Version Other N.S. 1978 99,970 17,293 11,420 5,873 82,677 68,061 1,156 1,071 11,075 68 874 372 1977 103,488 17,144 11,570 5,574 86,344 68,220 1,327 1,437 12,792 67 1,478 1,023 1976 102,948 15,353 10,446 4,907 87,595 65,704 1,545 1,694 15,270 71 1,469 1,842 1975 -102, 382 14,597 10,069 4,528 87,785 66,356 1,123 2,13 16,631 34 9 919 1974 103, 348 13,150 8,966 4,184 90,198 65,373 1,174 3,012 19,425 31 30 1,153 1973 103,616 11,642 8,093 3,549 91,974 65,077 1,274 3,388 21,218 39 33 945 1972 109,949 10,878 7,221 3,657 99,071 68,501 1,481 3,966 23,613 31 22 1,457 1971 123,711 11,002 7,077 3,925 112,709 77,274 1,766 4,280 27,995 68 45 1,281 1970 139,226 11,145 6,774 4,371 128,081 86,978 2,093 5,118 32,218 75 68 1,530 1969 135,732 9,735 6,017 3,718 125,997 82,573 2,202 5,519 34,192 80 33 1,388 1968 131,413 8,878 5,256 3,622 122,535 79,098 2,144 5,879 33,141 112 488 1,673 661 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 TABLE 1A: DISTRIBUTION OF LIVE BIRTHS BY METHOD OF DELIVERY, NEW YORK CITY, 1968-78 C-BIRTH Total Primary Repeat 17.30 11.42 5.87 16.57 11.18 5.39 14.91 10.14 4.76 14.26 9.83 4.42 12.72 8.67 4.04 11.24 7.81 3.42 9.89 6.56 3.32" 8.89 5.72 3.17 8.00 4.86 3:13 7.17 4.43 2.73 6.76 4.00 2.76 VAGINAL BIRTH High/Mid Low Total* Spontaneous Breech Forceps Forceps 82.70 68.08 1:15 1.07 11.08 83.43 65.92 1.28 1.38 12.36 85.08 63.82 1.50 1.63 14.83 85.74 64.81 1.09 2.64 16.24 87.28 63.25 1.13 2.90 18.79 88.76 62.80 1.22 3.26 20.47 90.11 62.30 1.34 3.59 21.47 91.1) 62.46 1.42 2.45 22.62 92.00 62.47 1.50 3.66 23.14 92.83 60.83 1.62 4.06 25.19 93.24 60.19 1.63 4.47 25.22 * Includes all other categories not shown separately. NOTE: Percentages may not add to 100.0 due to rounding. 00¢ 1977 1976 1975 1974 1973 1972 TABLE 1B: Total 11. 12. 13. 12. 13. 13. 13. 15. 16. 39 73 08 90 55 31 57 10 .40 86 NEONATAL MORTALITY RATES* BY METHOD OF DELIVERY, NEW YORK CITY, 1968-77 C-BIRTH Total Primary Repeat 12.95 14.78 9.15 12.44 14.46 8.15 14.93 15.99 12.59 l6.73 16.95 16.25 17.61 18.66 15.22 15.17 15.23 15.04 17.36 17.52 17.07 20.73 21.85 18.99 24.65 28.59 18.29 25.79 28.35 22.09. * 4 t+ 5-9 deaths; ( ) 1-4 deaths; -0 deaths. Per 1,000 live births. Includes all other categories not shown separately. VAGINAL BIRTH . High/Mid Low Total? Spontaneous Breech Forceps Forceps 11.08 10.61 93.44 4.871 4.53 12.79 12.30 110.68 2.9511 4.72 12.77 13.91 73.91 4.42 3.92 12.34 13.26 84.33 4.32 5.10 13.04 14.23 87.91 4.43 5.42 13.10 14.47 79.00 6.05 5.12 13.20 14.36 77.58 8.64 5.18 14.62 16.45 76.92 7.82 5.09 16.84 19.62 84.01 5.80 5.88 16.21 19.22 "77.89 5.85 5.43 10¢ TABLE 1C: FETAL DEATH RATES” BY METHOD OF DELIVERY, NEW YORK CITY, 1968-78 C-BIRTH VAGINAL BIRTH High/Mid Low Total Total Primary Repeat Total™ Spontaneous Breech Forceps Forceps 1978 6.96 4.95 6.09 2.72 7.38 7.13 128.57 (2.79) (2.07) 1977 7.49 5.45 6:27 3.75 7.89 7.93 47.38 3.4711 1.64 1976 7.33 4.93 5.24 4.26 7.78 7.28 41.56 3.5371 3.26 1975 6.96 6.33 8.08 2.42 7.07 7.72 27.71 (1.47) 2.28 1974 6.88 5.60 6.43 3.81 7.07 7.47 28.15 (0.66) 2.52 1973 9.47 11.13 13.65 5.33 9.26 10.12 38.49 3.24 2.91 1972 10.31 9.92 12.58 4.63 10.35 11.20 43.90 3.27 2.58 1971 10.60 9.36 11.59 5.52 10.72 12.41 35.50 5.35 2.60 1970 11.59 13.02 18.40 4.55 11.46 12.46 35.04 4.28 3.34 1969 11.92 14.08 17.95 7.74 11.75 13.12 38.43 2.71 3.47 1968 12.36 13.23 17.39 7.13 12.30. 14.24 38.57 2.88 3.00 * Per 1,000 live births plus fetal deaths 28 weeks and over. T Includes all other categories not shown separately. tt 5-9 deaths; ( ) 1-4 deaths; - 0 deaths. 20¢ TABLE 1D: PERINATAL MORTALITY RATES® BY METHOD OF DELIVERY, NEW YORK CITY, 1968-77 C-BIRTH VAGINAL BIRTH High/Mid Low Total Total Primary Repeat Total? Spontaneous Breech Forceps Forceps 1977 18.80 18.33 20.70 13.05 18.89 18.45 136.40 8.32 6.17 1976 19.97 17.31 21.33 12.38 20.44 19.49 147.64 6.47 7.96 1975 19.95 21.17 23.94 17.18 19.75 21.52 99.57 5.89 6.24 1974 19.68 22.23 23.27 2C.06 19.32 20.63 110.10 4.938 7.60 1973 22.90 28.54 32.05 20.46 22.18 24.20 123.02 7.65 8.32 1972 23.48 24.94 27.62 19.60 23.32 25.51 119.43 9.30 7.69 1971 24.03 26.56 28.91 22.30 23.78 26.60 110.32 13.94 7-77 1970 26.52 33.48 39.85 23.46 25.91 28.70 109.27 12.06 8.41 1969 28.39 38.38 46.03 25.89 28.39 32.48 119.21 8.49 7-33 1968 29.01 38.68 45.24 29.06 28.31 33.19 113.45 8.82 8.42 * Neonatal deaths plus fetal deaths, 28 weeks and over per 1,000 live births plus fetal deaths, 28 weeks and over. t+ Includes all categories not shown separately. €02 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 TABLE 1E: Total 3.25 3.06 3.01 2:79 2.85 3.07 PUSTNEUNATAL MOKTALITY RATES® BY MeTHOL OF DELIVERY, NEW YORK CITY, 1968-77 C-BIRTH Total Primary Repeat 3.79 3.80 3.77 3.32 3.45 3.06 2.06 1.99 2.21 2.51 2.45 2.63 3.09 2.97 3.38 3.03 2.63 3.83 2.45 1.55 4.08 3.14 2.95 3.43 5.24 5.98 4.03 5.07 4.19 6.35 * Per 1,000 live births T includes all other categories not shown separately. t+ 5-9 deaths; ( ) 1-4 deaths - 0 deaths. VAGINAL BIRTH % High/Mid Low Total Spontaneous Breech Forceps Forceps 3.14 5.21 8.29 5.57 2.1 2.87 3.09 3.881 (1.77) 2.10 2.64 2.89 g.o1ftt (1.47) 1.14 3.13 3.35 7.671% (1.33) 2.21 3.00 3.06 7.061t (1.77) 2.69 2.77 3.08 4.731% (0.77) 1.99 2.89 2.89 5.66 2.34 2.75 3.06 3.45 4.78 1.17 2.17 3.47 3.78 8.17 1.63Tt 2.63 3.22 3.63 2.80 Tt 1.87 2.44 ¥02 TABLE 1F: INFANT MORTALITY RATES* BY METHOD OF DELIVERY, NEW YORK CITY, 1968-77 C-BIRTH VAGINAL BIRTH High/Mid Low Total Total Primary Repeat Total Spontaneous Breech Forceps Forceps 1977 14.64 16.74 18.58 12.92 14.22 13.82 101.73 10.44 6.64 1976 15.67 15.76 17.90 11.21 15.65 15.39 114.56 4.721% 6.81 1975 15.64 16.99 17.98 14.80 15.41 16.80 81.92 5.90 5.11 1974 15.96 19.24 19.41 18.88 15.48 16.61 91.99 5.64 7.31 1973 16.56 20.70 21.62 18.60 16.03 17.29 94.98 6.20 8.11 1972 16.10 18.20 17.86 18.87 15.86 17.55 83.73 6.81 7-11 1971 16.43 19.81 19.08 21.15 16.09 17.25 83.24 10.98 2.93 1970 18.17 23.87 24.80 22.42 17.68 19.90 81.70 8.99 7.26 1969 21.00 29.89 34.57 22.32 20.31 23.40 92.19 7.43 8.51 1968 20.20 30.86 32.53 28.44 19.43 22.85 80.69 7.82 7.88 - Per 1,000 live births. Includes all other categeries net chown separately. tt 5-9 deaths; ( ) 1-4 deaths; -0 deaths. G0¢ TABLE 2A: METHOD OF DELIVERY BY SELECTED CHARACTERISTICS, ALL INFANTS, NEW YORK CITY, 1976-77 and 1968-69 1976-77 1968-69 TOTAL C-BIRTH VAGINAL BIRTH TOTAL C-BIRTH VAGINAL BIRTH . ] Sponta- . Sponta- N= % Total Primary Repeat Total" neous Breech Forceps N= % Total Primary Repeat Total® neous Breech Forceps TOTAL 206,436 100.0 15.74 10.66 5.07 84.26 64.87 1.39 16.08 267,145 100.0 6.95 4.21 2.74 93.05 60.51 1.62 29.46 ETHNIC GROUP White (non PR) 102,554 100.0 15.73 10.67 5.04 84.19 60.63 1.43 18.71 141,520 100.0 7.06 4.19 2.86 92.94 55.18 1.80 34.65 White (PR) 23.767 100.0 16.75 10.32 6.43 83.25 67.66 1.59 11.99 45,055 100.0 7.60 4.44 3.15 92.40 63.32 1.91 25.79 Black 73,266 100.0 15.37 10.65 4.70 84.63 70.39 1.27 10.54 76,532 100.0 6.48 4.16 2.31 93.52 68.73 1.11 21.93 Other 6,827 100.0 16.46 11.70 4.76 83.54 59.70 1.31 20.35 3,974 100.0 5.75 3.49 2.26 94.25 60.46 2.26 30.82 AGE £17 years 12,194 100.0 11.09 10.09 0.99 88.91 67.20 1.15 17.96 12,914 100.0 4.89 4.28 0.61 95.11 55.45 1.28 37.15 18-29 years 146,190 100.0 14.36 9.78 4.57 85.64 65.63 1.33 15.72 195,453 100.0 5.87 3.64 2.25 94.13 59.66 1.60 31.45 2 30 years 48,046 100.0 21.14 13.47 7.65 78.86 61.96 1.57 12.47 58,757 100.0 11.05 6.12 4.93 88.95 64.45 1.77 21.17 BIRTH ORDER 1 91,763 100.0 17.63 17.15 0.48 82.37 55.66 1.13 22.19 105,280 100.0 7.25 7.07 0.18 92.75 43.11 1.76 46.75 2 61,680 100.0 15.42 4.76 10.66 84.58 68.93 1.47 11.17 74,208 100.0 7.09 1.96 5.13 92.91 65.95 1.51 24.07 3 or more 52,993 100.0 12.82 6.29 6.53 87.18 76.08 1.74 6.33 87,631 100.0 6.53 2.71 3.82 93.47 76.83 1.56 13.29 EDUCATION < High School Grad 67,957 100.0 14.65 9.48 5.17 85.35 69.62 1.45 11.79 100,620 100.0 6.80 4.08 2.72 93.20 66.09 1.53 24.22 High School Grad 92,646 100.0 15.68 10.42 5.26 84.32 64.12 1.42 15.74 113,094 100.0 7.07 4.19 2.88 92.93 58.09 1.60 31.81 Some College 42.355 100.0 17.54 13.07 4.47 82.46 59.10 1.22 18.93 42,001 100.0 6.98 4.55 2.43 93.02 52.65 1.82 37.30 HOSPITAL Voluntary 147,136 100.0 16.39 11.09 5.30 83.61 61.90 1.38 17.20 182,834 100.0 7.20 4.30 2.90 92.80 57.49 1.68 32.28 Proprietary 10,814 100.0 15.38 9.82 5.56 84.62 69.79 1.75 10.27 25,783 100.0 7.34 4.55 2.79 92.66 68.19 1.55 21.72 Municipal 48,071 100.0 13.96 9.64 4.32 86.04 72.59 1.35 9.87 56,385 100.0 6.09 3.82 2.27 93.91 68.05 1.45 22.52 SERVICE General 101,341 100.0 14.42 9.89 4.53 85.58 69.50 1.36 12.56 120,375 100.0 6.45 3.97 2.48 93.55 64.21 1.57 26.56 Private 103,685 100.0 17.22 11.55 5.67 82.78 60.17 1.42 1.77 140,162 100.0 7 4.62 3.09 92.29 55.91 1.74 33.32 # OF PRENATAL VISITS 9 or more visits 88,007 100.0 17.83 12.42 5.41 82.17 60.47 1.15 16.54 116,099 100.0 7.90 4.91 2.99 92.10 55.63 1.57 33.66 5-8 visits 72,365 100.0 15.40 10.06 5.34 84.60 65.77 1.43 14.76 88,427 100.0 6.88 3.95 2.93 93.12 61.99 1.59 28.32 1-4 visits 25,282 100.0 13.53 8.84 4.69 86.47 68.70 1.76 13.78 37,993 100.0 5.26 3.17 2.09 94.74 69.07 1.79 22.62 No visits 15,367 100.0 9.63 6.83 2.80 90.37 77.22 1.80 8.07 9,990 100.0 3.65 2.66 0.99 96.35 74.15 1.84 17.75 PLURALITY Single 201,966 100.0 15.51 10.43 5.08 84.49 65.31 1.08 15.21 261,404 100.0 6.88 4.15 2.73 93.12 60.69 1.32 29.72 Multiple 4,470 100.0 25.87 20.93 4.94 74.13 44.85 15.05 10.00 5,741 100.0 10.56 7.19 3.37 89.44 52.60 15.31 26.02 SOURCE OF PAYMENT Self 30,411 100.0 14.80 10.74 4.06 85.20 59.63 1.42 16.57 Medicaid 77,016 100.0 13.77 8.97 4.80 86.23 71.26 1.37 11.12 N.A. N.A. N.A. Other 95,885 100.0 17.60 11.99 5.61 82.40 61.41 1:37 17.92 NOTE: Percentages may not add up to 100.0 due to rounding. * Includes all other categories not shown separately. 902 TABLE 2B: METHOD OF DELIVERY BY SELECTED CHARACTERISTICS, VERY SMALL INFANTS (1500 gms or less), NEW YORK CITY, 1976-77 and 1968-69 1976-77 1968-69 TOTAL C-BIRTH VAGINAL BIRTH TOTAL C-BIRTHS VAGINAL BIRTHS Sponta- ) Sponta- N= 5 Total Primary Repeat Total* neous Breech [lorceps N= % Total Primary Repeat Total* neous Breech Forceps TOTAL 3,013 100.0 15.50 13.14 2.36 84.50 64.29 11.82 4.98 4,265 100.0 6.05 4.71 1.34 93.95 74.68 8.46 6.82 ETHNIC GROUP White (non PR) 936 100.0 17.95 14.85 3.09 82.05 59.82 13.03 6.18 1,393 100.0 7.90 5.74 2.15 92.10 69.63 11.27 8.24 White (PR) 311 100.0 18.65 15.11 3.53 81.35 60.77 12.54 4.49 645 100.0 6.05 4.80 1.24 93.95 73.02 10.07 6.97 Black 1,721 100.0 13.31 11.62 1.68 86.69 67.46 11.15 4.40 2,194 100.0 4.97 4.10 0.86 95.03 78.30 6.24 5.78 Other 45 100.0 26.66 22.22 4.44 73.34 60.00 6.66 4.43 33 100.0 5.75 3.49 2.26 94.25 78.78 6.06 12.12 AGE $17 years 276 100.0 7.25 6.88 0.36 92.75 69.20 13.04 6.88 382 100.0 2.62 2.62 --- 97.38 78.27 4.71 11.78 18-29 years 2,051 100.0 14,68 12.77 1.90 85.32 64.85 12.04 4.97 2,924 100.0 4.75 3.83 0.92 95.25 75.96 8.45 6.70 2 30 years 686 100.0 21.28 16.76 4.52 78.72 60.64 10.64 4.22 957 100.0 11.38 8.25 3.13 88.62 69.28 10.03 5.22 BIRTH ORDER 1 1,453 100.0 14.45 14.38 0.07 85.55 64.21 11.36 6.68 1,710 100.0 4.04 3.98 0.06 95.96 73.57 7.43 11.87 2 796 100.0 15.33 10.30 5.03 84.67 64.95 12.31 4.15 1,100 100.0 5.91 3.91 2.00 94.09 76.00 9.55 4.18 3 or more 764 100.0 17.67 13.74 3.93 82.33 63.74 12.17 2.62 1,455 100.0 8.52 6.19 2.34 91.48 74.98 8.87 2.96 EDUCATION < High School Grad 1,218 100.0 15.44 12.7% 2.71 84.56 65.11 11.25 8.46 1,969 100.0 5.64 4.57 1.07 94.36 76.69 7:52 6.81 High School Grad 1,209 100.0 14.39 12.57 1.82 85.61 64.35 12.74 4.96 1,580 100.0 6.58 4.87 1.71 93.42 73.04 9.30 6.90 Some College 493 100.0 19.27 16.43 2.84 80.73 60.85 11.16 6.29 436 100.0 6.20 4.59 1.61 93.80 71.10 9.86 9.63 HOSPITAL Voluntary 1,888 100.0 16.79 14.30 2.49 83.21 62.87 11.76 5.24 2,371 100.0 7.55 5.48 2.07 92.45 20.9 10.42 $27 Proprietary 82 100.0 18.29 14.63 3.66 81.71 68.29 9.76 2.43 220 100.0 7.27 6.82 0.45 92.73 Le 0.45 Sa Municipal 1,041 100.0 12.97 10.95 2.02 87.03 66.57 12.01 4.71 1,646 100.0 3.77 3.34 0.43 96.23 80. 4 . SERVICE General 1,988 100.0 14.43 12.37 2.06 85.57 66.00 11.27 5.13 2,792 100.0 5.02 4.12 0.90 94.98 5.07 Ei $48 Private 964 100.0 18.67 15.56 3.11 81.33 59.96 13.59 4.98 1,282 100.0 9.21 6.71 2.50 90.79 68. . \ # OF PRENATAL VISITS 9 or more visits 284 100.0 24.30 20.07 4.23 75.70 49.65 13.03 6.34 310 100.0 13.23 10.32 2.90 86.77 3.9 10.52 1.2 5-8 visits 857 100.0 19.84 18.09 1.75 80.16 58.81 13.07 5.83 898 100.0 9.02 7.13 1.89 90.98 5.2 3.28 5.47 1-4 visits 909 100.0 13.97 11.11 2.86 86.03 65.24 11.33 5.83 1,398 100.0 5.01 3.51 1.50 94,99 nH 5.92 3.77 No visits 790 100.0 10.26 8.61 1.65 89.74 72.78 10.13 3.29 929 100.0 2.80 2.48 0.32 97.20 1. : L PLURALITY Single 2,503 100.0 15.34 13.14 2.20 84.66 66.88 9.63 5.07 3,568 100.0 6.03 4.82 1.21 93.97 ne oh 4 Multiple 510 100.0 16.28 13.14 3.14 83.72 51.57 22.55 4.51 697 100.0 6.17 4.16 2.01 92.83 62. . - SOURCE OF PAYMENT Self 339 100.0 17.99 15.04 2.95 82.01 55.46 15.93 6.78 N.A NA. N.A. Medicaid 1,504 100.0 13.70 11.50 2.19 86.30 68.15 10.97 4.12 : Other 1,028 100.0 18.00 15.56 2.43 82.00 61.87 11.58 5.54 Footnote: See Table 2A £02 TABLE 2C: METHOD OF DELIVERY BY SELECTED CHARACTERISTICS, INFANTS 1501-2000 gms, NEW YURK CITY, 1976-77 and 1968-69 1976-77 1968-69 TOTAL C-BIRTH VAGINAL BIRTH TOTAL C-BIRTH VAGINAL BIRTH Sponta- Sponta- N= % Total Primary Repeat Total* neous Breech Forceps N= % Total Primary Repeat Total* neous Breech Forceps TOTAL 3,764 100.0 21.56 17.34 4.22 78.44 59.80 6.26 9.34 5,033 100.0 9.43 6.53 2.90 90.57 65.05 6.33 15.72 ETHNIC GROUP white (non PR) 1,302 100.0 24.03 19.66 4.37 75.97 53.68 7.45 11.67 1,842 100.0 11.88 8.46 3.42 87.12 56.94 8.25 20.88 White (PR) 421 100.0 20.18 14.96 5.22 79.82 61.28 9.50 6.88 897 100.0 9.91 6.68 3.23 90.09 64.32 7.46 15.37 Black 1,966 100.0 19.87 15.86 4.01 80.13 63.68 4.83 8.43 2,248 100.0 7.33 4.98 2.35 92.67 72.01 4.13 13.42 Other 75 100.0 30.66 29.33 1.33 69.34 56.00 5.33 6.66 42 100.0 4.76 2.38 2.38 95.24 61,90 16.66 16.67 AGE < 17 years 363 100.0 11.56 10.46 1.10 88.44 68.04 5.78 12.94 433 100.0 4.15 3.92 0.23 95.85 69.05 3.23 21.47 18-29 years 2,578 100.0 19.50 15.51 3.99 80.50 61.55 6.12 9.41 3,450 100.0 7.82 5.27 2.55 92.18 65.73 6.49 17.32 > 30 years 823 100.0 29.43 26.12 6.31 70.57 50.66 6.92 7.52 1,150 100.0 16.25 11.30 4.95 83.75 61.47 7.04 12.18 BIRTH ORDER 1 1,666 100.0 20.64 20.16 0.48 79.36 57.38 5.64 14.22 1,986 100.0 6.65 6.19 0.45 93.35 57.05 6.45 27.90 2 1,054 100.0 22.00 13.47 8.53 78.00 60.62 6.45 6.73 1,278 100.0 10.02 5.56 4.46 89.98 69.48 6.65 11.66 3 or more 1,044 100.0 22.60 16.76 5.84 77.40 62.83 7.08 4.21 1,768 100.0 12.16 7.64 4.52 87.84 70.81 6.00 7.35 EDUCATION < High School Grad ~~ 1,598 100.0 19.39 15.39 4.00 80.61 64.45 6.07 7.31 2,352 100.0 77 5.18 2.59 92.23 70.40 5.18 14.19 High School Grad 1,546 100.0 22.76 17.59 5.17 77.24 57.43 6.40 10.54 1,887 100.0 10.70 7.47 3.23 89.30 62.21 6.88 17.52 Some College 559 100.0 24.68 22.36 2.32 75.32 52.41 6.44 12.33 520 100.0 11.34 8.65 2.69 88.66 52.50 8.84 25.56 HOSPITAL Voluntary 2,438 100.0 23.09 19.03 4.06 76.91 57.83 6.35 9.80 3,034 100.0 10.57 7.58 2.99 89.43 60.11 7.44 19.10 Proprietary 154 100.0 ~~ 27.26 15.58 11.68 72.74 55.84 8.44 2.59 304 100.0 13.48 8.55 4.93 86.52 66.44 6.57 12.16 Municipal 1,169 100.0 17.70 14.11 3.59 82.30 64.41 5.81 9.32 1,656 100.0 6.64 4.34 2.29 93.36 74.21 4.22 12.19 SERVICE General 2,339 100.0 20.04 15.98 4.06 79.96 62.89 5.38 9.35 3,073 100.0 7.60 5.10 2.50 92.40 69.18 5.53 15.39 Private 1,358 100.0 25.25 20.54 4.71 74.75 53.53 8.10 9.71 1,781 100.0 13.52 9.65 3.87 86.48 55.58 8.36 20.15 # OF PRENATAL VISITS 9 or more visits 762 100.0 31.88 25.98 5.90 68.12 48.16 7.34 9.57 971 100.0 12.24 9.16 3.08 87.76 55.81 10.19 19.34 5-8 visits 1,353 100.0 23.64 18.69 4.95 76.36 57.79 6.06 9.97 1,532 100.0 11.54 7.24 4.30 88.46 60.83 6.59 18.07 1-4 visits 824 100.0 17.47 14.32 3.15 82.53 63.83 6.06 9.45 1,484 100.0 8.08 5.66 2.42 91.92 70.75 5.18 14.53 No visits 664 100.0 13.10 10.54 2.56 86.90 69.87 5.57 8.28 553 100.0 5.41 4.15 1.26 94.59 74.32 3.79 13.55 PLURALITY Single 3,061 100.0 21.09 16.98 4.11 78.91 62.52 4.05 9.63 4,075 100.0 9.75 6.79 2.96 90.25 67.38 3.82 17.04 Multiple 703 100.0 23.60 18.91 4.69 76.40 47.93 15.93 8.10 958 100.0 8.02 5.42 2.60 91.98 55.11 17.01 14.39 SOURCE OF PAYMENT Self 390 100.0 23.06 17.94 5.12 76.94 54.35 5.64 10.25 Medicaid 1,994 100.0 19.35 15.44 3.91 80.65 63.99 5.51 8.27 N.A. N.A. N.A. Other 1,293 100.0 24.74 20.41 4.33 75.26 55.68 7.50 10.04 Footnote: See Table 2A 802 TABLE 2D: METHOD OF DELIVERY BY SELECTED CHARACTERISTICS, OTHER LOW BIRTH WEIGHT INFANTS (2001-2500), NEW YORK CITY, 1976-77 and 1968-69 1976-77 oo 1968-69 TOTAL C-BIRTH VAGINAL BIRTH TOTAL C-BIRTH VAGINAL BIRTH - Sponta- ] Sponta- N= ° Total Primary Repeat Total* neous Breech Forceps N= % Total Primary Repeat Total® neous Breech Forceps TOTAL 12,627 100.0 16.88 11.63 5.25 83.12 65.09 3.70 11.55 18,024 100.0 8.01 4.84 3.17 91.99 63.77 3.50 22.90 ETHNIC GROUP White (non PR) 4,839 100.0 18.16 12.77 5.39 81.84 60.23 4.48 14.25 3,960 100.0 8.98 5.78 3.19 91.02 57.90 4.66 26.92 White (PR) 1,528 100.0 15.72 9.88 5.82 84.29 65.57 4.12 11.90 3,105 100.0 8.31 3.73 4.57 91.69 63.57 3.96 22.14 Black 5,934 100.0 16.23 11.13 5.08 83.77 68.99 2.88 9.09 7,178 100.0 6.85 4.30 2.54 93.15 70.03 2.06 18.91 Other 324 100.0 14.80 11.41 3.39 85.20 64.19 1.91 13.88 199 100.0 4.56 1.97 2.59 95.44 63.81 4.02 30.00 AGE < 17 years 1,086 100.0 10.40 8.93 1:47 89.60 70.16 2.30 14.82 1,285 100.0 3.73 2.80 0.93 96.27 62.64 2.33 29.87 18-29 years 8,953 100.0 15.48 10.46 5.02 84.52 66.50 3.65 11.45 12,917 100.0 6.62 3.99 2.63 93.38 63.64 3.51 24.35 2 30 years 2,588 100.0 23.47 16.76 7.61 76.53 58.07 4.44 10.46 3,821 100.0 14.10 8.40 5.70 85.90 64.56 3.84 15.56 BIRTH ORDER 1 5,898 100.0 16.01 15.63 0.38 83.99 60.63 2.86 17.69 7,513 100.0 6.02 5.75 2.66 93.98 52.31 3.62 36.84 2 3,455 100.0 18.19 7.14 11.05 81.81 67.26 4.31 7:35 4,590 100.0 8.58 2.90 5.69 91.42 68.45 3.42 17.28 3 or more 3,274 100.0 17.01 9.13 7.88 82.99 70.83 4.55 4.87 5,918 100.0 10.10 5.20 4.90 89.90 74.70 3.41 89.53 EDUCATION < High School Grad 4,999 100.0 15.00 9.54 5.46 85.00 69.49 3.36 9.80 7,930 100.0 7:73 4.67 3.06 92.27 67.99 2:59 19.97 High School Grad 5,382 100.0 17.16 11.89 5.27 82.84 63.61 4.29 12.00 7,053 100.0 8.24 4.74 3.50 91.76 61.12 4.23 24.57 Some College 1,987 100.0 20.62 16.10 4.52 79.38 58.48 3.17 14.28 2,231 100.0 8.11 5.60 2.51 91.89 56.61 4.25 20.78 HOSPITAL Voluntary 8,608 100.0 17.53 11.98 5.55 82.47 62.80 3.84 12.89 11,493 100.0 10.57 7.58 2.99 89.43 61.26 3.72 24.90 Proprietary 528 100.0 17.41 10.60 6.81 82.59 67.61 5.49 7-19 1,292 100.0 13.48 8.55 4.93 86.52 68.96 4.10 14.31 Municipal 3,485 100.0 15.17 10.90 4.27 84.83 70.30 3.07 8.88 5,074 100.0 6.12 3.74 2.38 93.88 69.19 2.85 19.44 SERVICE General 7,347 100.0 15.38 10.38 5.00 84.62 68.06 3.36 10.90 9,911 100.0 7.01 4.20 2.81 92.99 65.97 2.94 22.46 Private 5,120 100.0 19.52 13.76 5.76 80.48 60.46 4.27 12.79 7,495 100.0 9.97 6.08 3.89 90.03 58.77 4.50 25.30 # OF PRENATAL VISITS 9 or more visits 3,716 100.0 21.25 14.88 6.37 78.75 57.9% 3.84 13.66 971 100.0 9.86 5.88 3.98 90.14 58.94 4.31 25.46 5-8 visits 4,635 1920.0 17.12 11.90 5.22 82.88 64.20 4.09 11.97 1,532 100.0 8.47 4.95 3.52 91.53 62.31 3.62 23.98 1-4 visits 2,259 109.0 14.47 9.16 5.31 85.53 69.76 3.32 10.48 1,484 100.0 6.38 3.93 2.45 93.62 69.44 2.75 19.85 No visits 1,586 109.0 10.21 7.50 2.71 89.79 76.10 2.64 8.00 553 100.0 4.10 2.99 1.11 95.90 75.02 2.82 15.38 PLURALITY Single 11,256 199.0 16.95 10.85 5.20 83.05 67.59 2.23 11.60 16,256 100.0 7.82 4.68 3.14 92.18 65.00 2.22 23.35 Multiple 5,120 100.0 23.55 17.94 5.61 76.45 45.29 15.68 11.00 1,768 100.0 9.66 6.33 3.33 90.34 52.43 15.21 18.59 SOURCE OF PAYMENT Self 1,432 100.0 16.82 12.70 4.12 83.18 60.19 3.98 12.83 Medicaid 6,124 100.0 14.43 9.04 5.37 85.59 70.23 3.24 9.43 N.A. N.A. N.A. Other 4,830 100.0 20.01 14.63 5.38 79.99 60.14 4.12 13.84 Footnote: See Table 2A 602 TABLE 2E: METHOD OF DELIVERY BY SELECTED CHARACTERISTICS, INFANTS OVER 2500 GMS., NEW YORK CITY, 1976-77 and 1968-69 1976-77 1968-69 TOTAL C-BIRTH VAGINAL BIRTH TOTAL C-BIRTH VAGINAL BIRTH Sponta- Sponta- N= % Total Primary Repeat Total® neous Breech Forceps N= % Total Primary Repeat Total® neous Breech Forceps TOTAL 186,986 100.0 15.55 10.43 5.13 84.45 61.01 0.97 15.63 239,274 100.0 6.85 4.11 2.74 93.15 59.93 1.26 30.65 ETHNIC GROUP White (non PR) 95,464 100.0 15.47 10.41 5.06 84.53 60.75 1.08 20.17 130,497 100.0 6.87 4.03 2.84 93.13 54.85 1.44 35.61 White (PR) 21.503 100.0 16.74 10.19 6.54 83.26 68.04 1.10 12.23 40,299 100.0 7.52 4.44 3.08 92.48 63.16 1.50 26.63 Black 63,617 100.0 15.21 10.43 4.78 84.79 70.82 0.74 10.92 64,279 100.0 6.46 4.12 2.34 93.54 68.16 0.73 23.14 Other 6,382 100.0 16.31 11.44 4.87 83.69 59.51 1.05 20.98 3,694 100.0 5.71 3.44 2:27 94.29 60.07 1.76 31.54 AGE < 17 years 10,464 100.0 11.24 10.28 0.96 88.76 66.84 0.54 18.79 10,783 100.0 5.15 4.54 0.61 84.85 53.26 1.33 39.60 18-29 years 132,584 100.0 14.18 9.59 4.59 85.82 65.67 0.94 16.34 175,766 100.0 5.80 3.58 2.22 94.20 58.99 0.70 32.68 2 30 years 43,932 100.0 20.74 13.00 7.74 79.26 62.42 1.15 12.83 52,711 100.0 10.72 5.80 4.92 89.28 64.43 0.40 22.08 BIRTH ORDER 1 82,727 100.0 17.75 17.25 0.50 82.25 55.13 0.74 23.63 93,852 100.0 7.42 7.26 0.17 92.58 41.53 1.41 48.60 2 56,364 100.0 15.14 4.38 10.76 84.86 69.24 1.05 11.61 67,098 100.0 6.95 1.79 5.16 93.05 65.56 1.15 25.10 3 or more 47,895 100.0 12.25 5.75 6.50 87.75 76.94 1.27 6.56 78,302 100.0 6.09 2.34 3.75 93.91 77.17 1.19 13.86 EDUCATION < High School Grad 60,122 100.0 14.46 9.26 5.20 85.54 69.87 0.96 12.24 88,161 100.0 6.72 3.98 2.73 93.28 65.58 1.20 25.28 High School Grad 84,488 100.0 15.49 10.17 5.32 84.51 64.28 0.98 16.25 102,379 100.0 8.05 4.74 3.31 91.95 66.87 1.40 38.29 Some College 39,311 100.0 17.26 12.74 4.52 82.74 59.21 0.92 19.44 38,754 100.0 6.87 4.44 2.43 93.13 52.21 1.50 38.24 HOSPITAL Voluntary 134,168 100.0 16.20 10.85 5.35 83.80 61.91 0.98 17.80 165,574 100.0 7.05 4.17 2.88 92.95 57.00 1.31 33.40 Proprietary 10,048 100.0 15.07 9.65 5.42 84.93 70.13 1.39 10.63 23,939 100.0 7.08 4.39 2.69 92.92 68.14 1.28 22.41 Municipal 42,356 100.0 13.80 9.39 4.41 86.20 73.16 0.82 10.11 47,867 100.0 6.16 3.83 2.33 93.84 67.30 1.08 23.84 SERVICE General 89,642 100.0 14.20 9.64 4.56 85.80 69.87 0.87 12.95 104,330 100.0 6.41 3.91 2.50 93.59 63.57 1.17 27.83 Private 96,223 100.0 16.99 11.28 5.7 83.01 60.25 1.06 18.30 129,397 100.0 7.50 4.45 3.05 92.50 55.65 1.39 34.24 # OF PRENATAL VISITS 9 or more visits 83,255 100.0 17.53 12.16 5.37 82.47 60.73 0.93 17.59 109,287 100.0 7.76 4.81 2.95 92.24 55.45 1.34 34.27 5-8 visits 65,505 100.0 15.06 9.65 5.41 84.94 66.14 1.00 15.07 79,616 100.0 6.65 3.77 2.88 93.35 61.96 1.21 29.09 1-4 visits 21,273 100.0 13.289 8.51 4.78 86.71 68.93 1.02 14.67 31,109 100.0 5.02 2.95 2.07 94.98 68.65 1.19 24.05 No visits 12,314 100.0 9.35 6.44 2.91 90.65 78.06 0.94 8.41 7,289 100.0 3.55 2.51 1.04 96.45 73.03 1.02 20.35 PLURALITY Single 185,105 100.0 15.40 10.27 5.13 84.60 65.21 0.85 15.68 236,975 100.0 6.79 4.06 2.75 93.21 60.04 1.14 30.76 Multiple 1,881 100.0 31.10 26.05 5.05 68.90 41.57 12.12 11.54 2,299 100.0 13.57 9.48 4.09 86.43 48.63 13.79 19.79 SOURCE OF PAYMENT Self 28,241 100.0 14.56 10.50 4.06 85.44 59.73 1.06 14 gg Medicaid 67,370 100.0 13.56 8.72 4.84 86.44 71.65 0.87 11.53 WR Other 88,722 100.0 17.38 11.69 5.69 82.62 61.56 1.02 18.41 N.A. N.A. A. Footnote: See Table 2A 01¢ TABLE 3: DISTRIBUTION OF LIVE BIRTHS BY BIRTH WEIGHT AND METHOD OF DELIVERY NEW YORK CITY, 1976-77 and 1968-69 C-BIRTH VAGINAL BIRTH High/Mid Low Total Total Primary Repeat Total Spontaneous Breech Forceps Forceps Version Other N= % 1976-77 TOTAL 206,436 100.0 15.74 10.66 5.08 84.26 64.87 1.39 1.51 13.59 0.06 1.42 x. < 1000 gms 1,310 100.0 8.93 7.02 1.91 91.07 69.08 15.73 0.22 2.29 0.22 0.83 2: 1001-1500 gms 1,703 100.0 20.55 17.85 2.70 79.45 60.59 8.81 0.40 6.45 0.64 0.64 1. 1501-2000 gms 3,764 100.0 21.57 17.35 4.22 78.43 59.80 6.27 0.39 8.95 0.39 0.87 1, 2001-2500 gms 12,627 100.0 16.88 11.63 5.25 83.12 65.09 3.70 0.86 10.67 0.26 1.14 1. 2501-3000 gms 44,785 100.0 13.59 8.43 5.15 86.41 68.17 1.57 1.25 12.78 0.06 1.13 ¥. 3001-3500 gms 81,349 100.0 14.28 9.04 5.24 85.71 65.98 0.93 1.51 14.38 0.0 1.46 1. 3501-4000 gms 47,722 100.0 17.15 12.20 4.94 82.85 62.56 0.56 1.96 14.76 0.0 1.63 1: 2 4001 gms 13,130 100.0 24.36 19.33 5.03 75.64 56.47 0.57 1.93 13.43 0.0 1.80 1. N.S 46 100.0 4.35 4.35 -— 95.65 67.39 15.21 --- --- -— 4.34 8. 1968-69 TOTAL 267,145 100.0 6.97 4.22 2.75 93.03 60.52 1.63 4.26 25.20 0.07 0.19 1: < 1000 gms 2,115 100.0 3.40 2.74 0.66 96.60 81.80 8.18 0.28 2.78 0.28 0.33 4. 1001-1500 gms 2,150 100.0 8.65 6.65 2.00 91.35 68.98 8.74 1.52 8.97 ,0.74 0.23 2. 1501-2000 gms 4,724 100.0 9.44 6.54 2.90 90.57 65.05 6.34 1.74 14.80 0.75 0.15 1. 2001-2500 gms 17,113 100.0 8.01 4.84 3.16 91.99 63.77 3.51 2.42 20.36 0.27 0.20 1. 2501-3000 gms 61,225 100.0 6.35 3.22 3.12 93.65 62.35 1.91 3.42 24.54 0.07 0.20 1s 3001-3500 gms 105,224 100.0 6.28 3.55 2.73 93.72 60.05 1.14 4.45 26.77 0.0 0.18 1. 3501-4000 gms 56,143 100.0 7.42 4.97 2.44 92.58 58.08 0.85 5.35 27.00 0.0 0.20 1, 2 4001 gms 14,395 100.0 11.30 9.13 2.17 88.70 55.08 0.76 6.54 25.28 0.0 0.10 0. N.S. 321 100.0 6.92 4.55 2.36 93.08 57.37 2.55 2.18 20.58 0.0 0.54 9. NOTE: 0.0 quantity more than 0 but less than 0.05. Percentages may not add up to 100.0 due to rounding. 112 1976-77 TOTAL < 1000 gms 1001-1500 gms 1501-2000 gms 2001-2500 gms 2501-3000 gms 3001-3500 gms 3501-4000 gms 2 4001 gms N.S. 1968-69 TOTAL < 1000 gms 1001-1500 gms 1501-2000 gms 2001-2500 gms 2501-3000 gms 3001-3500 gms 3501-4000 gms 2 4001 gms N.S. TABLE 3A: DISTRIBUTION OF LIVE BIRTHS BY METHOD OF DELIVERY AND BIRTH WEIGHT NEW YORK CITY, 1976-77 and 1968-69 C-BIRTH VAGINAL BIRTH High/Mid Low Total Total Primary Repeat Total Spontaneous Breech Forceps Forceps Version Other N.S. N=206,436 32,497 22,016 10,481 173,939 133,924 2,872 3,131 28,062 138 2,947 2,865 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 0.63 0.36 0.41 0.23 0.69 0.68 7.17 0.10 0.10 2.17 0.37 1.22 0.82 1.08 1.38 0.43 0.78 0.77 5.22 0.22 0.39 7.97 0.37 1.11 1.82 2.50 2.97 1.52 1.70 1.68 8.21 0.48 1.20 10.86 1.11 2.26 6.11 6.56 6.67 6.33 6.03 6.13 16.26 3.51 4.80 23.9% 4.92 6.07 21.69 18.72 17.16 22.01 22.25 22.79 24.51 18.05 20.40 20.28 18.12 21.29 39.40 35.75 33.41 40.67 40.09 40.08 26.42 39.48 41.68 21.73 40.54 39.44 23.11 25.18 26.45 22.50 22.73 22.29 9.33 30.05 25.11 8.69 26.43 22.12 6.36 9.84 11.53 6.30 5.7 5.53 2.61 8.11 6.28 4.34 8.04 6.31 0.02 0.0 0.0 - 0.0 0.0 0.24 -— -— -— 0.06 0.14 N=267,145 18,613 11,273 7,340 248,532 161,671 4,346 11,398 67,333 192 521 3,071 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 0.79 0.39 0.51 0.19 0.82 1.05 3.98 0.05 0.09 3.13 1.34 2.93 0.80 1.00 1.27 0.59 0.79 0.92 4.33 0.29 0.29 8.33 0.96 1.50 1.88 2.55 2.91 1.98 1.83 2.02 7.34 0.77 1.10 19.79 1.53 2.80 6.74 7.76 7.74 7.77 6.67 7.10 14.51 4.00 5.45 25.52 7.10 7.88 24.09 21.96 18.44 27.37 24.25 24.82 28.41 19.39 23.46 25.00 25.91 23.38 39.69 35.80 33.41 39.46 39.99 39.39 27.81 41.57 42.16 13.02 38.19 36.82 20.62 21.97 24.32 18.36 20.52 19.79 10.86 25.91 22.09 4.16 21.49 18.91 5.15 8.36 11.15 4.07 4.91 4.68 2.41 7.91 5.16 1.04 2.97 4.00 0.12 0.14 0.17 0.10 0.12 0.12 0.18 0.13 0.08 -— 0.88 1.03 NOTE: 0.0 quantity more than 0 but less than 0.05. Percentages may not add up to 100.0 due to rounding. 21e TABLE 4: DISTRIBUTION OF LIVE BIRTHS BY POSITION AT DELIVERY AND METHOD OF DELIVERY, NEW YORK CITY, 1976-77 and 1968-69 C-BIRTH VAGINAL BIRTH High/Mid Low Total Total Total Primary Repeat Total® Spontaneous Breech Forceps Forceps N= % 1976-77 TOTAL 206,436 100.0 100.0 15.7 10.7 5.1 84.3 64.9 1.4 1.5 13.6 Normal 157,428 76.3 100.0 5.3 3.3 2.0 94.7 75.0 el X73 15.3 ROP/LOP/ROT/LOT 18,549 9.0 100.0 61.2 41.6 19.6 38.8 21.8 vd 4.8 10.5 Breech 7,030 3.4 100.0 49.4 42.9 6.5 50.6 10.9 36.4 0.1 0.6 Head 15,488 7.5 100.0 35.8 23.2 12.6 64.2 52.4 0.1 1.2 8.8 Other 910 0.4 100.0 74.3 62.2 12.1 25.7 15.2 .S 1.6 2.3 Not Stated 7,031 3.4 100.0 43.3 27.3 16.0 56.7 39.7 1.3 0.7 7.8 1968-69 TOTAL 267,145 100.0 100.0 7.0 4.2 2.7 93.0 60.5 1.6 4.3 25.2 Normal 221,496 82.9 100.0 2.0 1.0 1.0 98.0 65.5 v1 3.6 27.6 ROP/LOP/ROT/LOT 16,879 6.3 100.0 34.8 22.0 12.9 65.2 27.6 "| 15.5 2143 Breech 9,546 3.6 100.0 20.2 16.0 4.2 79.8 32.9 43.1 0.6 1.0 Head 8,834 3.3 100.0 27.3 15.1 12.2 72.7 48.4 0.1 5.7 17.7 Other 948 0.4 100.0 54.1 46.1 8.0 45.9 31.4 2.2 3.5 6.0 Not Stated 9,442 3.5 100.0 36.4 21.3 15.1 63.6 44.9 0.7 2.2 9.4 * Includes all other categories not shown separately. NOTE: 0.0 quantity more than 0 but less than 0.05. ] Percentages may not add up to 100.0 due to rounding. €le TABLE 4A: DISTRIBUTION OF LIVE BIRTHS-NORMAL PRESENTATIONS BY BIRTH WEIGHT AND METHOD OF DELIVERY, NEW YORK CITY, 1976-77 and 1968-69 C-BIRTH VAGINAL BIRTH High/Mid Low Total Total Primary Repeat Total * Spontaneous Breech Forceps Forceps 1976-77 he $ Total 157,428 100.0 5.34 3.29 2.03 94.66 75.00 0.09 1.26 15.32 < 1000 gms 648 100.0 3.86 3.39 0.46 96.14 89.66 1.23 0.30 2.93 1001-1500 gms 994 100.0 8.25 6.94 1.30 91.75 80.18 0.90 0.40 8.65 1561-2006 gms 2,401 100.0 8.33 6.49 1.83 01.67 77.00 6.70 3.33 11.25 2001-2500 gms 9,085 100.0 5.94 3.64 2.30 94.06 78.07 0.29 0.70 12.40 2501-3000 gms 34,746 100.0 4.50 2.49 2.00 95.50 77.61 0.12 1.06 14.16 3001-3500 gms 63,477 100.0 4.69 2.68 2.00 95.31 75.13 0.05 1.23 15.80 3501-4000 gms 36,632 100.0 5.90 ‘3.87 2.03 94.10 72.45 0.04 1.60 16.77 2 4001 9,424 100.0 8.99 6.65 2.33 91.01 69.40 0.03 1.69 16.15 1968-69 Total 221,496 100.0 2.01 1.01 0.98 97.99 65.48 0.05 3.60 27.60 < 1000 gms 928 100.0 1.29 1.07 0.21 98.71 90.08 0.32 0.53 4.20 1001-1500 gms 1,267 100.0 2.84 2.36 0.47 97.16 80.34 0.86 1.57 12.54 1501-2000 gms 3,490 100.0 2.95 1.89 1.06 97.05 74.81 0.28 1.80 18.33 2001-2500 gms 14,024 100.0" 2.54 1.38 1.15 97.46 70.50 0.11 2.20 25.26 2501-3000 gms 53,655 100.0 1.93 0.80 1.32 98.07 67.26 0.05 2.90 26.62 3001-3500 gms 89,953 100.0 1.80 0.82 0.97 98.20 64.55 0.04 3.67 28.73 3501-4000 gms 46,600 100.0 1.95 1.10 0.84 98.05 62.98 0.02 4.49 29.30 2 4001 gms 11,224 100.0 3.27 2.40 5.8 56.73 61.99 0.01 5.52 28.18 Footnote - See Table 4 AX TABLE 4B: DISTRIBUTION OF LIVE BIRTHS-ROP/LOP/ROT/LOT PRESENTATIONS BY BIRTH WEIGHT AND METHOD OF DELIVERY, NEW YORK CITY, 1976-77 and 1968-69 C-BIRTH VAGINAL BIRTH . . ” High/Mid Low Total Total Primary Repeat Total” Spontaneous Breech Forceps Forceps N= % 1976-77 TOTAL 18,549 100.0 61.21 41.64 19.56 38.79 21.75 0.10 4.75 10.53 < 1000 gms 52 100.0 26.92 26.92 -— 73.08 57.69 1.92 --- 7.69 1001-1500 gms 97 10u.0 47.42 46.20 2.2 52.55 2.26 2.08 1.03 7.71 1501-200C gms 335 100.0 60.60 47.46 13.13 39.40 26.56 -— 1.79 9.25 2001-2500 gms 1,066 100.0 55.07 35.64 19.41 44.93 29.83 0.46 3.18 9.94 2501-3000 gms 3,447 100.0 57.41 34.11 23.29 42.59 25.58 0.05 4.09 11.31 3001-3500 gms 7,131 100.0 59.40 37.98 21.41 40.60 22.07 0.05 4.82 11.97 3501-4000 gms 4,799 100.0 64.83 47.23 17.58 35.17 18.37 0.08 5.81 9.23 2 4001 gms 1,620 100.0 72.72 60.49 12.22 27.28 13.45 0.12 4.62 7.34 1968-69 TOTAL 16,879 100.0 34.85 21.95 12.89 65.15 27.61 0.05 15.51 21.14 < 1000 gms 98 100.0 14.29 13.26 1.02 85.71 69.38 -—— ——— 12.24 1000-1500 gms 121 100.0 24.79 17.35 7.43 75.21 49.58 0.82 5.78 18.18 1501-2000 gms 294 100.0 31.97 21.76 10.20 68.03 44.55 ES 5.10 17.34 2001-2500 gms 1,063 100.0 33.21 20.41 12.79 66.79 35.46 0.18 11.19 19.47 2501-3000 gms 3,725 100.0 32.83 17.12 15.70 67.17 30.97 0.0 13.25 22.06 3001-3500 gms 6,570 100.0 33.17 19.54 13.62 66.83 27.03 0.07 16.28 22.63 3501-4000 gms 3,807 100.0 37.73 26.58 11.18 62.25 22.74 0.0 18.30 20.22 > 4001 gms 1,175 100.0 46.21 38.38 7.82 53.79 19.06 —— 17.86 16.42 Footnote: See Table 4 G12 TABLE 4C: DISTRIBUTION OF LIVE BIRTHS-BREECH PRESENTATIONS BY BIRTH WEIGHT AND METHOD OF DELIVERY, NEW YORK CITY, 1976-77 and 1968-69 BIRT VAGINAL BIRTH . ] High/Mid Low Total Total Primary Repeat Total® Spontaneous Breech Forceps Forceps N= % 1976-77 TOTAL 7,030 100.0 49.43 42.91 6.51 50.57 10.85 36.45 0.07 "0.64 < 1000 gms 342 100.0 6.73 4.67 2.04 83.27 34.21 52.33 0.29 1.16 1001-1500 gms 296 100.0 31.42 28.04 3.37 68.58 18.24 43.58 0.33 0.33 1501-2000 gms 458 160.0 32.75 27.29 5.45 £7.25 17.24 44.97 0.0 0.87 2001-2500 gms 924 100.0 39.83 34.63 5.19 60.17 12.22 43.93 0.0 0.64 2501-3000 gms 1,628 100.0 47.85 41.70 6.14 52.15 10.44 38.39 0.06 0.73 3001-3500 gms 2,012 100.0 56.31 47.91 8.39 43.69 6.66 34.84 0.09 0.69 3501-4000 gms 1,015 100.0 66.60 59.21 7.38 33.40 7.38 23.84 0.09 0.39 2 4001 342 100.0 73.98 66.95 7.01 26.02 4.38 19.88 0.0 0.0 1968-69 TOTAL 9,546 100.0 20.20 15.98 4.22 79.80 32.87 43.15 0.57 1.01 < 1000 gms 551 100.0 2.18 2.00 0.18 97.82: 64.79 29.95 -— 0.36 1001-1500 gms 424 100.0 8.01 6.13 1.89 91.99 47.41 40.57 -- 0.24 1501-2000 gms 681 100.0 11.3 7.49 3.82 88.69 38.91 43.61 -—— 1.03 2001-2500 gms 1,309 100.0 13.75 9.63 4.13 86.25 36.21 45.15 0.23 1.07 2501-3000 gms 2,431 100.0 17.28 12.92 4.36 82.72 30.32 48.70 0.58 1.03 3001-3500 gms 2,650 100,0 25.06 20.11 4.94 74.94 28.26 43.40 1.02 1.09 3501-4000 1,159 100.0 34.17 28.73 5.44 65.83 24.68 38.57 0.60 2.12 24001 314 100.0 44.90 40.45 4.46 55.10 18.47 32.48 0.96 1.27 Footnote: See Table 4. 91¢ TABLE 4D: DISTRIBUTION OF LIVE BIRTHS-HEAD PRESENTATIONS BY BIRTH WEIGHT AND METHOD OF DELIVERY, NEW YORK CITY, 1976-77 and 1968-69 C-BIRTH VAGINAL BIRTH + High/Mid Low Total Total Primary Repeat Total Spontaneous Breech Forceps Forceps 1976-77 TOTAL 15,488 100.0 35.83 23.21 12.61 64.17 52.38 0.13 1.17 8.83 £1000 gms 124 100.0 17.74 15.32 2.41 82.26 75.80 0.80 0.0 0.80 1001-1500 gms 158 100.0 42.39 36.07 6.32 57.59 46.83 1.206 0.63 6.96 1501-2000 gms 308 100.0 42.86 35.71 7.14 57.14 45.45 0.97 0.0 8.11 2001-2500 gms 994 100.0 39.54 27.36 12.27 60.46 49.49 0.50 0.90 7.94 2501-3000 gms 3,251 _ 100.0 32.70 19.56 13.13 67.30 54.90 0.18 1.04 8.88 3001-3500 gms 5,967 100.0 33.63 20.44 13.18 66.37 54.56 0.03 1.13 9.33 3501-4000 gms 3,548 100.0 37.03 24.66 12.37 62.97 50.67 0.05 1.60 8.99 2 4001 gms 1,135 100.0 48.55 35.77 12.77 51.45 41.58 0.00 1.23 7.78 1968-69 TOTAL 8,834 100.0 27.33 15.13 32.19 72.67 48.39 0.11 5.70 17.73 < 1000 gms 145 100.0 3.45 1.37 2.06 96.55 88.27 1.37 0.68 2.06 1000-1500 gms 100 100.0 28.00 20.00 8.00 72.00 61.00 0.00 4.00 6.00 1501-2000 gms 192 100.0 31.77 23.43 8.33 68.23 50.52 0.52 2.08 14.06 2001-2500 gms 639 100.0 32.24 18.30 13.92 67.76 47.57 0.46 2.18 16.58 2501-3000 gms 2,108 100.0 25.38 11.81 13.56 74.62 49.90 0.09 4.82 19.07 3001-3500 gms 3,370 100.0 25.49 13.20 12.28 74.51 47.29 0.05 6.81 19.67 3501-4000 gms 1,740 100.0 30.69 18.50 12.18 69.31 47.52 0.00 5.34 15.91 2 4001 510 100.0 35.10 26.07 9.01 64.90 38.03 0.00 10.97 15.49 Footnote - See Table 4. {1Z TABLE SA: DISTRIBUTION OF LIVE BIRTHS BY BIRTH WEIGHT, METHOD OF DELIVERY AND RACE-ETHNIC GROUP, NEW YORK CITY, 1976-77 and 1968-69 1976-77 1968-69 C-BIRTH VAGINAL BIRTH TOTAL C-BIRTH VAGINAL BIRTH Sponta- Sponta- N= Primary Repeat Total* neous Breech Forceps N= Primary Repeat Total neous Breech Forceps ALL RACES* 206,436 100.0 10.66 5.08 84.26 64.87 1.39 16.08 267,145 100.0 4.22 2.75 93.03 60.52 1.63 29.47 < 1000 gms 1,310 100.0 7.02 1.91 91.07 69.08 15.73 2.52 2,115 100.0 2.74 0.66 96.60 81.80 8.18 3.07 1001-1500 gms 1,703 100.0 17.85 2.70 79.45 60.60 8.81 6.87 2,150 100.0 6.65 2.00 91.35 68.98 8.74 10.51 1501-2000 gms 3,764 100.0 17.35 4.22 78.43 59.80 6.27 9.35 5,033 100.0 6.54 2.90 90.56 65.05 6.34 16.55 2001-2500 gms 12,627 100.0 11.63 5.25 83.12 65.09 3.70 11.55 18,024 100.0 4.84 3.16 91.99 63.77 3.50 22.90 2501-4000 gms 173,856 100.0 9.75 5.14 85.11 65.61 1.00 15.65 225,509 100.0 3.81 2.77 93.42 60.23 1.29 30.59 2 4001 gms 13,130 100.0 19.33 5.03 75.64 56.47 0.57 15.37 13,765 100.0 9.13 2.17 88.70 55.08 0.76 31.83 WHITE (Non PR) 102,554 100.0 10.68 5.04 84.19 60.63 1.44 18.73 141,520 100.0 4.20 2.89 92.94 55.18 1.80 34.67 < 1000 gms 389 100.0 9.00 2.57 88.43 65.04 16.20 4.11 643 100.0 3.89 1.09 95.02 76.52 10.73 4.51 1001-1500 gms 547 100.0 19.01 3.47 77.51 56.12 10.79 7.68 750 100.0 7.33 3.07 89.60 63.73 11.73 11.47 1501-2000 gms 1,302 100.0 19.66 4.38 75.96 53.69 7.45 11.67 1,842 100.0 8.47 3.42 88.11 56.95 8.25 20.90 2001-2500 gms 4,839 100.0 12.77 5.38 81.84 60.24 4.48 14.26 7,538 100.0 5.78 3.20 91.02 57.91 4.67 26.93 2501-4000 gms 87,726 100.0 9.74 5.05 85.21 61.35 1.14 19.26 121,572 100.0 3.69 2.90 93.41 55.13 1.49 35.53 2 4000 gms 7,738 100.0 17.95 5.22 76.83 54.03 0.47 18.23 8,925 100.0 8.57 2.08 89.34 51.07 0.77 36.67 WHITE (PR) 23,767 100.0 10.32 6.43 83.25 67.67 1.59 12.00 45,055 100.0 4.45 3.15 92.40 63.33 1.91 25.81 < 1000 gms 132 100.0 9.09 5.30 85.61 66.67 15.15 me 298 100.0 5.03 0.34 94.63 78.86 9.06 2.35 1001-1500 gms 179 100.0 19.55 2.25 78.21 56.42 10.61 7.82 347 100.0 4.61 2.02 93.37 68.01 10.95 10.95 1501-2000 gms 421 100.0 14.96 5.23 79.81 61.28 9.50 6.88 897 100.0 6.69 3.23 90.01 64.33 7.47 15.38 2001-2500 gms 1,528 100.0 9.88 5.82 84.29 65.58 4.12 11.91 3,105 100.0 3.74 4.57 91.69 63.57 3.96 22.16 2501-4000 gms 20,065 100.0 9.43 6.62 83.94 68.68 1.14 12.21 38,245 100.0 4.10 3.1 92.78 63.31 1.53 26.74 2 4001 gms 1,438 100.0 20.79 5.42 73.78 59.18 0.56 12.38 2,054 100.0 10.76 2.39 86.85 60.27 0.93 24.59 BLACK 73,266 100.0 10.66 4.71 84.63 70.40 1.27 10.55 76,532 100.0 4.16 2.31 93.52 68.73 11.15 21.95 < 1000 gms 773 100.0 5.56 0.91 93.53 71.67 15.52 2.20 1,159 100.0 1.55 0.52 97.93 82.92 6.56 2.50 1001-1500 gms 948 100.0 16.56 2.32 81.12 64.03 7.59 6.22 1,035 100.0 6.96 1.26 91.79 73.14 5.89 9.47 1501-2000 gms 1,966 100.0 15.87 4.02 80.11 63.68 4.83 8.44 2,248 100.0 4.98 2.36 92.66 72.02 4.14 13.08 2001-2500 gms 5,934 100.0 11.14 5.09 83.77 68.99 2.88 9.10 7,178 100.0 4.30 2.55 93.15 70.03 2.06 17.29 2501-4000 gms 59,926 100.0 9.75 4.80 85.45 71.41 0.40 10.98 62,062 100.0 3.88 2.34 93.78 68.32 0.74 23.23 2 4001 gms 3,691 100.0 21.40 4.44 74.15 61.15 0.79 10.11 2,667 100.0 9.64 2.40 87.96 64.57 0.60 16.76 * Includes all other categories not shown separately. no ft (0) ALL RACES* < 1000 1001-1500 1501-2000 2001-2500 2501-4000 2 4001 gms gms gms gms gms gms WHITE (NON PR) < 1000 1001-1500 1501-2000 2001-2500 2501-4000 2 4001 WHITE (PR) < 1000 1001-1500 1501-2000 2001-2500 2501-4000 2 4001 BLACK < 1000 1001-1500 1501-2000 2001-2500 2501-4000 2 4001 gms gms gms gms gms gms gms gms gms gms gms gms gms gms gms gms gms gms TABLE 5B: 1976-77 C-BIRTH VAGINAL BIRTII Sponta- TOTAL Primary Repeat Total* neous Breecl Forceps N= 206,436 22,016 10,481 173,939 133,924 2,872 31,193 100.0 100.0 100.0 100.0 100.0 100.0 100.0 0.63 0.42 0.24 0.69 0.68 7.17 0.11 0.82 1.38 0.44 0.78 0.77 5.22 0.38 1.82 2.97 1.52 1.70 1.68 8.22 1.13 6.12 6.67 6.32 6.03 6.14 16.26 4.67 84.22 77.03 85.18 85.07 85.18 60.27 87.25 6.36 11.53 6.30 5.71 5.54 2.61 6.47 N= 102,554 10,950 5,178 86,336 62,181 1,472 19,206 100.0 100.0 100.0 100.0 100.0 100.0 100.0 0.38 0.32 0.19 0.40 0.41 4.28 0.08 0.53 0.95 0.37 0.49 0.49 4.01 0.22 1.27 2.34 1.10 1.15 1.12 6.59 0.79 4.72 5.64 5.04 4.59 4.69 14.74 3.59 85.54 78.06 85.50 86.58 86.55 67.87 87.97 7.55 12.68 7.80 6.89 6.72 2.45 7.35 N= 23,767 2,453 1,529 19,785 16,083 379 2,853 100.0 100.0 100.0 100.0 100.0 100.0 100.0 0.56 0.49 0.46 0.57 0.55 5.28 wa 0.75 1.43 0.26 0.71 0.63 5.01 0.49 1.77 2.57 1.44 1.70 1.60 10.55 1.02 6.43 6.16 5.82 6.51 6.23 16.62 6.38 84.42 77.17 86.92 85.13 85.68 60.16 85.87 6.05 12.19 5.10 5.36 5.29 2.1 6.24 N= 73,266 7,809 3,449 62,008 51,578 931 7,73% 100.0 100.0 100.0 100.0 100.0 100.0 100.0 1.06 0.55 0.20 1.17 1.07 12.89 0.22 1.29 2.01 0.64 1.24 1.18 7.73 0.76 2.68 4.00 2.29 2.54 2.43 10.20 2.15 8.10 8.46 8.76 8.02 7.94 18.37 6.98 81.79 74.84 83.36 82.58 82.97 25.67 85.06 5.04 10.12 4.76 4.41 4.38 3.11 4.82 DISTRIBUTION OF LIVE BIRTHS BY BIRTH WEIGHT, METHOD OF DELIVERY AND RACE-ETHNIC GROUP, NEW YORK CITY, 1976-77 and 1968-69 * Includes all other categories not shown separately. 1968-69 C-BIRTH VAGINAL BIRTH Sponta- Total Primary Repeat Total* neous Breech Forceps 267,145 11,273 2,340 248,532 161,671 4,346 78,731 100.0 100.0 100.0 100.0 100.0 100.0 100.0 0.79 0.51 0.19 0.82 1.05 3.98 0.08 0.80 1.27 0.59 0.79 0.92 4.33 0.29 1.88 2.92 1.99 1.83 2.03 7.34 1.06 6.75 7.74 7.78 6.67 7.11 14.52 5.24 84.41 76.18 85.20 84.76 84.01 67.10 87.61 5.15 11.15 4.07 4.91 4.69 2.42 5.57 141,520 5,940 4,056 131,524 78,095 2,548 49,064 100.0 100.0 100.0 100.0 100.0 100.0 100.0 0.45 0.42 0.17 0.46 0.63 2.71 0.06 0.53 0.93 0.57 0.51 0.61 3.45 0.18 1.30 2.63 1.55 1.23 1.34 5.97 0.78 5.33 7.34 5.94 5.22 5.59 13.81 4.14 85.90 75.62 86.91 86.34 85.82 71.08 88.04 6.31 12.88 4.59 6.06 5.84 2.7 6.67 45,055 2,003 1,420 41,632 28,533 862 11,630 100.0 100.0 100.0 100.0 100.0 100.0 100.0 0.66 0.75 0.07 0.68 0.82 3.13 0.60 0.77 0.80 0.49 0.78 0.83 4.41 0.33 1.99 3.00 2.04 1.94 2.02 2:71 1.19 6.89 5.79 10.00 6.84 6.92 14.27 5.92 84.86 78.33 83.87 85.23 84.86 67.75 87.93 4.56 11.03 3.46 4.28 4.34 2.20 4.34 76,532 3,185 1,771 71,576 52,601 853 16,798 100.0 100.0 100.0 100.0 100.0 100.0 100.0 1.51 0.57 0.34 1.59 1,83 8.91 0.17 1.35 2.26 0.73 1.33 1.44 7.15 0.58 2.94 3.52 2.99 2.91 3.08 10.90 1.75 9.38 9.70 10.33 9.34 9.56 17.35 7.39 81.09 75.64 81.93 81.31 80.60 53.58 85.82 3.48 8.07 3.61 3.28 3.27 1.88 2.66 61¢ TABLE 5C: NEONATAL MORTALITY RATES BY BIRTH WEIGHT, METHOD OF DELIVERY, RACE-ETHNIC GROUP, NEW YORK CITY, 1976-77 and 1968-69 1976-77 1968-69 C-BIRTH VAGINAL BIRTH Sponta- + Sponta- Total Primary Repeat Totall neous Breech Forceps Total Primary Repeat Total neous Breech Forceps ALL RACES t 12.06 14.63 8.68 11.94 11.44 102.72 4.55 17.13 28.48 20.16 16.53 19.42 80.99 5.88 < 1000 gms 733.59 554.35 800.00 746.02 734.81 815.53 515.15 844.92 672.41 714.29 850.71 856.05 861.27 769.23 1001-1500 gms 233.71 210.53 260.87 237.99 226.74 306.67 230.77 360.00 405.59 465.12 354.38 353.34 420.21 274.34 1501-2000 gms 59.51 73.51 75.47 55.56 52.42 67.80 51.14 106.89 191.49 253.42 96.09 96.52 144.20 75.63 2001-2500 gms 15.68 19.75 25.64 14.48 13.87 29.98 12.35 23.47 57.27 50.79 20.75 21.23 49.13 15.02 2501-4000 gms 3.34 6.19 3.14 3.03 2.90 21.95 2.13 4.03 10.48 7.99 3.66 3.84 13.37 2.73 > 4001 gms 6.93 9.06 (3.03) 6.65 5.93 106.67* (1.98) 5.59 13.52 (6.69) 4.75 4.62 (28.57) 4.33 WHITE (NON PR) 8.62 11.96 8.88 8.19 7.84 74.73 3.59 12.61 29.29 18.24 11.68 14.01 66.72 4.63 < 1000 gms 717.22 542.86 1,000.00 726.74 526.16 809.52 142.86* 852.26 760.00 714.29* 857.61 857.72 884.06 758.62 1001-1500 gms 241.32 173.08 526.32 245.28 228.01 322.03 238.10 406.67 381.82 521.74 404.76 403.77 465.91 325.58 1501-2000 gms © 74.50 93.75 87.72* 68.76 61.52 103.09 65.79 128.12 230.77 238.10 113.99 116.30 164.47 88.31 2001-2500 gms 15.09 22.65 26.82* 13.13 11.32 41.47% 13.04* 27.123 75.69 45.64 24.05 25.43 51.13 16.75 2501-4000 gms 2.88 5.73 2.94 2.54 2.49 18.02 1.72 3.53 11.35 8.23 2.87 48.98 12.70 2.32 > 4001 gms 5.04 5.04* (2.48) 5.21 4.54 (55.56) (1.42) 4.03 15.69 (10.75) 2.76 3.07 --- 2.44* WHITE (PR 11.99 18.75 11.12 11.22 10.38 73.88 5.26 17.71 25.46 21.83 17.20 19.14 78.89 6.45 * < 1000 gms 750.00 750.00* 714.29+ 752.21 715.01 200.00 -— 875.84 666.67 (1,000.00) 886.52 906.38 888.89 714,29¢ 357.14* 406.34 312.50* (428.57) 410.49 41°.49 500.00 236.84 1001-1500 gms 279.33 400.00 -—— 257.14 257.43 (157.89) -—— 121.52 183.33 241.38* 112.62 107.45 194.03 86.96 1501-2000 gms 52.26 (47.62) (90.91) 50.60 54.26 (50.00) (5.49) 25.76 (25.86) 63.38% 23.88 23.30 (32.52) (23.26) 2001-2500 gms 17.67 (13.25) 56.18* 15.53 17.96 === 2.86% 4.78 12.11 9.24 4.31 4.58 11.99* 2.84 2501-4000 gms 3.44 5.81 3.76* 3.15% 2.90 17.54 11.24 6.82 13.57) Co 6.17 5.65% (5.94) > 4001 gms 11.13 23.41* --- 8.48% (4.70) (125.00) {1.29 ’ $15 : ’ ’ BLACK 17.42 17.42 7.54 17.97 16.46 164.34 7:37 25.40 29.20 24.28 25.26 27.78 130.13 8.39 < 1000 gms 742.56 511.63 714.29* 756.57 750.90 800.00 470.59* 833.48 555.56 (666.67) 838.77 843.91 302.63 793.10 1001-1500 gms 220.46 203.82 (90.91) 227.57 217.46 333.33 203.39 309.18 444.44 384.62* 297.89 297.23 311.48 255.10 1501-2000 gms 48.83 54.49 63.29 46.98 44.73 (42.11) 48.19* 82.30 142.86 283.02 73.93 77.83 86.02% 5.10 2001-2500 gms 15.84 19.67 16.56 15.29 14.41 29.24 14.81 17.97 38.83 49.18* 16.15 16.91 54.05* 9.67 2501-4000 gms 4.12 7.02 3.13 3.85 3.55 62.76 3.19 4.54 8.30 6.89 4.33 4.17 19.69* 3.88 > 4001 gms 8.94 11.,39* --- 8.77 8.42 172.41° --- 9.75 (3.89) ww 10.66 8.13 (187.50) 17.90* t Includes all other categories not shown separately * 5-9 deaths ( ) 1-4 deaths -0 deaths 022 METHOD OF DELIVERY* Total® Primary C-birth Repeat C-birth Spontaneous Breech (Vaginal) Forceps POSITION AT DELIVERY* Total® Normal ROP/LOP/ROT/LOT Breech Head INDICATIONS* Total Third trimester bleeding Fetal distress Dystocia Abnormal presentation Previous C-birth None, unknown, other MORTALITY (per 1,000) Neonatal (under 28 days) Fetal = (28+ weeks gestation) Perinatal TT ? Postneonatal# Infant (<1 year) TABLE 6A: SELECTED CLINICAL FACTORS AT DELIVERY AND MORTALITY BY BIRTH WEIGHT GROUP NEW YORK CITY, 1976-77 and 1968-69 THE VERY LOW BIRTH WEIGHT GROUP THE LARGER LOW BIRTH WEIGHT GROUP ALL BIRTHS < 1000 GMS 1001-1500 GMS 1501-2000 GMS 2001-2500 GMS 1976-77 1968-69 1976-77 1968-69 1976-77 1968-69 1976-77 1968-69 1976-77 1968-69 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 10.66 4.22 7.02 2.74 17.85 6.65 17.34 6.53 11.62 4.84 5.08 2.75 1.91 0.66 2.70 2.00 4.22 2.90 5.25 3.16 64.87 60.52 69.08 80.47 60.60 68.98 59.80 65.05 65.09 63.77 1.39 1.62 15.78 8.18 8.80 8.74 6.26 6.33 3.69 3.50 15.11 29.47 2.52 3.07 6.87 10.51 9.34 16.54 11.53 22.88 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 76.26 82.91 49.47 43.88 57.87 58.93 63.79 69.34 71.95 77.81 8.99 6.32 3.97 4.63 5.76 5.63 8.90 5.84 8.44 5.90 3.41 3.57 26.11 26.05 17.59 19.72 12.17 13.53 7.32 7.26 7.50 3.3 9.47 6.86 9.39 4.65 8.18 3.81 7.87 3.55 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 1.09 0.50 8.47 1.61 8.63 3.44 6.00 2.94 2.68 1.48 3.19 1.07 2.60 0.66 4.64 2.70 4.84 2.15 3.93 1.28 5.57 2.84 0.99 0.24 1.47 0.47 1.99 0.85 2.57 1.36 2.13 2.79 10.92 7.57 7.99 7.44 6.32 5.82 4.13 3.83 4.49 2.31 1.45 0.33 1.35 0.98 4.70 1.85 4.41 2.57 83.53 90.50 75.58 90.59 75.92 84.98 77.74 86.39 81.69 89.48 12.06 17.13 733.59 844.92 233.71 360.00 59.51 106.89 15.68 23.47 7.41 12.14 167.63 200.68 109.31 153.54 55.93 67.62 17.58 17.39 19.38 29.06 778.27 876.04 317.45 458.27 106.35 167.28 32.99 40.45 3.13 3.53 100.29 45.73 33.72 27.62 11.02 14.91 7.48 7.84 15.15 20.61 760.31 852.01 259.54 377.67 69.87 120.21 23.05 31.13 * Distribution refers to live births. t+ Includes other, none, not stated; not shown separately. 11 Denominators are live births plus fetal deaths; # rates are per 1,000 survivors of neonatal period. 122 TABLE 6A: SELECTED CLINICAL FACTORS AT DELIVERY AND MORTALITY BY BIRTH WEIGHT GROUP NEW YORK CITY, 1976-77 and 1968-69 (Continued) THE VERY LOW BIRTH WEIGHT GROUP THE LARGER LOW BIRTH WEIGHT GROUP ALL BIRTHS 1000 GMS 1001-1500 GMS 1501-2000 GMS 2001-2500 GMS 1976-77 1968-69 1976-77 1968-69 1976-77 1968-69 1976-77 1968-69 1976-77 1968-69 MORTALITY (continued) Method of delivery Neonatal Primary C-birth 14.63 28.48 554.35 672.41 210.53 405.59 73.51 191.49 19.75 57.27 Repeat C-birth 8.68 20.16 800.00 714.29 260.87 465.12 75.47 253.42 25.64 50.79 Spontaneous 11.44 19.42 734.81 856.05 226.74 353.34 52.42 96.52 13.87 21.23 Breech (Vaginal) 102.72 80.99 815.53 861.27 306.67 420.12 67.80 144.20 29.98 49.13 Forceps 4.55 5.88 515.15 769.23 230.77 274.34 51.14 75.63 12.35 15.02 Fetal Primary C-birth 5.78 17.69 61.22*+ 134, 33** 41.01 158.82 32.59 57.31 11.45 30.00 Repeat C-birth 3.99 7.44 166.67 (125.00) 115.38* 122.45** 30.49** 32.11% 16.32 17.21 Spontaneous 7.61 13.67 171.25 196.00 120.20 164.51 62.47 70.68 18.39 17.75 Breech (Vaginal) 44.26 38.50 159.18 183.96 175.82 121.95 99.24 80.69 27.08 24.73 Forceps 2.62 3.18 --- (29.85) (25.00) (17.39) 14.01** 17.69 8.16 6.74 Perinatal Primary C-birth 20.32 45.66 581.63 716.42 242.90 500.00 103.70 237.82 30.98 85.56 Repeat C-birth 12.64 27.45 833.33 750.00 346.15 530.61 103.65 278.15 41.54 67.13 Spontaneous 18.96 32.83 780.22 884.27 319.69 459.72 111.62 160.37 32.01 38.63 Breech (Vaginal) 142.43 116.37 844.90 886.79 428.57 490.65 160.31 213.26 56.25 72.64 Forceps 7.16 8.72 515.15 776.12 250.00 286.96 64.42 91.98 20.41 21.66 zee TABLE 6A: SELECTED CLINICAL FACTORS AT DELIVERY AND MORTALITY BY BIRTH WEIGHT GROUP NEW YORK CITY, 1976-77 and 1968-69 (continued) THE VERY LOW BIRTH WEIGHT GROUP THE LARGER LOW BIRTH WEIGHT GROUP ALL BIRTHS 1000 GMS 1001-1500 GMS 1501-2000 GMS 2001-2500 GMS 1976-77 1968-69 1976-77 1968-69 1976-77 1968-69 1976-77 1968-69 1976-77 1968-69 MORTALITY (continued Position of delivery Neonatal Normal 8.33 11.10 705.25 830.82 208.25 337.02 51.65 86.25 12.99 18.97 ROP/LOP/ROT/LOT 9.33 16.71 673.08 744.90 288.66 363.64 59.70 122.45 18.76 31.04 Breech 73.83 96.58 821.64 869.93 260.14 422.17 78.60 151.25 31.39 44.31 Head 14.91 30.00 701.61 896.55 246.84 290.00 81.17 140.63 17.10 32.86 Fetal Normal 5.02 5.60 108.67 103.38 84.71 105.23 44.19 47.74 ¥s5.71 11.77 ROP/LOP/ROT/LOT 4.94 8.69 118.64* 109.09 126.13 110.29 34.58 63.69 15.70 13.91 Breech 33.68 43.30 193.40 197.96 142.03 152.00 89.46 70.94 29.41 26.77 Head 11.24 19.86 215.19 220.43 141.30 242.42 88.76 106.98 17.79 19.94 Perinatal Normal 13.32 16.63 737.28 848.31 275.32 406.78 93.55 129.88 28.49 30.51 ROP/LOP/ROT/LOT 14.22 25.25 711.86 772.73 378.38 433.82 92.22 178.34 34.16 44.53 Breech 105.02 135.70 856.13 895.20 365.22 510.00 161.03 211.46 59.87 69.89 Head 25.98 49.26 765.82 919.35 353.26 462.12 162.72 235.56 34.58 $2.15 €¢e TABLE 6B: METHOD OF DELIVERY* total’ Primary C-birth Repeat C-birth Spontaneous Breech (Vaginal) Forceps POSITION AT DELIVERY* TOTAL Normal ROP/LOP/ROT/LOT Breech Head INDICATIONS* TOTAL Third trimester bleeding Fetal distress Dystocia Abnormal presentatior Previous C-birth None, unknown, other MORTALITY (Per 1,000; Neonatal (under 28 days) Fetal (28+ weeks gestation) Perinataltt Postneonatal# Infant (< 1 year) 224 SELECTED CLINICAL FACTORS AT DELIVERY AND MORTALITY BY BIRTH WEIGHT GROUPS, NEW YORK CITY, The Moderate Birth Weight Group The Lowest Risk Birth Weight Group 1976-77 and 1968-69 The Large Birth Weight Group 2501-3000 gms 3001-4000 gms > 4000 gms 1976-77 1968-69 1976-77 1968-69 1976-77 1968-69 100.0 100.0 100.0 100.0 100.0 100.0 8.43 3.22 10.21 4.04 19.32 9.13 5.15 3.12 5.13 2.63 5.02 2.17 68.17 62.35 64.72 59.38 56.47 55.08 1.57 1.96 0.80 1.04 0.57 0.76 14.03 27.96 16.21 31.63 15.36 31.82 100.0 100.0 100.0 100.0 100.0 100.0 77.58 83.35 77.56 84.74 71.77 81.61 7.70 5.79 9.24 6.44 12.34 8.54 3.64 3.78 2.35 2.36 2.60 2.28 7.26 3.27 7-37 2.17 8.64 3.71 100.0 100.0 100.0 100.0 100.0 100.0 1.03 0.56 0.68 0.27 0.71 0.34 3.07 1.00 3.07 1.00 3.44 1.40 ‘3.56 1.78 6.03 3.16 12.73 7.49 2.27 2.55 1.62 2.50 2.81 3.41 4.50 2.65 4.61 2.25 4.35 1.77 85.57 91.51 33.98 90.83 76.27 85.59 5.31 5.97 2.66 3.26 6.93 5.59 4.22 5.30 1.70 2.92 4.78 2.721 9.52 11,23 4.35 6.18 11.67 13.26 3.84 3.83 1.83 2.45 1.53 1.90 9.13 9.77 4.49 5.70 8.45 7.48 * Distribution refers to live births. + Includes other, none, not stated; not shown separately. tt Denominators are l:ve births plus fetal deaths. # Rates are per 1,000 survivors of neonatal period. 225 TABLE 6B: SELECTED CLINICAL FACTORS AT DCLIVERY AND MORTALITY BY BIRTH WEIGHT GROUPS, NEW YORK CITY, 1976-77 and 1968-69 (continued) The Moderate Birth The Lowest Risk The Large Birth Weight Group Birth Weight Group Weight Group 2501-3000 gms 3001-4000 gms > 4000 gms 1976-77 1968-69 1976-77 1968-69 1976-77 1968-69 MORTALITY (continued) Method of Delivery Neonatal Primary C-birta 8.21 21.65 5.61 6.91 9.06 13.52 Repeat C-birth 5.20 12.44 "2.42 5.89 (3.03) (6.69) Spontaneous 4.68 5.48 2.25 3.15 5.93 4.62 Breech (Vaginal) 22.75 14.57 21.42 12.49 106.67** (25.57) Forceps 4.13 3.78 1.53 2.35 (1.98) 4.33 Fetal Primary C-birth 4.48 17.02 2.27 2.17 3.92 11.79 Repeat C-birth 1.73 i 1.06** 2.82 (3.02) (6.64) Spontaneous 4.43 5.08 1.47 2.78 5.23 7.07 Breech (Vaginal) (5.65) 13.58 9.64 11.18 (13.16 (18.69) Forceps 2.22 2.49 1.72 1.98 (1.98) 5.45 Perinatal Primary C-birth 12.65 38.30 7.87 14.03 12.95 25.16 Repeat C-birth 6.92 16.36 3.47 8.69 (6.04) {13.29) Spontaneous 9.10 10.54 3.72 5.92 11.13 11.66 Breech (Vaginal) 28.25 27.96 30.86 23.53 118.42** 46.73 Forceps 6.34 6.26 3.24 4.33 3.96** 9.76 ** 5-9 deaths. () 1-4 deaths. -—— 0 deaths. TABLE 6B: MORTALITY (continued) Position at Delivery Neonatal Normal ROP/LOP/ROT/LO1 Breech Head Fetal Normal ROP/LOP/ROT/LOT Breech Head Perinatal Normal ROP/LOP/ROT/LOT Breech Head 226 SELECTED CLINICAL FACTORS AT DELIVERY AND MORTALITY BY BIRTH WEIGHT GROUPS, NEW YORK CITY, 1976-77 and 1968-69 (continued) The Moderate Birth Weight Group The Lowest Risk Birth Weight Group The Large Birth Weight Group 2501-3000 gms 3001-4000 gms > 4000 gms 1976-77 1968-69 1976-77 1968-69 1976-77 1963-69 4.35 4.81 1.98 2.67 4.14 4.01 6.67 8.05 3.10 5.20 5.56** &.51 17.20 16.04 13.88 12.60 49.71 22.21 5.54 10.91 3.78 4.31 5.29 (3.92) 3.50 3.351 1.40 2:10 4.54 5.66 2. S2%* 7.99 1.84 3.27 (2.46) (3.39) 6.11 13.79 3.95 7.04 (5.81) 24.84% 7.93 6.60 2.31 6.03 4. 39%* 13.54% 7.83 8.10 3.37 4.76 8.66 ¢.65 8.97 15.98 4.94 8.45 8.00 11.87 23.20 29.61 12:77 19.55 55.23 40.58 13.43 17.44 6.08 10.50 9.65 17.41 xR 5-9 deaths. TABLE 7A: ONE MINUTE APGAR SCORES OF LIVE BIRTHS BY BIRTH WEIGHT AND METHOD CF DFLIVERY, NEW YORK CITY, 1976-77 and 1968-65 C-BIRTH VAGINAL BIRTH Total Total Primary Repeat Total Spontaneous Breech Forceps 1976-77 Birth Weight (gms) TOTAL 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 <4 1.83 3.95 4.92 1.89 1.45 1.19 13.96 1.17 4-6 4.72 5.13 10.66 5.90 3.90 3.17 20.29 5.16 7+ 91.67 85.89 83.35 91.23 92.75 93.75 63.71 92.12 N.S. 1.76 1.02 1.05 0.96 1.91 1.87 2.01 1.53 < 1000 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 <4 60.07 56.41 56.52 56.00 00.44 56.68 78.15 51.51 4-6 20.83 26.50 27.17 24.00 20.29 21.10 16.99 21.21 7+ 13.12 14.53 14.13 16.00 12.99 15.24 2.91 27.27 N.S. 5.95 2.56 2.17 4.00 6.29 6.96 1.94 0.0 1001-1500 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 <4 22.01 30.86 31.25 28.26 19.73 16.95 41.33 11.96 4-6 29.71 30.29 31.90 19.56 29.56 28.48 36.00 29.05 7+ 44.97 37.71 35.52 52.17 46.86 50.58 21.33 58.11 N.S. 3.28 1.14 1.3 0.0 3.84 3.97 1.33 0.85 1501-2000 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 < 4 7.89 13.55 13.62 13.20 6.33 5.28 14.40 6.53 4-6 18.96 24.26 25.26 20.12 17.51 16.25 29.06 16.76 7+ 70.61 61.08 60.03 65.40 73.24 75.47 54.66 75.85 N.S. 2.52 1.11 1.07 1.25 2.9 2.97 1.27 0.85 2001-2500 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 <4 2.84 6.85 7.90 4.52 2.03 1.55 6.20 3.15 4-6 7.93 14.55 16.35 10.55 6.59 4.97 26.3% R.71 7+ 87.08 77.43 74.59 83.71 89.04 91.11 66.16 87.03 N.S. 2.13 1.17 1.15 1.20 2:33 2.34 1.28 1.09 2501+ 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 <4 1.03 2.93 3.74 1.26 0.69 0.53 5.98 0.91 4-6 3.87 7.99 9.34 5.23 3.12 2.46 16.66 4.73 7+ 93.39 88.08 85.87 92.56 94.38 95.23 74.97 92.77 N.S. 1.68 1.00 1.03 0.93 1.81 1.76 2.38 1.57 {22 1968-69 Birth Weight (gms) TOTAL <4 4-6 7+ N.S. £1000 <4 4-6 7+ N.S. 1001-1500 <4 4-6 T+ N.S. 1501-2000 < 4 4-6 7+ N.S. 2001-2500 <4 4-6 7+ N.S. 2501+ <4 4-6 74 N.S. TABLE 7A: ONE MINUTE APGAR SCORES OF LIVE BIRTHS BY BIRTH WEIGHT AND Continued) METHOD OF DELIVERY, NEW YORK C-BIRTH Total Total Primary Repeat 100.0 100.0 100.0 100.0 1.80 3.64 4.79 1.86 5.18 8.88 11.33 5.09 89.12 81.27 77.67 86.78 3.88 6.22 6.20 6.25 100.0 100.0 100.0 100.0 57.53 37.50 39.65 28.57 21.56 19.44: 13.79 42.85 11.91 20.83 24.13 7.14 14.98 22.22 22.41 21.42 100.0 100.0 100.0 100.0 20.09 21.51 21.67 20.93 32.09 32.26 33.56 27.90 39.58 39.78 37.06 48.83 8.23 6.45 7.69 2.32 100.0 100.0 100.0 100.0 6.61 8.21 11.85 8.90 18.63 24.42 26.13 20.54 68.32 55.37 54.10 58.21 6.41 9.26 7.90 12.32 100.0 100.0 100.0 100.0 2.46 6.09 7.67 3.67 8.47 14.68 19.12 7.88 84.49 71.75 66.09 80.38 4.57 7.48 7.10 8.05 100.0 100.0 100.0 100.0 1.03 2.84 3.81 1.35 4.26 7.60 9.81 4.28 91.08 83.64 80.46 88.40 3.60 5.92 5.90 5.95 TY, 1976-77 and 1968-860 VAGINAL BIRTH Total Spontaneous Breech 100.0 100.0 100.0 1.67 1.53 10.49 4.91 4:12 17.94 89.71 90.40 67.60 3.71 3.93 3.95 100.0 100.0 100.0 52.03 51.58 61.27 21.63 21.85 18.49 11.60 11.92 12.13 14.73 14.62 8.09 100.0 100.0 100.0 19.96 18.67 31.38 32.08 31.82 38.82 39.56 40.59 26.59 8.40 8.90 3.19 100.0 100.0 100.0 6.16 5.33 13.79 18.03 17.25 26.64 69.68 70.76 55.17 6.12 6.65 4.38 100.0 100.0 100.0 2.15 1.68 8.87 7.93 7.09 18.22 85.60 86.54 69.88 4.32 4.66 3.01 100.0 100.0 100.0 0.90 0.65 6.19 4.02 3.08 15.62 91.64 92.65 74.28 3.44 3.60 3.90 Forceps 100.0 1.33 5.73 90.28 2.64 100.0 47.69 32.30 12.30 7.69 100.0 15.92 30.08 50.44 3.53 100.0 6.00 17.04 74.06 2.88 100.0 2.20 8.48 86.98 2.32 100.0 1.13 5.35 90.85 2.65 8¢¢ TABLE 7B: FIVE MINUTE APGAR SCORES OF LIVE BIRTHS BY BIRTH WEIGHT AND METHOD CF DELIVERY, NEW YORK CITY, 1976-77 and 1968-69 C-BIRTH VAGINAL BIRTH Total Total Primary Repeat Total Spontaneous Breech Forceps 1976-77 Birth Weight (gms) TOTAL 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 <4 0.73 0.95 1.15 0.51 0.70 0.62 2:78 0.30 4-6 1.19 2.58 "3.20 1.25 0.94 0.82 6.61 0.82 7+ 97.17 96.02 95.12 97.91 97.39 97.59 84.74 98.53 N.S. 0.89 0.45 0.50 0.31 0.98 0.95 0.83 0.34 £1000 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 <4 45.64 37.01 36.95 40.00 46.44 43.53 59.70 42.42 4-6 23.20 26.50 26.08 28.00 22.88 22.76 24.27 18.18 7+ 22.44 31.62 33.69 24.00 21.54 23.97 11.65 33.33 N.S. 8.70 4.27 3.26 8.00 9.14 9.72 4.36 6.06 1001-1500 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 <4 10.04 12.00 13.15 4.34 9.53 8.04 20.00 8.54 4-6 17.14 20.29 18.09 34.78 16.33 15.60 24.00 10.25 7+ 69.17 66.86 67.76 60.86 70.51 72.09 55.33 76.06 N.S. 3.64 0.86 0.98 0.0 4.36 4.26 0.66 5.12 1501-2000 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 < 4 2.63 4.43 3.82 6.91 2.13 1.82 4.23 2.55 4-6 7.12 9.24 10.41 4.40 6.54 5.81 14.83 5.96 7+ 88.23 85.34 84.68 88.05 89.02 90.09 80.93 91.19 N.S. 2.01 0.99 1.07 0.62 2.30 2.26 0.00 0.28 2001-2500 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 < 4 0.87 1.78 1.83 1.65 0.70 0.64 1.92 0.68 4-6 2.16 4.65 5.38 3.01 1.66 1.26 3.85 3.15 7+ 95.62 93.15 92.23 95.17 96.12 96.64 93.36 95.81 N.S. 1.33 0.42 0:54 0.15 1.52 1.44 0.85 0.34 2501+ 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 <4 0.27 "0.51 0.65 0.20 0.23 0.20 2.54 0.17 4-6 0.70 1.93 2.46 0.85 0.48 0.41 2.76 0.58 + 98.25 97.15 96.41 98.63 98.29 98.58 94.13 98.91 N.S. 0.75 0.41 0.46 0.30 0.82 0.80 0.55 0.31 62¢ TABLE 7B: FIVE MINUTE APGAR SCORES OF LIVE BIRTHS BY BIRTH WEIGHT AND METHOD OF DELIVERY, NEW YORK CITY, 1976-77 and 1968-69 (continued) C-BIRTH VAGINAL BIRTH Total Total Primary Repeat Total Spontaneous Breech Forceps 1968-69 Birth Weight (gms) TOTAL 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 <4 0.72 0.96 1.25 0.49 0.71 0.75 3.91 0.37 4-6 1.01 1.98 2.57 1.06 0.94 0.88 5.22 0.78 7+ 84.65 80.63 80.35 81.04 84.95 83.07 80.76 89.97 N.S. 13.60 16.44 15.81 17.39 13.40 15.28 10.10 8.86 £ 1000 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 <4 36.26 29.17 29.31 28.57 36.51 36.07 42.19 35.38 4-6 17.30 12.50 8.62 28.57 17.47 37.15 22.54 21.53 7+ 16.54 27.78 31.03 14.28 16.15 16.09 17.91 29.23 N.S. 29.88 30.56 31.03 28.57 29.86 30.66 17.34 13.84 1001-1500 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 2 4 8.09 5.38 5.59 4.65 8.35 8.09 13.82 5.30 4-6 17.62 15.59 15.38 16.27 17.82 16.79 26.06 16.37 7+ 54.09 59.14 62.23 48.83 53.62 53.27 48.93 66.37 N.S. 20.18 19.89 16.78 30.23 20.21 21.84 11.17 11.94 1501-2000 100.0 100.0 100.0 100.0 100,0 100.0 100.0 100.0 < 4 2.14 2.74 3.34 1.36 2.08 1.86 4.38 2.04 4-6 5.48 6.74 6.07 8.21 5.35 5.00 10.34 4.56 7+ 77.36 70.32 71.75 67.12 78.10 77.51 73.35 - 84.27 N.S. 15.00 20.21 18.84 23.28 14.46 15.60 11.91 9.12 2001-2500 100.0 100 0 100.0 100.0 100.0 100.0 100.9 100.0 <4 0.85 2.15 2.74 1.22 0.74 0.60 2.85 0.70 4-6 1.47 2.91 3.89 1.40 1.35 1.20 3.64 1.42 7+ 83.34 77.77 75.83 80.73 83.83 82.50 85.57 88.53 N.S 14.32 17.17 17.52 16.63 14.08 15.68 7.92 9.32 2501+ 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 <4 0.29 0.62 0.81 0.32 0.27 0.23 1.22 0.28 4-6 0.59 1.56 2.11 0.71 0.52 0.41 2.74 0.64 7+ 85.83 81.72 81.69 81.74 86.14 84.39 86.16 90.25 N.S. 13.28 16.11 15.37 17.2% 13.07 14.95 9.86 8.81 0€¢ 231 SECTION III - MEDICAL, OBSTETRICAL AND NEONATAL PROBLEMS This section focuses more closely on the medical, obstetrical and neonatal problems surrounding the cesarean birth. It is divided into eight chapters. While extensive, not all issues can be discussed. In addition, data review, Chapter Chapter Chapter Chapter Chapter Chapter Chapter Chapter XI XII XIL1lI XIV XV XVI XVII the data is presented as a pertinent not as a textbook for patient care. - Maternal Mortality and Morbidity - Anesthesia - Neonatal RDS Dystocia - Repeat Cesarean Birth - The Problem of the Breech Presentation - Fetal Distress Other Maternal and Fetal Indications for Cesarean Birth Ta se Lee we] Chapter X - Maternal Mortality and Morbidity 235 MATERNAL MORTALITY INTRODUCTION Maternal mortality is presented here as a primary issue reflecting the risk of death to the mother following a cesarean birth. Other materials relating to maternal mortality are presented in Chapters VIII, IX and XIV. Maternal mortality in the United States has decreased from a level of 582.1 per 100,000 births in 1935 to a level of 9.9/100,000 in 1978, the latest year for which figures are available. 7? TABLE I MATERNAL MORTALITY, USA 1935-1978 Maternal deaths* per Year 100,000 births 1935 582.1 1945 207.2 1955 47.0 1965 31.6 1970 21.5 1975 12.8 1978 9.9 *Maternal death is the death of any woman, from any cause, while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of pregnancy. Unfortunately, many State Health Departments do not ask for information relative to the mode of delivery. Thus, nationwide statistics are not 236 available for maternal mortality following cesarean births as compared to mortality following vaginal delivery. The data that is available is summarized in Table II. The largest single tabulation of information on cesarean births in the United States comes from the Professional Activities Study (PAS) of the Commission on Professional and Hospital Activities (CPHA).> This organization collects data from a large number of hospitals through- out the United States providing obstetrical care. From these PAS records we obtained maternal mortality ratios for both cesarean and vaginal deliveries for the years 1970, 1974 and 1978. During this eight year period, the maternal mortality ratio for vaginal delivery declined steadily from 20.4 per 100,000 deliveries to a level of 9.8 per 100,000 deliveries. The maternal mortality ratio for cesar- ean births also declined from 113.8 per 100,000 cesarean births in 1970 to 40.9 per 100,000 operations in 1978. Thus, as illustrated graphically in Figure I, the maternal mortality noted for cesarean births declined more sharply from 1970 to 1978 than did the maternal mortality ratio for vaginal deliveries. The maternal mortality ratios for cesarean and vaginal deliveries by complication for the three years are tabulated in Table III. In this table, complications have been grouped for ease of interpretation. The more detailed data on specific complications are presented in Chapter VIII. As seen in Table III, the relative risk of maternal death in all cesarean births when compared with all vaginal deliveries regardless of complications declined from 5.5 in 1970 to 4.2 in 1978. 237 In contrast, the relative risk of maternal death in a cesarean delivery complicated by a previous cesarean delivery increased during the eight year period. This obtains because the maternal mortality ratio for all vaginal deliveries fell over this time period from 20.4 to 9.8 while the maternal mortality with previous cesarean birth remained stable, increasing slightly but not significantly in 1974. LITERATURE REVIEW Evrard and Gold,” in a study on cesarean birth-related deaths in Rhode Island for the years 1965 through 1975, reported 9 maternal deaths in 12,941 operations, a maternal mortality rate of 69.5/100,000 operations. Seven of the deaths were due to sepsis, one due to hemorrhage, and one due to an anesthetic complication. This mortality rate was compared to 149,715 vaginal deliveries with 4 fatalities, a rate of 2.7/100,000 vaginal deliveries. Thus, in this study the calculated risk of maternal death associated with cesarean birth was 26 times greater than for vaginal delivery. However, as the authors also point out, a review of the case histories suggested that the cesarean per se was, respon- sible for only 4 of the 9 deaths, for a corrected maternal mortality rate of 31/100,000. A possible criticism of this study is the extremely low maternal mortality rate reported for vaginal deliveries. This could have occurred because of an under-reporting of maternal deaths, a major problem when ascertainment is by death certificate informa- tion only. In a report on cesarean births in California for the years 1973 through 1975, Petitti, et a’ compared maternal mortality rates 238 associated with cesarean birth with those of vaginal delivery. The risk of maternal death associated with cesarean birth in California was 2 to 3 times greater than that for vaginal delivery. During the 3 years surveyed, and similar to overall national figures on maternal mortality, there was a decline in the number of fatalities associated with cesarean birth as well as vaginal deliveries. Because of the methods used for identifying maternal deaths, under-reporting of deaths in this study may also have influenced the relatively low death ratio in cesarean births as compared to the other reports summarized in Table II. In Georgia a recently completed analysis of maternal deaths by route of delivery for the years 1975 and 1976 showed a maternal mortal- ity ratio of 105.3/100,000 births by cesarean. ® After excluding the deaths in the cesarean group that were due to the conditions which led to cesarean deliveries, the mortality ratio was 59.3/100,000 cesarean births. This was compared to a maternal mortality ratio of 9.7/100,000 births by vaginal delivery. In this analysis, maternal deaths were determined by linking all birth records for 1975-1976 with all death certificates of women between the ages 10 through 44 years. Smaller series from individual hospitals report a similar vari- ability in maternal mortality ratios, emphasizing the problem of drawing conclusions from small numbers and differing populations. For example, at the Boston Hospital for Women, 10,231 cesarean births 7 were per formed between 1968 and 1978 without a single maternal death. In contrast, for the years 1963 to 1975 there were 2 maternal deaths in 239 2,563 consecutive cesarean births at Charlotte Memorial Hospital in Charlotte, North Carolina, a maternal mortality ratio of 78/100,000. 8 Since only one of these deaths was related to the operation (an anes- thetic death secondary to aspiration), the corrected cesarean birth- related mortality ratio was 39/100,000. Interestingly, both maternal deaths occurred in the first 338 operations so that there were no deaths in the subsequent 2,225 operations. In another survey from Parkland Memorial Hospital in Dallas, Texas for the years 1964 to 1978, 9,025 cesareans were performed with 9 maternal fatalities, a mortality rate of approximately 99.7/100,000.° Again in several instances these deaths were not solely related to the opera- tive procedure. For example, cardiac arrest near the completion of the operation was the cause of one death; the mother was a 40 year old gravida 15 who was markedly obese and diabetic. The cesarean was per formed to control active bleeding from placenta previa. A most extensive collection of data on maternal mortality associated with cesarean birth is that tabulated each triennium in England and Wales by the Department of Health and Social Security. 10 The most recent report is for the years 1973 through 1975. During this time, 81 deaths (61 true maternal and 20 caused by associated disease) occurred in an estimated 100,870 women delivered by cesarean. It was estimated that the fatality rate of the operation was 80/100,000 procedures, a figure that is not corrected for deaths due to causes other than the operative procedure. 240 THE PROBLEMS IN DATA EVALUATION Thus, as stated at different points in this report, examination and comparison of maternal mortality by method of delivery is difficult for several reasons. First, and probably most important, death due to pregnancy and childbearing is now an extremely rare event. There are only about 350 maternal deaths in the United States each year (Table I). When a maternal mortality ratio is based on a small number of deaths, it is potentially subject to large sampling errors. Avoidance of this sampling error requires substantial numbers of deaths on which to base rates. This has led investigators either to use vital records in large states, or in small states over a period of time, 4? or to aggregate the experience of several institutions.’ Each of these approaches has methodologic problems. These problems may account for the substantial variability in maternal mortality ratios and risks of cesarean delivery among the reported studies. The second problem in data evaluation concerns the fact that mater- nal deaths are probably seriously; under-reported in vital records. ® In addition, the accuracy and completeness of recording the mode of delivery is not 100%. The extent to which this may bias estimates of maternal mortality in vital statistics data by mode of delivery has not been studied and may be considerable. On the other hand, maternal deaths ascertained by institution may miss those which occur after discharge or after transfer to another institution. This is a major problem with the previously discussed PAS data. In the third assessment problem, the cesarean delivery is often 241 per formed for conditions that are of themselves a threat to the life of the mother. It is important to distinguish between death due to the condition that necessitated cesarean delivery and death which is due to the procedure itself. Finally, demographic features of the population examined and the level of medical care and expertise available strongly influence mortality rates reported from single institutions. SUMMARY 1. Overall, cesarean delivery carries about 4 times the risk of maternal mortality of a vaginal delivery. Cesarean delivery for previous cesarean carries 2 times the risk of maternal mortality of all vaginal deliveries. Since 1970 there has been no reduction in maternal mortality for the diagnostic category of previous cesarean, and this may reflect the current limit of safety for this procedure in heterogeneous populations and patient care settings. Noted in this section is the fact that some maternal mortality following cesarean birth is related to maternal illness, irrespec- tive of the operative intervention. Also noted in several places in this report, some cesarean births cannot be avoided, as in certain maternal medical illnesses, placen- tal positions and fetal positions, without death to mother or fetus. As noted elsewhere in this report, maternal mortality rates follow- ing cesarean birth are influenced by the skills of the clinician (obstetrician and anesthesiologist) and the availability of adequate hospital resources. Maternal mortality is still under-reported. Study PAS(3) Evrard(4) Petitti(5) Rubin(6) Frigoletto(7) Jones (8) Pritchard(9) MATERNAL MORTALITY BY ROUTE OF DELIVERY 242 TABLE II Place 1 Rhode Island California Georgia Boston Hosp. for Women Charlotte Mem. Hosp. Parkland Mem. Hosp. IN THE UNITED STATES Maternal Mortality Number of Ratio(a) Deaths Years Vaginal Cesarean Vaginal Cesarean 1970 20.4 113.8 204 69 1974 15.2 62.9 174 72 1978 9.8 40.9 100 72 1965-1973 2.7 69.5 4 9 2.7 31.0(b) 4 4 1973 12.9 27.0 35 8 1974 10.7 30.9 30 11 1975 9.6 19.4 27 8 1975-1976 9.7 105.3 14 16 9.7 59.3(b) 14 9 1968-1978 10.2 zero 6 0 1963-1975 -- 78.0 - 2 1964-1978 ee 99.7 -- 9 (a) - per 100,000 deliveries by that route, excludes deaths due to abortion and ectopic pregnancy. (b) - excludes deaths where death was due to disease which necessitated cesarean birth. 243 TABLE III MATERNAL MORTALITY RATIOS(1) BY COMPLICATION 1970, 1974 and 1978, CPHA 1970 1974 1978 Complication Cesarean Vaginal Cesarean Vaginal Cesarean Vaginal No mention 463.8 14.2 218.4 10.4 * 4.9 Lacerations * 16.4 * 11.8 % 57 Previous cesarean 17.9 * 29.3 * 18.4 % Dystocia(2) 106.7 24.8 29.1 10.8 41.9 14.1 All malpresentations 108.1 36.5 81.5 16.6 18.9 27+2 Other "maternal"(3) 158.1 155.4 204.1 97.6 109.4 125.6 Other "fetal" (4) 105.9 49.8 89.9 38.6 6l.4 18.2 Other and unspec. 619.3 59.4 187.2 45.6 160.7 24.2 All 113.8 20.4 62.9 15.2 40.9 9.8 * too few births to provide stable estimates of rates (1) deaths before discharge from hospital per 100,000 deliveries by that route (2) fetopelvic disproportion, abnormal pelvis, prolonged labor (3) antepartum hemorrhage, prior gyn surgery (4) premature rupture of membranes, prolonged rupture of membranes, premature labor, prolonged pregnancy, fetal distress, multiple MATERNAL MORTALITY RATIO (Deaths per 100,000 deliveries)’ 110 100 90 80 70 60 50 40 30 20 10 244 Figure 1 MATERNAL MORTALITY RATIO FOR CESAREAN SECTION VS. VAGINAL DELIVERIES 1970, 1974 AND 1978 CPHA, ALL HOSPITALS A138 X - Vaginal A - Cesarean 0 - All 40.9 14.3 9.8 1970 1974 1978 YEAR 245 BIBLIOGRAPHY 10. Facts of Life and Death. United States Department of Health, Education and Welfare, 1978, Publication No. 79-1222. Monthly Vital Statistics Report. Vol. 27, No. 13, p. 8, 1979. CPHA, Unpublished data. Evrard, J.R. and Gold, E.M.: Cesarean section and maternal mortal- ity in Rhode Island, incidence and risk factors, 1965-1975. Obstet. Gynecol. 50:594-597, 1977. Petitti, D., Olson, R.0. and Williams, R.L.: Cesarean section in California 1960 through 1975. Am. J. Obstet. Gynecol. 133: 391-397, 1979. Rubin, George: Personal communication. Frigoletto,F.D., Ryan, K.J., and Phillippe, M.: Maternal mortality rate associated with cesarean section: An appraisal. Am. J. Obstet. Gynecol. 136:969-970, 1980. Jones, 0.H.: Cesarean section in present day obstetrics. Am. J. Obstet. Gynecol. 126:521-530, 1976. Pritchard, J.A. and MacDonald, P.C.: Williams Obstetrics, 16th Edition. Appleton-Century-Crofts, New York (In press, 1979) Report on confidential enquiries into maternal deaths in England and Wales 1973-1975. Department of Health and Social Security, Her Majesty's Stationary Office, London, 1979. 246 MATERNAL MORBIDITY FOLLOWING CESAREAN BIRTH INTRODUCTION The incidence of puerperal morbidity following vaginal delivery ranges from 3% to 7%, whereas maternal morbidity rates are generally five 1,2,3 Based on their to ten times higher following cesarean birth. clinical observations, this high risk for postpartum infectious morbidity in association with cesarean delivery is widely acknowledged by practic- ing obstetricians. This infectious morbidity has been suggested as being inversely related to socio-economic status, and thus leading to higher rates of postpartum infection after abdominal delivery in hospitals serving the medically indigent. Depending upon the population samples studied, and the definitions used (i.e.increased fever index, standard morbidity, endometritis, wound infection, any bacterial infection), postpartum infection following abdominal delivery has been reported to 1,4,296 pjthough occur with a frequency ranging from about 10 to 65%. some of these figures certainly appear high, they are of limited meaning for comparison with vaginal birth without knowing the frequency with which postpartum infection would be expected to occur in comparable vaginally delivered patients. Only with the latter rates for comparison can the relative risk be estimated. Examination of three widely used textbooks of obstetrics failed to yield an estimate of the risk for postpartum infection after vaginal delivery. However, Vorherr’ estimated that 3 to 4% of all puerperas developed postpartum fever and endometritis. Based on a two year review of 6436 deliveries, Sweet and Ledger | reported postpartum endometritis in approximately 2.7% of gravidas after vaginal delivery. 247 These authors cited three additional studies indicating that the overall rate of endometritis in teaching hospitals was in the 3% range. | In a prospective randomized study of high risk laboring, monitored gravidas, without amnionitis, 2 of 70 patients (3%) who went on to deliver vaginally developed endometritis. Thus, it would appear that a 3 to 4% risk for puerperal infection after vaginal delivery represents a reasonable estimate. Several selected puerperal complications associated with both cesarean delivery and vaginal delivery are compared in Tables I and II. This data was obtained from the Obstetrical Statistical Cooperative” for the years 1973-1977 and involved 23,169 cesarean deliveries and 142,030 vaginal deliveries. As noted in these tables, the two most common causes of infectious morbidity following both cesarean and vaginal delivery were endometritis and urinary tract infection. Both complications occur with greater frequency following cesarean birth. INFECTIOUS MORBIDITY FOLLOWING CESAREAN BIRTH Reported morbidity rates in different series of cesarean births vary widely. 2-13 For example, in the 1974 U.S. Professional Activities Study, selected puerperal and postoperative complications were recorded in only 4.2% of 120,684 cesarean delivered patients. Puerperal sepsis and postoperative wound infection accounted for approximately three-fourths of these complications. Similarly in a report from the Mayo Clinic only 12% of 592 women delivered by cesarean were considered to have had a morbid postoperative course. 10 Again the most frequently listed cause for morbidity was fever associated with endometritis. 248 However, most of this febrile morbidity was relatively benign. The average number of febrile days was 2.8 and the average stay in the hospital was prolonged by only one day. Contrasting with these reports, in a retrospective analysis of cesarean births performed at Charlotte Memorial Hospital, Jones | reported a 33% postoperative complication rate among 2,563 women. Jones noted that morbidity was significant in 12% and more serious in % of women. Again the major complication was endometritis. In this series, serious morbidity included injury to the urinary tract in 7 patients, and postoperative hemorrhage in 14 patients (necessitating hysterectomy in three). Eighteen percent of all patients received blood transfusions. Similarly, Hibbard 12 in an analysis of cesarean births at Los Angeles County Hospital reported a maternal morbidity rate of approximately 50% during each of 4 time periods between the years 1948 and 1974. In this study febrile morbidity secondary to urinary tract infection was the most’ common complication and endometritis was second. In addition, there were a number of these dangerous complications requiring prolonged hospitalization and some complications compromising future childbearing. Four of 929 women delivered by cesarean required subsequent hysterectomy for hemorrhagic or infectious complications. In a recent retrospective analysis of cesarean births, Evrard’? et al reviewed the postoperative complications of 1,011 women delivered by cesarean at Womens and Infants Hospital of Rhode Island during 1977. 249 These investigators compared the morbidity following primary cesarean to the morbidity following elective repeat cesarean. In this series there were 689 primary and 322 repeat procedures. Primary cesarean delivery was associated with a postoperative complication rate of 24.3% as compared with 10.2% for repeat cesarean. As in all other reports, the major febrile complication in both groups was endometritis. Puerperal and urinary tract infections accounted for 75% of all the postoperative morbidity. Other significant complications included 3 instances of bladder injury, while severe postoperative hemorrhage occurred 8 times, necessitating hysterectomy in 2 of these patients. Thirty-six patients (3.5%) received a blood transfusion. Other investigators have also noted that the risk of infection following primary cesarean is significantly higher than that associated with an elective repeat cesarean birth. 14-18 In this review it is clear that complication rates following cesarean birth vary markedly among institutions. It is also apparent that these differences are principally due to the incidence of infection following the procedure. The variation in reported uterine infection following cesarean birth in 6 university hospitals is illustrated graph- 1,14-17,19,20 The incidence of endometritis varied ically in Figure I. from a low of 12% in private patients from Ann Arbor, Michigan’ to a high of 51% among indigent patients in Dallas, Texas. 20 Several of these studies clearly point out that a woman's risk of developing pelvic infection following cesarean is dependent on the risk status and the socio-economic status of the patient at the time of surgery. The duration of labor and 250 of ruptured membranes, number of vaginal exams, and use and duration of internal fetal monitoring are all associated with a greater risk of postoperative infection. The importance of identifying risk factors for febrile morbidity of cesarean is strikingly illustrated by the studies of Cunningham, et al. 18,20 In this study, pelvic infection complicated the postoperative course of 51% of all cesarean delivered women. However, the incidence of uterine infection was 85% in women undergoing cesarean birth six or more hours following rupture of the membranes as compared with a 29% infection rate when cesarean was undertaken during labor but with intact fetal membranes. There was a 15% infection rate when delivery was by elective repeat cesarean birth. Wound and pelvic abscesses developed in less than % of women delivered with intact membranes while these complications developed in over 30% of women with membranes ruptured greater than 6 hours. The incidence of septicemia was four times greater in those women whose membranes were ruptured. MORBIDITY FOLLOWING CESAREAN BIRTH AS COMPARED WITH VAGINAL BIRTH How much is risk for infection increased after cesarean delivery? A simple approach is to divide the frequency of postpartum infection after cesarean delivery by the frequency of infection after vaginal delivery in patients from the same institution. On this basis, estimates that the risk of postpartum infection is increased range between 7-fold’ and 20-fold.% These estimates probably represent the maximal relative risk, but may markedly overestimate that risk. There is a difference between "relative risk following abdominal delivery" and "increased risk due to abdominal delivery". As noted earlier in this report, some of the 251 increased risk observed in patients delivered abdominally may be explained by factors which predispose the patient both to need for cesarean delivery and postpartum infection. An example may demonstrate this point. Amnionitis, recognized during labor, clearly precedes delivery and is generally accepted as a major risk for postpartum infection of both mother and child. Utilizing the Perinatal Database at Cleveland Metropolitan General Hospital, it was possible to relate amnionitis to culture proven bacterial infection of the neonate, in 6943 consecutive vaginal and primary abdominal deliveries during a 2-1/2 year period ending in January, 1979. Amnionitis was diagnosed in 1.1% of the cases and was followed by neonatal infection in 21% of the cases. This was an 11-fold increase over cases not complicated by amnionitis (x2 = 130.8, p<<.00001). Primary cesarean birth, which accounted for approximately 10% of the deliveries, was found to increase the risk of neonatal infec- tion 3-fold (x2 = 34.5, p<<.00001). However, amnionitis was found to be associated with a greater than 3-fold increase in the frequency of cesarean birth. This suggests that attributing the observed increase in neonatal infection to abdominal delivery would be inappropriate. From a clinical perspective there is no reason to suspect that abdominal delivery, a "more sterile" route for the infant than the vaginal route, should inherently raise the risk for neonatal infection. Yet, even controlling for clinically recognized infection during labor, by considering only cases without amnionitis, the significant relation of cesarean birth to neonatal infection was found to persist. This example suggests that in 252 addition to amnionitis, there are yet other predisposing factors for postpartum infection and that these factors act as confounding variables in estimating the increment in risk for infection attributable to cesar- ean birth. Important among these variables is length of labor, which has been found to be a major determinant of maternal postpartum morbidity.® Inasmuch as dystocia is a major concomitant of cesarean birth, longer labor may account for some of the high rate of postpartum infection after abdominal delivery. There are undoubtedly a multitude of other such confounding factors. To estimate the increase in risk for postpartum infection attributable to cesarean delivery, potential covarying risks must be examined using multivariate statistical models.” Further studies are required. A final issue further complicates the situation. Prophylactic antibiotics have been demonstrated to decrease the risk of postpartum infection after primary cesarean delivery.’ Thus, prophylactic anti- biotics can be seen as a "negative risk" for postpartum infection and must be considered, not only in studying the risks of cesarean birth using multivariate techniques, but also in considering the risk/benefit and cost/benefit ratios from the medical and public policy perspectives. At present, it may be concluded that while cesarean delivery probably increases the risk for postpartum infection, by engendering greater tissue trauma and decreasing host resistance, the magnitude of the increase in risk attributable to cesarean delivery itself has not yet been estimated with precision. 253 OTHER EFFECTS OF CESAREAN BIRTH EARLY EFFECTS A cesarean delivery is a major operative procedure and as such is associated with many complications leading to maternal morbidity that are never encountered in a vaginal delivery. Examples of these complications include operative injuries to the urinary tract and bowel, wound abscess, wound dehiscence, evisceration, operative and postoperative hemorrhage, and paralytic ileus. In addition, complications such as pulmonary emboli, venous thrombosis, and anesthesia related morbidity are more common following a major operative procedure. Consequently maternal morbidity associated with cesarean delivery is substantially higher than the morbidity associated with a vaginal delivery. REMOTE EFFECTS The major remote effects on maternal organ systems after abdominal delivery involve the uterus, the bowel, and the bladder. While these major complications are uncommon, the results can be decidedly unfavorable if they are not diagnosed and treated appropriately. Uterus One of the sequelae of repeat cesarean may be a defective scar. Attempts have been made to diagnose the defect by a hysterogram per formed after the abdominal delivery.2! At the time of a sub- sequent operation, the obstetrician may elect to perform a cesarean hysterectomy because of a defective previous scar 22 A defective scar is liable to result in uterine rupture in a subsequent pregnancy, and even with a well-healed scar, repeat cesarean delivery is a routine practice (see Chapter XIV). 254 Bowel The patient may develop adhesions which result in intestinal obstruc- tion. Adhesions between the uterus and the abdomen may fix adherent loops which then may be damaged when the next peritoneal incision is made . 2° Bladder Subsequent to the cesarean, the bladder flap may become markedly adherent to the uterus. This may cause later urinary tract symptoms. Obstetric At a subsequent abdominal delivery, the bladder may be injured when the peritoneal cavity is entered. This occurs because of adhesions between the abdominal peritoneum and the visceral perito- 24 The bladder may also be injured when it is dissected free of the stores. neum overlying the bladder. Gynecologic At the time of abdominal hysterectomy there is an increased risk of bladder injury when the bladder is markedly adherent to the uterus. ?’ Following a cesarean birth, an abdominal hysterectomy may be difficult to perform. Vesico-cervical fistula Injury to bladder during an abdominal delivery may result in a fistula between the bladder and uterus, with development of apparent amenor- rhea and cyclical hematuria (vesical menstruation). 1. 255 SUMMARY Cesarean birth is a major surgical procedure, and as such will always be associated with a morbidity rate greater than that of a vaginal delivery. Endometritis, urinary tract infection and wound infection are the major causes of postoperative morbidity. The infectious morbidity rate following this procedure is influenced by the demographic features of the population cared for, the number of high risk patients and particularly the events surrounding labor and delivery. In addition, the types and severity of morbidity associated with cesarean birth are often related to the circumstances necessitating operative delivery. All of these factors make it impossible to assign a specific morbid- ity rate for this operative procedure that would apply for all women. 256 TABLE I PUERPERAL COMPLICATIONS OBSTETRICAL STATISTICAL COOPERATIVE 1973-1977 Cesarean Delivery Vaginal Delivery No. No. Percent Percent Endometritis 3733 16.11 1990 1.40 Mastitis 229 1.00 636 2.45 Thrombophlebitis 139 0.60 181 0.13 Infected Wound 731 3.16 145 0.10 Peritonitis 114 0.49 16 0.01 Septicemia 91 0.29 26 0.02 Pyelonephritis 1057 4.56 584 0.41 Urinary Retention 102 0.44 3945 2.78 Oliguria/Anuria 19 0.08 24 0.02 Other Urinary 504 2.18 771 0.54 Respiratory 438 1.89 306 0.21 Abd. Wound Dehis. 171 0.74 14 0.01 Post-Spinal Synd. 182 0.79 165 0.12 Psychosis 48 0.21 99 0.07 Other 331 1.43 713 0.50 257 TABLE II PUERPERAL MORBIDITY OBSTETRICAL STATISTICAL COOPERATIVE 1973-1977 Cesarean Delivery Vaginal Delivery No. Percent No. Percent One Day Fever 3248 14.02 3532 2.48 Standard Fever 4949 21.36 1633 1.15 Total Fever 8197 35.38 5165 3.63 Single Deliveries 23,169 142,030 PERCENT 70 60 — nN Ol $e QQ QQ OO OO o© 258 REPORTED FREQUENCY OF UTERINE INFECTION FOLLOWING CESAREAN SECTION ( UNIVERSITY HOSPITALS 1971-1978) High Risk EE rs a ERE SR Clinic All A SER LEE ERS dn : 1978 1979 1973 1971 1978 Charleston Phila. Miami Los Angeless* Ann Arbor (14,15) (16) (19) a7” (1) Patients in labor, primary cesarean section. % SEEN OR OAT ERE Vey ey Yen) 2 XH SR TIRE 3 SLANE 2 SE 2 PRN NL SHAE 3 SE 2 78 i POT 2 2 1978 Dallas (20) Patients in labor with ruptured membranes & internal fetal monitoring. Figure 1 259 BIBLIOGRAPHY 1. Sweet, R.L. and Ledger, W.J.: Puerperal infectious morbidity: A two year review. Am. J. Obstet. Gynecol. 117:1093-1100, 1973. 2. Collea, J.V.: Current management of breech presentation. Clin. Obstet. Gynecol. 23:525-531, 1980. 3. Obstetrical Statistical Cooperative, unpublished data. 4. Evrard, J.R. and Gold, E.M.: Cesarean section and maternal mortality in Rhode Island, incidence and risk factors, 1965-1975. Obstet. Gynecol. 50:594-597, 1977. 5. D'Angelo, L.J. and Sokol, R.J.: Determinants of postpartum morbid- ity in laboring monitored patients: A reassessment of the bacteri- ology of the amniotic fluid during labor. Am. J. Obstet. Gynecol. 135: 575-578, 1980. 6. D'Angelo, L.J. and Sokol, R.J.: Short- versus long-course prophy- lactic antibiotic treatment in cesarean section patients. Obstet. Gynecol. 55:583-586, 1980. 7. D'Angelo, L.J. and Sokol, R.J.: Time-related peripartum deter minants of postpartum morbidity. Obstet. Gynecol. 55:319-323, 1980. 8. Vorherr, H.: Puerperal genitourinary infection. Gynecology and. Obstetrics. Vol. 2, edited by J.J. Sciarra. Harper and Row, Hagers- town, Md., 1978, Chapter 91. 9. Lowe, J.A., Klassen, D.F., and Loup, R.J.: Cesarean section in the United States. PAS Hospitals. PAS Reporter, Special Issue 14:37-38, 1976. 10. Aard, L.A. and Saed, F.: Low incidence of cesarean section: 12 year experience. Mayo Clinic Proceedings 50:365, 1975. 11. Jones, 0.H.: Cesarean section in present-day obstetrics. Am. J. Obstet. Gynecol. 126:521-530, 1976. 12. Hibbard, L.T.: Changing trends in cesarean section. Am. J. Obstet. Gynecol. 125:798-803, 1976. 13. Evrard, J.R., Gold, E.M., and Cahill, T.F.: Cesarean section: A contemporary assessment. J. Reprod. Med. 24:147-152, 1980. 14. 15= 16. 17 18. 19. 20. 21. 22. 25. 24. 260 Kreutner, A.K., DelBene, V.E., Delamar, D., Huguley, V., Harmon, P.M. and Mitchell, K.S.: Perioperative antibiotic prophylaxis in cesarean section. Obstet. Gynecol. 52-279-284, 1978. Kreutner, A.K., DelBene, V.E., Delamar, D., Badden, J.L. and Loodholt, C.B.: Perioperative cephalosporin prophylaxis in cesarean section: Effect on endometritis in the high-risk patient. Am. J. Obstet. Gynecol. 134:925-932, 1979. Gibbs, R.S.,Hunt, J.E. and Schwarz, R.H.: A follow-up study on prophylactic antibiotics in cesarean sections. Am. J. Obstet. Gynecol. 117:419-422, 1973. Wong, R., Gee, C.L. and Ledger, W.J.: Prophylactic use of cefazolin in monitored obstetric patients undergoing cesarean section. Obstet. Gynecol. 51:407-411, 1978. DePalma, R.T., Leveno, K.J., Cunningham, F.G., Pope, T., Kappus, S.S., Roark, M.L. and Nobles, B.J.: Identification and management of women at high risk for pelvic infection following cesarean section. Am. J. Obstet. Gynecol. 55:185-191, 1980. Weissberg, S.M., Edwards, N.L. and O'Leary, J.A.: Prophylactic antibiotics in cesarean section. Obstet. Gynecol. 38:290-293, 1371. Cunningham, F.G., Hauth, J.C., Strong, J.D., and Kappus, S.S.: Infectious morbidity following cesarean section: Comparison of two treatment regimens. Obstet. Gynecol. 52:656-661, 1978. Velasco, R., Guerro, R., Morales, A. and Gamiz, R.: Post cesarean section hysterographic control. Am. J. Obstet. Gynecol. 90:222-226, 1964. Pritchard, J.A. and MacDonald, P.C.: Cesarean section and cesarean hysterectomy. In Pritchard, J.A. and MacDonald, P.C. (Eds): Williams Obstetrics, Ed. 15, New York, Appleton-Century-Crofts, 1976, p. 917. Jones, R.S.: [Intestinal obstruction. In Sabiston, D.C. (Ed.): Davis and Christopher Text Book of Surgery, Ed. 11, Vol. 1, Phila- delphia, W.B. Saunders Co., 1977, p. 10003. Klempner, E., Oppenheimer, G. and Glickman, S.: Trauma to the urinary tract. In Rovinsky, J.J., Guttmacher, A.F. (Eds.): Medical, Surgical and Gynecologic Complications of Pregnancy, Ed. 2, Balti- more, Williams and Wilkins, 1965, p. 284. 25. 26. 261 Williams, T.J.: Abdominal hysterectomy, myomectomy, and presacral neurectomy: With management of bladder injury and attention to thromboembolic disease. In Ridley, J.H. (Ed.): Gynecologic Surgery. Errors, Safeguards and Salvage. Baltimore, Williams and Wilkins, 1978, p. 31. Falk, H.C.: Management of vesical fistulas after cesarean section. In Falk, H.C.: Urologic Injuries in Gynecology. Philadelphia, F.A. Davis Co., 1957, p. 85. Chapter XI - Anesthesia 265 INTRODUCTION A concern in considering the risks and the benefits of the cesarean birth is the role of anesthesia, a necessary component in the operative procedure. This is in contrast with a vaginal delivery, where analgesia and anesthesia may not be necessary, be indicated or be desired. For a cesarean birth, anesthesia must be provided and its risks must be taken into account. Recently there has been a rapid growth in published studies dealing with anesthesia for cesarean birth. This may in part reflect the emergence of obstetrical anesthesia as a recognized sub- specialty of anesthesiology, and, in association with increased cesarean birth rates, a response to the increased involvement of anesthesiologists in obstetrical patient care. Important and presented in this review are known and potential hazards of anesthesia for mother and child, recommendations for optimal anesthetic management, and areas where more information or more research is needed. CURRENT PRACTICE - TYPES OF ANESTHESIA USED FOR CESAREAN BIRTH The results of several surveys of the types of anesthesia used for cesarean delivery are presented in Table I. Safe and effective anesthesia can be provided with any of these techniques. The more prevalent use of general anesthesia in the CPHA, survey, which includes a larger sample of non-teaching hospitals, is noted. This chart may be looked at as general information. Though collected during different years, the data in each study are not from the same hospitals. TABLE I 266 ° © ACOG* ° CPHA** © SOAP*** © BOSTON HOSPITAL FOR WOMEN® ° 0 1971(1)° 1974 ° 1976(2) ° 1979 ’ 1. General Anesthesia : 32% : 55% : 43% : 38% : -2. Regional Anesthesia ’ - . : : a. Spinal . 53% . 35% . 24% . 36% : : b. Epidural . 3% 4% . 32% . 26% : ° Total 56% © 39% © 56% © 62% ° ’ c. Local : 1% ° 0 . % . 0 : Je Combination . 10% i 6% . 0 o 0 . * ACOG - American College of Obstetrics & Gynecology ** CPHA - Commission on Professional and Hospital Activities *¥%*¥ SOAP - Society for Obstetric Anesthesia and Perinatology 267 LOCAL ANESTHESIA Local anesthesia is the infiltration or field block of the maternal abdominal wall. It has few advocates’, While it may possibly be of value in the absence of trained anesthesia personnel, this technique is not widely used because of the difficulty in achieving adequate pain relief (most patients require supplemental drugs) and the need to use large quantities of local anesthetic solution. This low rate may also reflect the fact that it is rarely used or taught in most training environments for the obstetrician and anesthesiologist. GENERAL ANESTHESIA The practice of general anesthesia for cesarean birth has changed markedly in the past 10 or 15 years. The potent but flammable anesthetics such as ether and cyclopropane have virtually been abandoned in favor of balanced anesthesia. Preanesthetic medication is used sparingly if at all. To minimize the time interval between the induction of general anesthesia and delivery of the infant, the patient's abdomen should be prepared and draped before induction of anesthesia is begun. Following a period of maternal preoxygenation, anesthesia is usually induced with an intravenous agent such as thiopental and then followed by intravenous injection of a quick-acting muscle relaxant such as succinylcholine which is used to facilitate endotracheal intubation. Anesthesia is then maintained with the use of nitrous oxide, oxygen and additional muscle relaxant. This program is at times supplemented by use of a low concen- tration of one of the newer non-flammable potent inhalation anesthetic 268 agents such as halothane or enflurane until the infant is delivered. Following delivery, additional thiopental, narcotic agents or other adjuvant drugs may be given to assure adequate depth of anesthesia. General anesthesia may often be indicated in emergency situations when speed is essential, for example in the case of an immediate life endangering threat to the fetus such as in the case of placental abrup- tion or placenta previa or where maternal bleeding and hypovolemia are present. Some patients prefer general anesthesia because of their fears of spinal or epidural anesthesia. Finally, general anesthesia may be used in situations where the regional block techniques may not be available because of a lack of qualified personnel. The major advantages of general anesthesia are its reliability, controllability and the avoidance of severe hypotension. The disadvantages include an unconscious patient, the greater possibility of aspiration of gastric contents into the lungs, and the depression of the newborn by the anesthetic drugs. REGIONAL ANESTHESIA Spinal anesthesia continues to be widely used for cesarean birth; however, the use of lumbar epidural anesthesia is increasing. Both techniques involve the injection of a local anesthetic into an area of the spine. In the case of spinal anesthesia, a local anesthetic, usually tetracaine or lidocaine, is injected through a lumbar puncture into the lumbar subarachnoid space. The principal advantages of spinal anesthesia include simplicity, dosage (only a small dose of one drug is required), 269 speed of administration, reliability of anesthetic effect, and an awake mother with minimal risk of aspiration. The principal disadvantages of this technique include a high incidence of maternal hypotension and the possibility of post-lumbar puncture headache ("spinal headache"). The frequency of post-lumbar puncture headache can be minimized through the use of a very small 25 or 26 gauge needle. In recent years, lumbar epidural anesthesia has found increasing use in obstetrics for both vaginal and cesarean births. A single injection of the local anesthetic can be made into the lumbar epidural space. More often a catheter is inserted so that reinforcement of pain relief may be provided as necessary. This technique is more complex than spinal anesthesia and hence more likely to fail. The onset of anesthesia is slower. The incidence of hypotension is significantly less than with spinal anesthesia. In comparison with spinal anesthesia, larger doses of local anesthetic (usually bupivacaine or chloroprocaine) are required. Absorption from the epidural space into the maternal blood stream is rapid. The local anesthetic is transferred across the placenta to the fetus. Dural puncture is avoided and hence post-lumbar puncture headache does not occur. In summary, there are three major techniques in use to provide anesthesia for cesarean birth. Each has its advantages and disadvantages. No one technique is clearly superior to any other in the provision of satisfactory anesthesia to meet the needs of the patient and the surgeon. Selection of anesthesia depends on medical indications and contraindica- tions, the availability and experience of anesthesia personnel, the indication for and urgency of the cesarean, and maternal preference. Whether the technique used is a general anesthetic, a local skin injection 270 or a regional block, most agents with a few exceptions may be expected to transfer across the placenta. Common to all anesthetic techniques is the need for expert technical skills. MATERNAL MORTALITY AND MORBIDITY Maternal Aspiration A major maternal problem associated with general anesthesia is the risk of aspiration of gastric contents into the lungs. The pregnant patient is at high risk for this complication since labor and pain may delay gastric emptying and the operation is more often performed under emergency conditions. If solid food is aspirated, immediate asphyxia may result with hypoxic brain damage or death. Even in the absence of recent intake of food, pregnant women, whether or not in labor, tend to accumulate large 4 The entry of such fluid volumes of fluid of low pH in the stomach. into the lungs may result in the acid aspiration syndrome. The recogni- tion of these forms of aspiration and their importance in pregnancy dates to the classic paper by Mendelson in 1946.° The acid aspiration syndrome has been titled "Mendelson's syndrome." Accurate data on the incidence of these complications and their contribution to maternal mortality are scarce. One such study, from Great Britain, reports the following overall maternal death rates assoc- iated with anesthesia in three-year periods from 1964 through 1975° (Table II). 271 TABLE II 1964-66 1967-69 1970-72 1973-75 Deaths Associated with Anesthesia 50 50 37 31 Incidence/ 100,000 Deliveries 1.92 2.023 1.61 1.61 Rate/100 True Maternal Deaths 8.7 10.9 10.4 13.2 In this study in 1970-72, of the 37 anesthesia-associated maternal deaths, 16 or 43% resulted from aspiration of stomach contents into the lungs. Two of the 16 aspirations were of the solid food variety and resulted in obstructive asphyxia. The remaining 14 were of the acid aspiration variety. Of the 16 women who died of this complication, 9 or 56% were associated with cesarean birth (1 elective, 8 emergency). Fourteen of the 16 were classified as avoidable deaths. Two were classified as doubtfully avoidable deaths. Data from England, Scotland, and Wales for 1973-75 (6,6a) reveal that general anesthesia caused 21% of the maternal deaths associated with cesarean delivery in England and Wales and 38% of those in Scotland. The death rate for anesthesia in this triennium was 1 in 6,000 cesarean deliveries in England and Wales and 1 in 7,500 in Scotland. All of the anesthesia-related deaths associated with cesarean delivery occurred in conjunction with general anesthesia. Ninety-four per cent of these deaths were deemed associated with avoidable factors. Similar comprehensive data are unavailable in the United States. In a review published in 1974, Phillips and Capizzi’ pointed out the importance of aspiration during general anesthesia as a major cause of 272 maternal mortality. Of the 40 maternal deaths which occurred in the 40,360 pregnancies of the Collaborative Perinatal Project (rate: 1:1000), 17 were classified as due to direct obstetric causes.’ Though no case details are given, three of the 17 were anesthesia related, and 2 of the 3 were due to aspiration of vomitus. Looking at maternal mortality, Hardy and his associates’ reviewed 63,000 live births at Emory University in Atlanta between 1962 and 1971. There was 1 anesthesia related death due to aspiration, for a rate of 1.6/100,000 deliveries.’ In a five-year survey of 501 maternal deaths in Texas from 1969 to 1973,10 the overall maternal mortality rate from direct obstetric causes including anesthesia ws 28.0/100,000 live births. Three hundred and nine of the 501 deaths were classified as direct and obstetrically related. Of the 309 direct deaths, 16 (5%) were related to anesthesia. No further details are given. In a study of 11 years' experience in Rhode Island from 1965 through 1975, of 163,000 live births, there were 9 deaths associated with cesarean delivery. !! One of these 9 was classified as an anesthetic death and attributed to the aspiration syndrome. In 1976, in New York City, complications of anesthesia were the leading cause of puerperal deaths (8 out of 32 or 25%). Five of these 8 maternal deaths (63%) were associated with cesarean deliveries. 12 In contrast, 68,645 births at the Boston Hospital for Women for the 11 years between 1968 and 1978 were reviewed. This study included 10,231 cesarean deliveries (overall rate = 15%). There were no anesthesia 273 related maternal deaths in either group of patients. There were no maternal deaths from any cause in the cesarean delivery group and 6 deaths in those delivered vaginally. Among the entire group, the maternal mortality rate was 7.2/100,000 (6/68,645 births}, VIP Reviewing this information, the best estimates suggest that 5 to 15% of direct obstetrical maternal deaths may be the result of anesthesia, and that the majority of these deaths are related to aspiration of gastric contents into the lungs. It can further be assumed that with the decline in the use of general anesthesia for vaginal delivery, the majority of these maternal anesthetic deaths are associated with cesarean birth. PREVENTION OF THE ASPIRATION SYNDROME Prevention of these tragedies can be attempted in several ways. Most important is the avoidance of general anesthesia in those patients where regional anesthesia can safely be accomplished. This implies the availability of skilled and experienced anesthesia personnel for all patients who require obstetrical anesthesia. Also generally accepted is the need for protection of the airway if general anesthesia is to be used. The most common technique for airway protection is rapid intubation of the trachea with a cuffed endotracheal tube, following intravenous induction of anesthesia. Skill and experience are required. Pressure should be applied to the cricoid cartilage during these maneuvers to compress the upper esophagus and to minimize the possibility of regurgitation of gastric contents into the pharynx and hence into the lungs. 274 Another approach to avoid the aspiration syndrome is the prophylactic administration of oral antacid medications during labor in order to increase the pH of the gastric contents. Based on animal and human studies, it is estimated that aspiration of no more than 25 ml of gastric fluid of pH below 2.5 may produce Mendelson's syndrome. Roberts and Shirley” showed that the administration of an antacid within 4 hours of induction of anesthesia resulted in maintaining a pH of the gastric contents above 2.5 in almost all patients. The use of antacids in this way has achieved widespread clinical acceptance. However, the idea that such antacid therapy would materially reduce maternal mortality associated with general anesthesia has not been supported by data. Some evidence to the contrary exists. As Scott pointed out in 1978, 12 the number of maternal deaths from aspiration in Great Britain from 1973 through 1975, when antacids were in general use, did not differ substantially from that in 1970-72 when antacids were not in general use. During 1973-75, all patients who died from aspiration had received antacids. This disturbing point is buttressed by the detailed case reports of two patients, both of whom died of Mendelson's syndrome following general anesthesia for cesarean birth, despite the use of antacid therapy and endotracheal intubation with cricoid pressure. In both cases, the stomach contained large volumes of gastric fluid. Furthermore, Gibbs and his associates have recently demonstrated in dogs that the aspiration into the lungs of antacid itself results in a marked and persistent bronchopneumonia associated with antacid particu- late matter in large macrophages. Current preliminary studies suggest that soluble antacids, unlike the suspension antacids, may not produce this effect. 275 MATERNAL CARDIOVASCULAR EFFECTS OF ANESTHESIA The maternal cardiovascular effects of general anesthesia are wininal, Both blood pressure and cardiac output are well maintained and usually increase transiently. The major problems with general anesthesia, as already noted, derive from inadequacies in airway management, ventilation and oxygenation. By contrast, spinal anesthesia and to a lesser degree epidural anesthesia may result in hemodynamic changes which may vary from mild and easily correctable to severe and, in extreme cases, lethal. The hemo- dynamic changes associated with both spinal and epidural anesthesia for 19,20 The pregnant patient cesarean delivery have been well described. at term, and in the supine position, exhibits a tendency toward hypotension because of compression of the vena cava by the gravid uterus. This results in impairment of venous return and a fall in cardiac output. With either subarachnoid or epidural instillation of local anesthetic, this supine hypotensive effect is magnified by the added blockade of the sympathetic nervous system which inevitably accompanies a regional anesthetic block that extends to the upper thoracic dermatomes. "Under the above noted conditions, the incidence of maternal hypoten- sion after spinal anesthesia is as high as 80%. 2] Maternal deaths have occurred from this combination of supine position, high spinal anesthesia, inadequate cardiac output, hypotension and cardiac arrest. The hypovolemic patient is more sensitive to these problems. Although the same sequence of events is possible with epidural anesthesia, the hypotension is not as frequent or severe. This may relate to the slower onset of the anesthesia. 276 PREVENTION OF MATERNAL HYPOTENSION Since these effects result from identifiable and predictable events, at least hypothetically, no patient should ever die in this way. These blocks should not be used in the hypovolemic patient without adequate volume replacement. Close observation of vital signs through adequate monitoring should detect problems at a time when they are still reversible. Caval compression by the gravid uterus is easily corrected (see below). The cardiovascular changes can be combated by rapid infusion of fluids and by the use of appropriate vasopressors such as ephedrine. Too high a spread of local anesthetic with embarrassment of ventilation can be corrected with the institution of artificial ventilation. Since cardiovascular side effects are so common, several techniques have evolved for their prevention or minimization. The first technique is the avoidance of the supine position or, alternatively, displacement of the uterus manually or with the use of a displapenent device, or with the simple expedient of tilting the patient to the left on a blanket roll or rubber wedge which may be placed under one hip. This left uterine displacement is of clear benefit and should be part of the anesthetic management of all patients undergoing cesarean birth. The second preventive technique is prehydration of the patient, usually with 1000 ml of crystalloid solution, within 15 to 30 minutes before induction of anesthesia. Using both of these methods, Wollman and Marx 22 reported a near zero incidence of hypotension during spinal 21,23 anesthesia with cesarean birth. However, others report an inci- dence closer to 50% despite these precautions. All agree that should 277 hypotension occur, it should be promptly treated by further uterine displacement if possible, rapid intravenous fluid infusion, and the injection of a vasopressor such as ephedrine which improves maternal circulation without further compromising the fetus. 2? Vasopressors with predominantly or exclusively alpha adrenergic stimulating properties are not recommended. The prophylactic use of ephedrine has been reported to decrease the incidence of maternal hypotension during spinal anesthesia to 2 522 and is routinely practiced in some, though not all, obstetric anesthesia services. Its total acceptance is tempered by the possibility of post- partum hypertension associated with the use of vasopressone. 28 In summary, given appropriate drug dose and careful monitoring by experienced personnel, these problems, especially to a life-threatening degree, should be largely preventable and/or quickly and effectively reversible. MATERNAL COMPLICATIONS Nausea and Vomiting Intraoperative nausea and vomiting is associated with hypotension and usually disappears when the hypotension is corrected. It is more often associated with spinal anesthesia. Post Lumbar Puncture Headache The incidence and severity of post lumbar puncture ("spinal") headache is related to size of the needle. As noted earlier, present practice includes lumbar puncture with 25 or 26 gauge needles in order to 278 minimize the frequency of this complication.’ Lumbar epidural block requires the insertion of a large needle, usually 17 or 18 gauge. If inadvertent dural puncture occurs, postpartum headache may follow. The incidence of dural puncture during attempted epidural block varies mainly with the experience of the anesthetist and should be less than 1%. Intravenous Drug Injection Another more serious consequence of attempted epidural anesthesia is the inadvertent injection of the local anesthetic into an epidural vein and thence directly into the maternal systemic circulation. If such injection occurs, symptoms may very from mild transient sensory effects such as perioral tingling and auditory hallucinations to frank epilepti- form seizures and even cardiac arrest. Prevention of this mishap is again a function of meticulous technique and experience on the part of the anesthetist. Treatment requires skilled personnel who are immediately available. With appropriate treatment, such toxic reactions to local anesthetics should be reversible. 28 Recall of Intraoperative Events Finally, an unpleasant though less serious complication associated with general anesthesia is maternal recall of intraoperative events. This results from the deliberate practice of using low doses and concen- trations of anesthetic agents during cesarean birth in order to minimize fetal exposure. If not specifically addressed, this complication may occur in as many as one-third of parturients.’ Its occurrence can be minimized or eliminated through shortening of the induction to delivery 279 interval, the administration of morphine and diazepam when the cord is clamped, 0 or through the use of low concentrations of a potent inhala- tion anesthetic such as halothane. FETAL AND NEONATAL EFFECTS OF MATERNAL ANESTHESIA Introduction Of unique concern in obstetrical anesthesia are the effects on the fetus and newborn of drugs and techniques used to provide maternal pain relief. A comprehensive review of the perinatal pharmacology of analgesics and anesthetics is beyond the scope of this presentation. The fetus and newborn may be affected either directly or indirectly. Direct effects are those traceable to the placental passage of drugs which then exert actions in utero or following delivery. Indirect effects are those attributable to anesthesia-induced alterations in maternal physiology (e.g., hypotension) with secondary effects on the fetus. These effects may persist following delivery. Separation of these two types of actions may be difficult or impossible. The problem is compounded by the difficulty in distinguishing other influences on the fetus and newborn during gestation, delivery and in neonatal life. Most of the older literature is of little value since, as already noted, material changes have taken place in anesthetic practices, such as the increased reliance on regional anesthesia, the use of new local anesthetic agents, the abandonment of potent inhalation agents such as ether and cyclopropane, the decreased use of adjuvant drugs such as sedatives and tranquilizers for preanesthetic medication, the recognition of the importance of avoiding the supine position, and finally the marked changes in the practice of obstetrics and neonatology. 280 Direct Drug Effects on the Fetus As pointed out in a recent review of anesthesia for surgery in pregnant patients, 2 little is known of the direct effects on the fetus of maternal anesthesia for cesarean birth. Almost all drugs used for anesthesia may cross the placenta and gain access to the fetus. In most instances, concentrations in fetal blood are lower than those in maternal blood. However, studies of pharmacokinetics and fetal drug effects are 33,34 scarce. In general, few fetal effects have been demonstrated of drugs given to the mother in appropriate doses and without complications. Direct Drug Effects on the Neonate Drug effects in the newborn have been more extensively studied but are subject again to the difficulties noted above. Pharmacokinetics in the neonate is another underdeveloped area of research.” There are few comprehensive quantitative studies of the disposition of anesthetics by the neonate. It should also be noted that even though a drug may be found in the newborn following maternal administration, its presence alone does not necessarily connote harmful effects. In general, the ability of the newborn to metabolize drugs is less well developed than in the adult. For example, studies of local anesthetics show that newborns are able to eliminate these drugs, and in some cases the rates are close to those in adults. >® The traditional indicators of drug effects in the newborn are Apgar scores and acid-base status at the time of delivery. Many older studies show correlations between low Apgar scores at delivery and deep general anesthesia.’’ By contrast, a number of more recent studies using the 281 techniques indicated above support the concept that immediate outcome is excellent following any form of uncomplicated anesthesia for cesarean delivery including general, spinal or epidural anesthesia. 2? 738-42 Neurobehavioral Effects on the Neonate There remains the unresolved and currently controversial question of the effects of anesthesia on more subtle aspects of newborn function termed neurobehavior. Space does not permit a detailed review of the methodology nor of the results so far obtained. This is reviewed in Chapter XXI. The great majority of studies of infant neurobehavior and maternal pain relief have involved infants born after vaginal 43, 44, 45 qnis issue is currently under study by the delivery. Food and Drug Administration. After the initial FDA hearing in March of 1979, the evidence presented was deemed insufficient to warrant drug regulatory action. Only three studies of newborn neurobehavior following 46,47,48 no definitive conclusions cesarean delivery have been reported; can be drawn except for the remarkable paucity of effects in all three series. In a long term prospective study, the Collaborative Perinatal Project, no differences were noted in neurologic testing at one year 3 and in IQ testing at age §» between infants born by vaginal of age or by cesarean delivery. These data, incomplete as they are, combined with the neonatal Apgar and acid-base data, suggest that anesthesia for cesarean birth, if meticulously carried out, has neither short term nor long term effects on the offspring. 282 Indirect Anesthetic Effects on Fetus and Neonate A major concern is the effect on the fetus and neonate of altera- tions in maternal hemodyamics during anesthesia for cesarean birth. Several studies have shown lower Apgar scores and relative fetal acidosis following even brief episodes of maternal hypotension during spinal 25940438,51 Although the biological significance of these anesthesia. findings is not clear, emphasis should be placed on the prevention of this complication and its prompt and appropriate therapy if it should occur. Fetal oxygenation is dependent not only on adequacy of uteroplacental blood flow, but also on the oxygenation of maternal blood. Any factor that decreased oxygen content of maternal blood or the release of oxygen at the placenta would be expected to adversely affect oxygen delivery to the fetus. Supplemental oxygen for the mother is recommended during regional anesthesia for cesarean birth since fetal oxygenation is 25138,39,52 Maternal hyperoxia has no deleterious 53 thereby improved. effect on fetal oxygenation or on uterine blood flow. Adequate preoxygenation prior to induction of general anesthesia is necessary since a period of apnea follows between induction of neuro- muscular block and resumption of ventilation after endotracheal intubation. Arterial oxygenation falls more rapidly during apneic episodes in the pregnant as compared to the non-pregnant patient.”? This may be the result of increased oxygen consumption and decreased functional residual capacity in pregnant women. 283 It has been demonstrated that optimal fetal outcome under general anesthesia also requires higher than normal maternal Fi0, to the level of 65 to 70%. °°1°65°7,58 This limits the inspired concentration of nitrous oxide and hence contributes to the problem of maternal awareness alluded to above. Another issue is that of appropriate ventilation. Maternal and fetal co, tensions are closely correlated in normal patients over a wide range of values. Passive maternal hyperventilation under general anesthesia to arterial pCO, levels of about 20 or below has been 2 associated with relative fetal hypoxemia and acidosis, >7160,671,62 This clinical observation could not be duplicated in monkeys . The potential harm to the fetus because of maternal hyperventilation may result from any one or a combination of factors such as uterine artery vasoconstric- tion, umbilical vessel constriction, decreased placental blood flow because of increased intrathoracic pressure, and shift of the maternal oxyhemoglobin dissociation curve to the left with alkalosis and consequent lessened release of oxygen by maternal blood. In any case, both hyper- ventilation as well as hypoventilation should be avoided during general anesthesia for cesarean birth. Even though hemodynamic changes are less under general or epidural anesthesia as ——— with spinal anesthesia, tilting of the patient to accomplish uterine displacement is still important to relieve the arterial flow component of the aortocaval compression syndrome. Despite the absence of maternal hypotension, fetal outcome is improved following delivery with uterine displacement .”276% 284 A final point is that of the optimal timing of delivery by cesarean birth and its relationship to anesthesia, Whatever direct or indirect effects on the fetus may result from anesthesia, it seems clear that they would be lessened by minimizing the time between induction of anesthesia and delivery of the infant. Such appears to be the case. However, the most recent studies with both regional and general anesthesia show that if aortocaval compression is avoided, if maternal Fio, is at least 65%, and if there is no hypotension, then induction-delivery interval appears to have little effect on the acid-base status of the newborn, 52168 ORGANIZATION AND PROVISION OF OBSTETRIC ANESTHESIA SERVICES The quality and availability of appropriately trained and experienced personnel to provide anesthesia for the parturient, especially for emergency cesarean delivery, remains a public health issue. In the only comprehensive study of this question, now 10 years old, anesthesia for cesarean birth was provided by either an anesthesiologist or a nurse anesthetist in 93% of cases. The larger the maternity service, the more frequent the involvement of an anesthesiologist and the less common the use of inhalation anesthesia. In only 8% of the hospitals surveyed was an anesthesiologist available on a 24-hour basis for obstetric anesthesia. In 16% of the hospitals surveyed a nurse anesthetist was available and in the hospital on a 24-hour basis. Newer data of comparable scope are not available. Such data would be of great interest in view of the marked increase in frequency of cesarean birth. 285 The importance of the immediate availability of competent anesthesia personnel is widely recognized. Several organizations have offered recommendations concerning anesthesia services for the obstetric patient. In a recently published American College of Obstetricians and Gynocologists Technical Bulletin, ®’ the following statements appear: "Safety of obstetric anesthesia depends principally upon the skill of the anesthetist. Obstetric anesthesia must be consid- ered as emergency anesthesia demanding a competence of personnel and availability of equipment similar to or greater than that required for elective procedures." "In any hospital with an obstetric service, a qualified anesthe- tist should be readily available in an emergency to administer an appropriate anesthetic and maintain support of vital functions." "In larger hospitals (Levels II and III), with active obstetric services, 24-hour in-house anesthesia coverage is strongly recommended." The last paragraph above is a paraphrase of the recommendations of the Committee on Perinatal Health.%® The latter group, in addition, recommended that in Level II and III hospitals there be "capability for cesarean birth with a short start-up time (goal to be 15 minutes) in contrast to Level I where the recommendation is "cesarean section capability within 30 minutes at any hour." In 1979 in its most recent manual, the Joint Commission on Accreditation of Hospitals states: "A qualified anesthetist shall be available to provide anesthesia care for patients whenever and wherever it is required in the hospital...The same competence of anesthesia personnel shall be available for all procedures requiring anesthesia services, whether elective or emergency." 286 Finally, the American Society of Anesthesiologists in its document "Guidelines for Patient Care in Anesthesiology" has noted the following with respect to obstetric anesthesia: "Except as emergency or near- emergency conditions make it impractical, there should be no difference from the care provided surgical patients as described above." Perhaps the time is appropriate for another survey similar to the one performed by Acog in 1970 in view of the increase in frequency of cesarean deliveries and the progress that has been made in regionalization of maternal and newborn services. CARE OF THE NEWBORN IN THE DELIVERY ROOM A related issue is the responsibility for recognition and immediate care in the delivery room of the infant who is in distress. The follow- ing statement has recently been approved (1979) and published jointly by the Committee on Fetus and Newborn of The American Academy of Pediatrics and the Committee on Obstetrics: Maternal and Fetal Medicine of the American College of Obstetricians and Gynecologists; it has also been endorsed by the American Society of Anesthesiologists. 287 CARE OF THE NEWBORN IN THE DELIVERY ROOM Rationale The first minutes of life may determine the quality of that life. Prompt, organized, and skilled response to emergencies in this period requires that institutions delivering maternal-infant care have written policies delineating responsibility for immediate newborn care, resuscitation, selection and maintenance of necessary equipment, and training of personnel in proper techniques. These policies should be approved by the medical staff of the hospital. Each institution should develop a list of maternal and fetal complications which require the presence in the delivery room of an individual qualified in newborn resuscitation. The individual who delivers the baby is responsible for the immediate post-delivery care of the newborn unless another person assumes this duty. Commonly, routine care of the healthy newborn may be delegated to appropriately trained nurses. Recognition and immediate resuscitation of the distressed infant requires an organized plan of action and immediate availability of qualified personnel and equipment. In general, the individual who resuscitates the newborn should be the one who is best qualified to do so. Planning for the provision of such services and equipment should be carried out jointly by the directors of obstetrics, anesthesia and pediatrics with the approval of the medical staff. A physician must be designated to assume primary responsibility for the establishment of standards of care, review of practjces, maintenance of appropriate drugs, and training and evaluation of personnel. Planning must include specific identification and immediate in-house availability of qualified personnel 24 hours a day. Responsibility for identification and resuscitation of the distressed infant may rest with a physician or may be delegated to appropriately trained nurse anesthetists, labor and delivery room nurses, nurse midwives, nursery nurses, or respiratory therapists. To qualify for performance of infant resuscitation, an individual must : 288 1. Demonstrate knowledge of intrauterine fetal physiology and adaptations to extrauterine life. 2. Demonstrate knowledge of the physiology and pharamacology of resuscitation. 3. Demonstrate skills in evaluation of the newborn including Apgar scoring, airway management, laryngoscopy, endotracheal intubation, artificial ventilation, suctioning of airways, cardiac massage, and maintenance of thermal stability. Equipment and Drugs The designated physician, with the approval of the medical staff, must assume responsibility for the provision and mainten- ance of appropriate jnfapt resuscitation equipment and drugs in the obstetric suite.”’”? References 1 SUMMARY Obstetric Analgesia and Anesthesia, ACOG Technical Bulletin, No. 11, The American College of Obstetricians and Gynecologists, Chicago, 1973. Standards for Obstetric-Gynecologic Services, The American College of Obstetricians and Gynecologists, Chicago, 1974. Marx, G.F. and Snider, S.M.: The obstetric suite. Chapter 19 in Handbook of Hospital Facilities for the Anethesiologist. American Society fo Anesthesiologists, Park Ridge, Illinois, 2nd edition, 1974. Standards and Recommendations for Hospital Care of Newborn Infants, Committee on Fetus and Newborn, American Academy of Pediatrics, Evanston, Illinois, 6th edition, 1977. 1. Obstetric anesthesia is a unique anesthetic application in that it requires attention to the health of two patients: mother and fetus. Substantial increases in knowledge of perinatal physiology and pharmacology of both mother and fetus have improved clinical manage- ment of anesthesia for cesarean birth. It is important to recognize that anesthesia for cesarean delivery often occurs under less than ideal, non-elective emergency conditions. 289 Available clinical data suggest that excellent maternal and fetal outcomes can be expected following either general anesthesia or regional anesthesia (spinal or epidural). Choice of anesthesia, where medical circumstances permit, should be jointly determined by the anesthesiologist, obstetrician, and patient. Where choice is possible there has been an increase in the use of epidural anesthesia for cesarean births. All methods of anesthesia by their nature influence mother, fetus, and neonate. Appropriate selection and management of anesthesia can minimize these risks. In particular, the risk of maternal aspiration of gastric contents can be avoided through the more widespread use of regional anesthesia where not contraindicated. There is a need for more information on perinatal pharmacology of anesthesia, particu- larly in the fetus at risk. Anesthesia-related maternal deaths, although at a very low incidence, continue to occur and are potentially avoidable in the presence of appropriately trained personnel. 290 BIBLIOGRAPHY 1. 6a. 10. 11. 11a. 11b. National Study of maternity care: Survey of obstetric practice and associated services in hospitals in the United States. Chicago, American College of Obstetricians and Gynecologists, 1971. Hicks, J.S.: Levinson G, Snider SM: Obstetric anesthesia training centers in the U.S.A. - 1975. Anesth. Analg. (Cleve). 55:839-845, 1976. Ranney, B, Stanage W.F: Advantages of local anesthesia for cesarean section. Obstet. Gynecol. 45:163-167, 1975. Roberts, R.B., Shirley, M.A.: Reducing the risk of acid aspiration during cesarean section. Anesth. Analg. (Cleve). 53:859-868, 1974. Mendelson, C.L: The aspiration of stomach contents into the lungs during obstetric anesthesia. Am. J. Obstet. Gynecol. 52:191-205, 1946. Report on confidential enquiries into maternal deaths in England and Wales 1973-75. Department of Health and Social Security, Her Majesty's Stationery Office, London, 1979. Moir, D.D: Editorial: Maternal mortality and anesthesia. Br. J. Anaesth. 52:1-3, 1980. Phillips, 0.C., Capizzi L.S.: Anesthesia mortality in public health aspects of critical care medicine and anesthesiology, Clinical Anesthesia. Edited by Safar P. Volume 10, no. 3, 1974, pp 219-244. Marmol, J.G., Vollman,.R.F., Gordon, M. et al.: Maternal death and high risk pregnancy: An analysis of 40 maternal deaths in the Collaborative Project. Obstet. Gynecol. 30:816-820, 1967. Hardy, W.E., Freeman, M.G., Thompson, J.D.: A ten-year review of maternal mortality. Obstet. Gynecol. 43:65-72, 1974. Gibbs, C.E., Locke, W.E.: Maternal deaths in Texas, 1969 to 1973. Am. J. Obstet. Gynecol. 126:687-692, 1976. Evrard, J.R., Gold,E.M.: Cesarean section and maternal mortality in Rhode Island: incidence and risk factors, 1965-1975. Obstet. Gynecol. 50:594-597, 1977. Pakter, J., Schiffer, M.A., Nelson, F.: Maternal and perinatal mortality. In Marx,F.G (ed.): Clinical Management of Mother and Newborn, New York, Springer-Verlag, 1979. pp 241-264. Frigoletto, F.D., Ryan, K.J., Phillippe, M.: Maternal mortality rate associated with cesarean section: an appraisal. Am. J. Obstet. Gynecol. 136:969-970. 1980. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 291 Scott, D.B.: Mendelson's syndrome. Br. J. Anaesth. 50:977-978, 1978. Whittington, R.M., Robinson, J.S., Thompson, J.M.: Fatal aspiration (Mendelson's) syndrome despite antacids and cricoid pressure. Lancet 2:228-230, 1979. Gibbs, C.P., Schwartz, D.J., Wynne, J.E. et al.: Antacid pulmonary aspiration in the dog. Anesthesiology 51:380-385, 1979. Cohen, S.E.: Aspiration syndromes in pregnancy. Anethesiology 51:375-377, 1979. Howard, F.A., Sharp, D.S: Effect of metoclopramide on gastric emptying during labour. Br. Med. J. 1:446-448, 1973. Stoelting, R.K.: Gastric fluid pH in patients receiving cimetidine. Anesth. Analg. (Cleve). 57:657-677 1978. Ueland, K., Hansen, J, Eng, M., et al.: Maternal cardiovascular dynamics V. Cesarean section under thiopental, nitrous oxide, and succinylcholine anesthesia. Am. J. Obstet. Gynecol. 108:615-622, 1970. Ueland, K., Gills, R.E., Hansen, J.M.: Maternal cardiovascular dynamics I. Cesarean section under subarachnoid block anesthesia. Am. J. Obstet. Gynecol. 100:42-54, 1968. Ueland, K., Akamatsu, T.J., Eng, M., et al.: Maternal cardiovascular dynamics VI. Cesarean section under epidural anesthesia without epinephrine. Am. J. Obstet. Gynecol. 114:775-780, 1972. Clark, R.B., Thompson, D.S., Thompson, C.H.: Prevention of spinal hypotension asociated with cesarean section. Anesthesiology 45:670- 674, 1976. Wollman, S.B., Marx, G.F.: Acute hydration for prevention of hypo- tension of spinal anesthesia in parturients. Anesthesiology 29:374-380, 1968. Datta, S., Brown, W.U: Acid-base status in diabetic mothers and their infants following general or spinal anesthesia for cesarean section. Anesthesiology 47:272-276, 1977. Ralston, D.H., Snider, S.M., de Lorimier, A.A.: Effects of equipo- tent ephedrine, metaraminol, mephentermine, and methoxamine on uterine blood flow in the pregnant ewe. Anesthesiology 40:354-370, 1974. Gutsche, B.B.: Prophylactic ephedrine preceding spinal analgesia for cesarean section. Anesthesiology 45:462-465, 1976. Casady, G.N., Moore, D.C., Bridenbaugh, L.D.: Postpartum hypertension after use of vasoconstrictor and oxytocic drugs. JAMA 172:1011-1015, 1960. 27. 28. 29. 30. 31. 32. 33. 34. 25. 36. 37. 38. 39. 40. 41. 292 Ostheimer, G.W.: Headache in the postpartum period, Clinical Management of Mother and Newborn. Edited by Marx, G.F. New York, Springer Verlag, 1979, pp 27-41. Alper, M.H.: Toxicity of local ‘anesthetics. N. Eng. J. Med. 295: 1432-1433, 1976. Wilson, J., Turner, D.J.: Awareness during caserean section under general anaesthesia. Br. Med. J. 1:280-283, 1969. Abouleish, E., Taylor, F.H.: Effect of morphine-diazepam on signs of anesthesia awareness, and dreams of patients under N,0 for cesarean section. Anesth. Analg. (Cleve). 55:702-705, 1976. Kangas, L., Erkkola, R., Kanto, J., et al.: Halothane Anaesthesia in cesarean section. Acta Anaesthesiol. Scand. 20:189-194, 1976. Pendersen, H., Finster, M.: Anesthetic risk in the pregnant surgical patient. Anesthesiology 51:439-451,1979. Mirkin., B.L.: Perinatal pharmacology: placental transfer, fetal localization, and neonatal disposition of drugs. Anesthesiology 43:156-170, 1975. Boreus, L.0. (ed.): Fetal Pharmacology. New York, Raven Press, 1973. Morselli, P.L.: Clinical pharmacokinetics in neonates. Clin Pharma- cokinet. 1:81-98, 1976. Ralston, D.H., Snider, S.M.: The fetal and neonatal effects of regional anesthesia in obstetrics. Anesthesiology 48:34-64, 1978. Benson, R.C, Berendes, H., Weiss, W.: Fetal compromise during elective cesarean section. Am. J. Obstet. Gynecol. 105:579-588, 1969. James, F.M., Crawford, J.S., Hopkinson, R., et al: A comparison of general anesthesia and lumbar epidural analgesia for elective cesarean section. Anesth. Analg. (Cleve). 56:228-235, 1977. Fox, G.S., Smith, J.B., Namba, Y., et al.: Anesthesia for cesarean section: further studies. Am. J. Obstet. Gynecol. 133:15-19, 1979. Marx, G.F., Cosmi, E.V., Wollman, S.B.: Biochemical status and clinical condition of mother and infant at cesarean section. Anesth. Analg. (Cleve). 48:986-994, 1969. Downing, J.W., Houlton, P.C., Barclay, A.: Extradural analgesia for caesarean section: a comparison with general anaesthesia. Br. J. Anaesth. 51:367-374, 1979. 42. 43. 44. 45. 46. 47. 48. 49. 50. 51. 52. 53. 293 Belfrage, P., Irestedt, L., Raabe, N., et al.: General anaesthesia or lumbar epidural block for caesarean section? Effects on the foetal heart rate. Acta Anaesthesiol. Scand. 21:67-70, 1977. Brackbill, Y.: Obstetrical medication and infant behavior, Handbook of Infant Development. Edited by Osofsky, J.D. New York, John Wiley & Sons, 1979, pp 76-125. Hodgkinson,R.: Effects of obstetric analgesia-anesthesia on neonatal neurobehavior, Clinical Management of Mother and Newborn. Edited by Marx,G.F. New York, Springer-Verlag, 1979, pp 85-100. Scanlon, J.W.: Clinical neonatal neurobehavioral assessment: methods and significance, Clinical Management of Mother and Newborn. Edited by Marx, G.F. New York, Springer-Verlag, 1979, pp 65-83. Palahniuk, R.J., Scatliff, J., Biehl, D,, et al.: Maternal and neonatal effects of methoxyflurane, nitrous oxide and lumbar epi- dural anaesthesia for cesarean section. Can. Anaesth. Soc. J. 24:586-596, 1977. Hodgkinson, R., Bhatt, M., Kimm, S.S., et al.: Neonatal neuro- behavioral tests following cesarean sectin under general and spinal anesthesia. Am. J. Obstet. Gynecol. 132:670-674, 1978. Hollmen, A.I., Jouppila, R., Koivisto, M., et al.: Neurologic activity of infants following anesthesia for cesarean section. Anesthesiology 48:350-356, 1978. Broman, S.H., Nichols, P.L., Kennedy, W.A.: Preschool IQ: Prenatal and Early Developmental Correlates. Hillsdale, New Jersey, Lawrence Erlbaum Associates, 1975. Cosmi, E.V., Marx, G.F.: Acid-base status of the fetus and clinical condition of the newborn following cesarean section. Am. J. Obstet. Gynecol. 102:378-382, 1968. Moya, F., Smith, B.: Spinal anesthesia for cesarean section: clinical and biochemical studies of effects on maternal physiology. JAMA 179:609-614, 1962. Datta, S., Alper, M.H., Ostheimer, G.W, et al.: Effects of maternal position on epidural anesthesia for cesarean section, acid-base status, and bupivacaine concentrations at delivery. Anesthesiology 50:205-209, 1979. Meschia, G., Battaglia, F.C.: Acute changes of oxygen pressure and the regulation of uterine blood flow, Foetal and Neonatal Physiology, Proceedings of Barcroft Centenary Symposium. Cambridge, England, Cambridge University Press, 1973. 54. 55. 56. 57. 58. 59. 60. 61. 62. 63. 64. 65. 66. 294 Archer, G.W., Marx, G.F.: Arterial oxygen tension during apnoea in parturient women. Br. J. Anaesth. 46:358-3260, 1974. Rorke, M.J., Davey, D.A., Du Toit, J.H.: Foetal oxygenation during cesarean section. Anaesthesia 23:585-596, 1968. Crawford, J.S.. Burton, M., Davies, P.: Anaesthesia for section: further refinements of a technique. Br. J. Anaesth. 45:726-732, 1973. Marx, G.F., Mateo, C.V.: Effects of different oxygen concentrations during general anaesthesia for elective caesarean section. Can. Anaesth. Soc. J. 18:587-591, 1971. Robertson, A., Fothergill, R.J., Hall, R.A., et al.: Effects of anaesthesia with a high oxygen concentration on the acid-base state of babies delivered at elective caesarean section. S. Afr. Med. J. 48:2309-2313, 1974. Low, J.A., Boston, R.W., Cervenko, F.W.: Effect of low maternal carbon dioxide tension on placental gas exchange. Am. J. Obstet. Gynecol. 106:1032-1043, 1970. Motoyama, E.K., Rivard, G., Acheson, F., et al.: Adverse effect of maternal hyperventilation on the foetus. Lancet 1:286-288, 1966. Moya, F., Morishima, H.0., Snider, S.M., et al.: Influence of maternal hyperventilation on the newborn infant. Am. J Obstet. Gynecol. 91:76-84, 1965. Peng, A.T.C., Blancato, L.S., Motoyama, E.K.: Effect of maternal hypocapnia v. eucapnia on the foetus during caesarean sectin. Br. J. Anaesth. 44:1173-1178, 1972. Parer, J.T., Eng, M., Aoba, H., et al.: Uterine blood flow and oxygen uptake during maternal hyperventilationin monkeys at cesarean section. Anesthesiology 32:130-135, 1970. Crawford, J.S., Burton, M., Davies, P.: Time and lateral tilt at caesarean section. Br. J. Anaesth. 44:477-484, 1972. Crawford, J.S., James, F.M., Crawley, M.: A further study of general anaesthesia for caesarean section. Br. J. Anaesth. 48:661-667, 1976. Datta, S., Alper, M.H., Brown, W.U., et al.: Anesthesia for cesarean section: importance of induction-delivery and uterine incision- delivery interval on neonatal outcome. Abstracts of Scientific Papers, Annual Meeting, American Society of Anesthesiologists, 1978, pp 103-104. 67. 68. 69. 295 Obstetric anesthesia and analgesia, ACOG Technical Bulletin #57 American College of Obstetricians and Gynecologists, Chicago, Illinois, January, 1980. Toward improving the outcome of pregnancy. Committee on Perinatal Health. The National Foundation-March of Dimes, White Plains, New York, 1976. Accreditation Manual for Hospitals. 1979 Edition. Joint Commission on Accreditation of Hospitals, Chicago, Illinois, 1979. Chapter XII - Neonatal RDS 299 INTRODUCTION Two questions are addressed regarding the effect on the newborn infant of delivery by cesarean birth. One question is the issue of avoiding elective cesarean delivery at a time of fetal lung immaturity that will lead to subsequent development of respiratory distress syndrome (RDS). The second is the question of whether being born by cesarean carries by itself some risk to the newborn, as compared with birth by vaginal delivery or by cesarean birth after onset of labor. EARLY INTERVENTION AND RESPIRATORY DISTRESS SYNDROME (RDS) RDS in an infant born by completely elective, scheduled cesarean is a serious complication which should be preventable by scheduling delivery based on appropriate assessment of gestational age or lung maturity. Thirty years ago, D'Espo at Sloane Hospital for Women | reviewed 1,000 consecutive cesarean births between 1942 and 1947 and noted 37 perinatal deaths (3.7%), including one attributed to incorrect assessment of gestational age. In the many series published subsequently, the incidence of this incorrect age assessment phenomenon varied widely. For example, Diddle, et al. in 19522 reported 88 perinatal deaths in 763 cesareans (11.5%). Of the 88 deaths, 19 were attributed to incorrect timing of delivery. Results in the 1950's showed continuing neonatal loss for the same reasons. Bryant in 1961° reported experience in Cincinnati with 6,265 cesarean births between 1950 and 1959. Of the elective, repeat operative births, 4.8% of the babies were judged premature by weight and 13 infants (12%) died. By contrast, only 5 of 2,112 (0.24%) normal mature babies delivered by operation died. Another series of repeat cesarean births reported in 19614 noted an overall corrected perinatal 300 mortality rate of 1.5%, comprising 9.8% in premature infants and 0.6% in mature infants. Of the 1,462 repeat sections studied, 67 or 6% resulted in the erroneous delivery of a premature infant; 4 of these 67 infants (6%) died. The authors commented on the universality and persistence of this error in judgment despite advances in obstetrics. In 1969, just prior to the beginning of the widespread availability of more objective means of determining fetal maturity, Kafka and his associates’ reported a series of 644 cesareans (330 primary and 314 repeat). Of the repeat cesareans, the overall perinatal death rate was 1.2%; the death rate in the prematurely delivered infants was 4.8%. The beginning of the decade of the 1970's witnessed the almost simultaneous introduction into obstetric practice of more objective indices of fetal size and maturation. Ultrasonography became available for measuring fetal head size’ (and thereby estimating gestational age), and analysis of amniotic fluid became available for biochemical estimation of fetal lung maturity’. At about the same time, there was a growth in interest in neonatal pediatrics and organization of neonatal intensive care units. One of the effects of the above changes resulted in a focusing of attention by neonatologists on the syndrome of RDS following cesarean birth. Four recent reports attest to the persistence of the problem of iatrogenically related RDS. In the first, Goldberg and Nelson® reviewed 100 consecutive cases of RDS in infants delivered at Yale-New Haven Medical Center between July 1, 1970 -and January 1, 1974. Both ultrasound and lecithin/sphingomyelin (L/S) ratio determinations were readily available. Of the 100 cases of RDS, 33 were classified as iatrogenic and 67 as the result of indicated deliveries. Nine infants 301 of the 33 were delivered by elective, repeat cesarean births without maturity studies, and 6 (also without maturity studies) followed cesarean births judged not to have been immediately indicated. In these 15 deliveries, 4 infants died. The Cleveland study by Hack and her associates’ showed that in the 6-month period from October 1, 1973 to March 31, 1974, 19 of the 245 infants admitted to the neonatal ICU (8% of all admissions) followed elective obstetric intervention (15 by cesarean ; 4 by vaginal delivery after elective induction). All of the infants had serious respiratory problems. They were transferred from ten different hospitals in the region and one was inborn. In none of these infants had lung maturity been assessed before delivery. During this same 6-month perod, no infant was admitted after an elective delivery which followed assessment of lung maturity. A review of the affected infants' records revealed that antenatal assessment of fetal maturity was based entirely on clinical criteria without any specific diagnostic procedures. One of the 15 infants born after cesarean birth died as did one of the 4 following vaginal delivery. The average cost of caring for these infants wag $3,600 per child with an average length of hospital stay of 17 days. Excluded from these calculations is the one infant who died after a prolonged and difficult course of 140 days at a total cost of $33,000. In the third study, Maisels, et.a1. 0 reviewed 1,020 consecutive admissions to the neonatal ICU in Hershey, Pennsylvania, between January 1973 and March 1976. Thirty-eight of the 1,020 infants (3.7%) were admitted following elective delivery (33 by cesarean birth; 5 by vaginal delivery following elective induction). Eighteen of these 38 infants developed RDS clearly related to premature delivery. Fifteen 302 of these followed cesarean and 3 followed vaginal delivery. In none of these 18 pregnancies had tests of fetal maturity been performed. Of the 15 post-cesarean babies with RDS, 1 died. The average hospital stay in this group was 12.7 days. Of further interest is the disparity in assessment of gestational age. The gestational age assigned by the obstetrician prior to elective delivery averaged 38.9 weeks compared to that determined after birth by the pediatrician on physical examination of 36.6 weeks. In 11 infants, the difference between these two estimates was 2 to 3 weeks; in 7, over 3 weeks; and in one infant, 7 weeks. Based on experience, Maisels and his colleagues estimated that at least 15% of the 40,000 cases of RDS seen annually in the United States were preventable. This may have been a conservative estimate; the figure may be as high as 30%. The fourth and most recent study is that of Flaksman, et al. 198, who reviewed 1,000 consecutive infants admitted to the regional neonatal ICU in Akron, Ohio between January 1975 and June 1976. Thirty-two iatrogenic- ally preterm infants were identified, 5 delivered after elective induction of labor, and 27 by elective cesarean birth. The mean gestational age based on the last menstrual period was 39.0 weeks, whereas the mean gestational age estimated neonatally was 35.4 weeks. One of the infants died of RDS in the initial hospitalization. Of the 31 who left the nursery, 22 have normal growth and development. Two of the remaining 9 subsequently died of unrelated events; 3 showed failure to thrive. The father of 1 infant required psychiatric hospitalization. Three infants 303 have been lost to follow-up. In none of these 32 pregnancies was amniotic fluid analysis or ultrasonography carried out. The overall incidence of this syndrome in this referral area was estimated at 1.6/1,000 live births. Despite at least 30 years of repeated admonitions in the medical literature, ill-timed delivery by cesarean birth continues to occur at great cost in human life and suffering and threatens to become a leading cause of RDS in infants. !! The inadequacy of a simple clinical estima- tion of fetal age and maturity has been amply documented despite careful attention to a number of traditional clinical signs. 12 Most, if not all, of this perinatal mortality and morbidity is at least hypothetically preventable. 122 To address the issue, the Committee on Obstetrics: Maternal and Fetal Medicine of the American College of Obstetricians and Gynecologists, and the Committee on Fetus and Newborn of the American Academy of Pediatrics have jointly prepared and released the following statement. "ASSESSMENT OF FETAL MATURITY PRIOR TO REPEAT CESAREAN SECTION AND ELECTIVE INDUCTION OF LABOR AT TERM" An elective repeat cesarean section or induction of labor may be performed on a patient with an uncomplicated pregnancy whose gestational age has been documented by auscultation of fetal heart tones for 20 weeks with a non-electronic fetoscope. This is the most reliable, safe, least expensive and non-invasive method of determining gestational age. In situations where the documentation of gestational age by auscultation of fetal heart tones for 20 weeks did not occur, other corroborative, supportive evidence of a term gestation -includes either of the following. (a) Thirty-three weeks gestation occurring after a positive pregnancy test done by a standard immunologic testing procedure (35 weeks using a positive radioreceptor assay) or 304 (b) Biparietal diameter measurements. The first should be obtained between 18 and 26 weeks gestation. If the EDC calcu- lated by this ultrasound is within one week of the menstrual dates, the latter can be accepted. If, however, it does not coincide with menstrual dates, then a second ultrasound should be obtained by the 30th week, no sooner than three weeks after the first ultrasound. The two measurements are then used to define gestational age. Any one of the above criteria is acceptable evidence of a term gestation. In the absence of these criteria, elective repeat cesarean section or elective induction of labor should be preceded by amniotic fluid evidence of fetal lung maturity. In the absence of fetal lung maturity and in patients without contraindication to labor it is a reasonable option to allow a patient to go into labor prior to repeat cesarean section. RESPIRATORY DISTRESS SYNDROME IN CESAREAN AND VAGINAL BIRTH The second issue is whether birth by cesarean is associated with an increased risk of respiratory distress at any gestational age, including term birth, when compared with vaginal delivery. This issue cannot be resolved definitively. Retrospective analyses in the older literature suffer from poor control of gestational age, birth weight, and confound- ing maternal factors. There are no large prospective studies where a consistent diagnosis of respiratory distress could be enforced. One major difficulty in retrospective studies of this issue is in defining respiratory distress precisely. Respiratory distress syndrome (RDS) is usually defined as the clinical equivalent of hyaline membrane disease (HMD) which is a pathologic diagnosis. RDS or HMD occurs primarily in infants of less than 36 weeks gestation and is clinically associated with tachypnea, retractions, alar flaring, grunting, and cyanosis. Radiographically, there is usually bilateral hypoexpansion of the lungs with a diffuse alveolar/interstitial infiltrative pattern (ground-glass 305 appearance) and air bronchograms. Extra-alveolar air leaks (pneumothorax, pneumomediastinum, pneumopericardium and, rarely, pneumoperitoneum) are common. Hypoxemia and hypercapnia are nearly always present. Case fatality rates of 10-40% are anticipated. It is now well documented that RDS/HMD develops in infants who have deficient alveolar surfactant which appears on a developmental spectrum between 28 and 36 weeks. Alveolar surfactant can apparently be lost, after existing in normal concentration, in response to fetal or neonatal distress (asphyxia). Alveolar surfactant presence can be predicted by measuring phospholipid concentrations (particularly lecithin, phosphatidylglycerol and phospha- tidylinositol) in ‘amniotic fluid, neonatal tracheal fluid, neonatal gastric fluid, or neonatal pharyngeal aspirates. Other forms of neonatal respiratory distress exist but are less well defined clinically, radiographically, and biochemically. They are quite common. These neonatal "wet-lung" diseases include transient tachypnea of the newborn (TTN), massive amniotic fluid aspiration, and RDS Type II. Other neonatal disease processes of pulmonary origin (pneumonia, meconium aspiration, pulmonary hypoplasia, tracheobronchial obstruction, lung cysts) and of non-pulmonary origin (asphyxia, acidosis, drug intox- ication, brain injury, metabolic abnormality) may cause respiratory distress and/or pulmonary failure. Transient tachypnea of the newborn is characterized by tachypnea, cyanosis, alar flaring, retractions, and grunting in a preterm or term infant. Radiographically, TIN has a diffuse alveolar/interstitial pattern with normal diaphragmatic expansion, and, occasionally, pleural 306 effusions. The disease process is almost always self-limited, and usually resolves spontaneously within 48 hours. It is assumed that the ' pathophysiology of TIN involves the delayed vascular or lymphatic clear- ance of normal fetal lung fluid. Massive amniotic fluid aspiration is a disputed clinical entity. It is said to develop in term or near-term infants who are stimulated to gasp repeatedly during parturition and who consequently aspirate large quanti- ties of amniotic fluid. The clinical picture is indistinguishable from the respiratory distress of RDS/HMD or TIN. The radiograph demon- strates diffuse alveolar infiltrates with normal expansion. Air leaks are common. The infants may have significant respiratory disease for 3 to 10 days. RDS Type II develops in term or near-term infants.’ The respira- tory distress is clinically indistinguishable from RDS/HMD, TTN, or massive amniotic fluid aspiration. They have a radiographic picture of hilar congestion and scattered alveolar infiltrates. Tracheal-bronchial obstruction from inspissated fluid or mucus has been postulated as the pathophysiological mechanism. Recovery is expected within 3 days. 16 , : , in a review of 6 years' exper- Nanninga and Stephenson in 1951, ience from 1943 through 1948, found roughly equal perinatal mortality rates in California following vaginal delivery (3.2%) and cesarean delivery (3.8%). In another study by Usher and his colleagues published in 197117, the incidence of respiratory distress syndrome was found to be significantly higher following birth by cesarean compared to infants delivered vaginally, but this difference disappeared with gestational age beyond 38 completed weeks. 307 Three more recent retrospective studies address the question of the association of RDS and cesarean delivery. In these studies, RDS as defined includes any degree of postnatal respiratory difficulty from mild tachypnea and grunting respirations to full-blown hyaline membrane disease. Jones and his colleagues analyzed the records of 16,458 infants born at the University of Colorado Medical Center between 1956 and 1968 where sufficient maternal menstrual history was available to allow calculation of gestational age. The overall cesarean birth rate was 3.8%. The overall incidence of RDS in these 629 patients was 3.6% versus 1.2% in the vaginally delivered group. When corrected for gestational age, the increased incidence was statistically significant (p < 0.05) for gestational age categories of 34-37 weeks and equal to or greater than 38 weeks. Roberts, et a,’ in a study of the influence of maternal diabetes on RDS, demonstrated an increased incidence of RDS at all gestational ages in infants delivered by cesarean birth compared to infants delivered vaginally in both diabetic and non-diabetic populations. A retrospective study of RDS in all live births in Norway (457,465 births) 20 When adjusted for gestational was carried out between the years 1967-1973. age, the incidence of RDS after cesarean delivery with no other complications was 7.9/1,000 as compared to an incidence of 1.7/1,000 in uncomplicated vaginal delivery. This was a relative risk increase of 4.6 (p < 0.05). The relative risk was even higher (11.2) in those infants of gestational age equal to or greater than 39 weeks. These investigators also compared the risk of 308 RDS in cesarean deliveries performed before the onset of labor with that after the onset of labor. The incidence of RDS, adjusted for gestational age, was 14.3/1,000 in the elective group versus 8.4/1,000 in those done after the onset of labor, a difference which just fails the 0.05 level of statistical significance. In a report from the Collaborative Perinatal Project of a comparison of outcome of 405 deliveries by elective cesarean birth with a series of 8,028 vaginal deliveries,’ neonatal mortality was 1% in the former group and 0.4% in the latter. Of interest is the long term follow-up of these infants. At four months of age, definite or suspected neurologic abnormalities were reported in 16% of infants delivered by cesarean versus 10% in vaginal deliveries. Further follow-up of these infants showed a lack of this difference between the two groups at one year of age. A further report from the Collaborative Perinatal Project of IQ testing at age 4 showed no significant effect on IQ in children born by cesarean delivery.2? In another study (Kaltreider and Simmons, personal communication) in which all maternal medical and obstetrical complications were rigorously eliminated, an association of cesarean birth with respiratory distress in term (39-42 weeks) infants was not demonstrated. In this study, 7,283 deliveries over 3 years were reviewed. Of these, 4,666 were babies between 39 and 42 weeks of gestational age (Table I). After eliminating all mothers who had a history of medical or obstetrical complications, or abnormalities of the antepartum or intrapartum course during the study pregnancy, there were 1,663 vaginal births and 234 cesarean births, of which 155 were primary cesarean births. There was no difference 309 in the incidence of respiratory distress between repeat and primary cesarean births (2/79 vs 4/155). In both repeat and primary cesarean birth, the rate of RDS is two times that of the vaginal group. Although p > 0.08 is not quite statistically significant, it is suggestive of a difference. Table I: Respiratory Distress in infants of 39-42 weeks gestational age born to mothers without complications. No Respiratory Respiratory Total Distress Distress Repeat Cesarean 2 77 79 Primary Cesarean 4 151 155 Vaginal Delivery 17 1646 1663 pi] 1874 1897 These observations place even greater importance upon accurate assessment of fetal maturity. For example, Usher and his associates in 196114 observed an 8.4% incidence of RDS in infants delivered by cesarean at 37 to 38 weeks versus an incidence of only 0.8% in a vaginally delivered group of the same gestational age. Even allowing for the vagaries of estimating gestational age this is an impressive difference. Hack, et al,’ noted no admissions for RDS after elective deliveries in which fetal maturity had been determined. Of the patients reported by Goldenberg and Nelson, 1 electively induced and 2 delivered by elective cesarean after maturity studies developed RDS. Two were diabetic in whom the L/S ratio may not be as accurate as a predictor of RDS. The third neonate had had an ultrasonic measurement that was not diagnostic of fetal maturity. 310 Gabert and his colleaguess strongly suppport the notion that RDS is not related to mode of delivery but rather to lung maturity. In their study of 240 patients (104 vaginal deliveries and 136 cesarean births), the presence or absence of respiratory distress was correctly predicted in all cases. Of particular interest is the group of 24 repeat cesarean births. All had mature L/S ratios prior to delivery and none developed RDS. The evidence clearly supports the need for accurate assessment of fetal lung maturity before elective delivery. CESAREAN BIRTH AND NEONATAL WATER DISTRIBUTION Cesarean delivery is associated with certain abnormalities of body water content and distribution. Cassady has shown that infants delivered by cesarean (with and without preceding labor) initially have an increased total body water and intracellular water, both of which return to normal by one day of age. The normal rate of decline in total body water was reduced in cesarean infants over the first 8 hours of life. Presumably, the excess water might be distributed in the lung and could cause TTN and consequently respiratory distress. However, this is a speculation. Bland, et al. , 2 measured extravascular lung water content in fetal rabbits born by vaginal or abdominal operative routes, both before and after labor. Both groups of rabbits born after onset of labor (vaginal delivery and operative delivery) had less lung water than the group delivered operatively without labor. There was no difference in lung water content among rabbits born vaginally or operatively, after the onset of labor. This study suggests that the 311 reduction in volume of fetal lung liquid in rabbits depends on the experience of labor, rather than on the mode (vaginal v8, uparalive) of delivery. An assumption would be that cesarean without labor might be associated with an increased neonatal lung water content, with consequent respiratory distress. Milner, et al. 2% per formed pulmonary function tests in the first 6 hours of life in 26 vaginally delivered infants and in 10 infants born by cesarean birth. A markedly diminished lung gas volume (19.7 ml/kg vs 32.7 ml/kg) was found in the infants born by cesarean. This study suggests that the volume of air in the lung of an infant born by cesarean is decreased because of increased lung liquid volume. The investigators speculate that the lack of thoracic compression in cesarean birth infants may lead to increased lung liquid volume and a tendency for mild respira- tory distress. Data from the British Perinatal Mortality Survey in 195827 con- cluded that the incidence of RDS in infants born by cesarean before the onset of labor was some four times greater than in infants delivered during labor, which in turn was higher than in those delivered vaginally. In a recent study of amniotic fluid and pharyngeal L/S ratios at term delivery in 3 _— infants, the highest values were found in those infants born by cesarean delivery after spontaneous labor of at least 4 hours duration. No differences were found between elective vaginal delivery following induction or elective cesarean del ivery. 28 It is possible that the higher incidence of respiratory distress after cesarean birth is due to more frequent development of "wet lung" 312 disorders in the infant. If so, the morbidity and mortality would be expected to be lower than if the respiratory distress were true RDS/HMD. If a less serious form of lung disease (wet lung syndromes) accounts for the higher frequency of respiratory distress in cesarean births, one would expect a lower mortality rate in post-cesarean respiratory distress. In a personal communication, Reed has demonstrated from the survey of Norwegian birthsZ0 that case fatality rates from respiratory distress after vaginal birth are not different from those after cesarean delivery. OTHER FETAL AND NEONATAL CONCERNS - Independent of respiratory distress, other adverse physiologic effects of cesarean birth on the fetus may exist. There is no doubt that certain untoward events may occur during a cesarean that are very unlikely in a vaginal delivery. As noted in the previous chapter, maternal anesthetic complications are more likely, but obviously infrequent. Direct fetal injuries (cord lacerations, placental disruption, fetal body lacerations, difficult extraction, etc.) are also rare but possible. Much concern has been directed to the potential effects of cesarean delivery on fetal/neonatal depression. No evidence exists that the incidence of significant fetal/neonatal depression or asphyxia is more frequent after cesarean birth. In a clinical study of acid-base and PO, values in infants born by elective cesarean birth, no difference was found during the first 3 hours of life among cesarean births compared to vaginal births. 28 313 SUMMARY (1) (2) (3) (4) (5) (6) (7) As reported in most retrospective studies, cesarean birth, indepen- dent of maternal complications, appears to be associated with an increased incidence of respiratory distress at all gestational ages. The overall conclusion from many epidemiologic and experimental studies is that birth by cesarean in the absence of labor results in a higher incidence of RDS. It is not clear that the more frequent respiratory distress is due to RDS/HMD. It is clear, however, that the increased respiratory distress contributes to clinical morbidity. Iatrogenic respiratory distress following illtimed cesarean birth continues to occur and should be preventable. The utilization of clinical, biophysical or biochemical estimates of fetal age and maturity, as outlined in the 1979 document of The American College of Obstetricians and Gynecologists and The American Academy of Pediatrics, is an acceptable guide to the timing of a cesarean birth. More research is needed to explain the effects of labor, the altered ‘hormonal environment associated with labor, the effects of thoracic compression during vaginal delivery, and the effects of anesthesia on neonatal physiology. In infants born at or near term with demonstrably mature lungs, respiratory distress is unlikely to be a problem whatever the route of delivery. 314 BIBLIOGRAPHY 1. 10. 10a. 11. 12. 12a. 13. 14. D'Esopo DA: A Review of cesarean sectin at Sloane Hospital for Women, 1942-47. Am J Obstet Gynecol 59:77-95, 1950. Diddle AW, Jenkins HH, Davis M, et al.: Analysis of fetal mortal- ity in cesarean section: Experience in an urban community. Am J. Obstet Gynecol 63:967-977, 1952. Bryant RD: Cesarean section in Cincinnati, Ohio, 1950-59. Am J Obstet Gynecol 81:480-492, 1961. oo Muller PF, Heisler W, Graham W: Repeat cesarean section. Am J Obstet Gynecol 81:867-875, 1961. Kafka H, Hibbard LT, Spears RL: Perinatal mortality associated with cesarean section. Am J Obstet Gynecol 105:589-596, 1969. Oong L, Major F, Weiongold A: Ultrasonic determination of fetal maturity at repeat cesarean section. Obstet Gynecol 38:294,1971. Gluck L, Kulovich MV, Borer RC, et al.: Diagnosis of the respiratory distress syndrome by amniocentesis. Am J Obstet Gynecol 109:440, 1271. Goldenberg RL, Nelson K: Iatrogenic respiratory distress syndrome. Am J Obstet Gynecol 123:617-620, 1975. Hack M, Fanaroff AA, Klaus MH, et al.: Neonatal respiratory distress following elective delivery. A preventable disease? Am J Obstet Gynecol 126:43-47, 1976. Maisels MJ, Rees R, Marks K, et al.: Elective delivery of the term fetus. An obstetrical hazard. JAMA 238:2036-2039, 1977. Flaksman RJ, Vollman JH, Benfield DG: Iatrogenic prematurity due to elective termination of the uncomplicated pregnancy: a major perinatal health care problem. Am J Obstet Gynecol 132:885-888, 1978. Gluck L: Iatrongenic RDS and amniocentesis (Editorial). Hosp Pract 12:11, 1977. Hertz RH, Sokol RJ, Knoke JD, et al.: Clinical estimation of gestational age: rules for avoiding preterm delivery. Am J Obstet Gynecol 131:395-402, 1978. Antenatal Diagnosis. Section II: Predictors of Fetal Maturity. NIH Publication No. 79-1973, 1979. Avery, M.E., Gatewood, 0.B., Brumley, G.: Transient tachypnea of the newborn. Am. J. Dis. Child. 111:380-385, 1966. Avery, M.E.: The lung and its disorders in the newborn infant. W.B. Saunders, Phila. 1968, p. 177-179. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 315 Sundell H, Garrott J, Blankenship WJ, Shepard FM, and Stahlinar MT: Studies on infants with type II rspiratory distress syndrome. J. Pediatr 78:754-764, 1971. Nanninga TR, Stephenson HA: An evaluation of cesarean section. California Med 74:151-154, 1951. Usher RH, Allen AC, McLean FH: Risk of respiratory distress syndrome related to gestational age, route of delivery and maternal diabetes. Am J Obstet Gynecol 111:826-832, 1971. Jones MD, Burd LI, Bowes WA, et al.: Failure of association of premature rupture of membranes with respiratory-distress syndrome. N Eng. J Med 292:1253-1257, 1975. Robert MF, Neff RK, Hubbell JP, et al: Association between maternal diabetes and the respiratory-distress syndrome in the newborn. N Eng. J Med 294:357-360, 1976. Reed DM, Bakketeig LS, Nugent RP: The epidemiology of respiratory distress syndrome in Norway. Am J Epidemiol 107:299-310, 1978. Beson RC, Berendes H, Weiss W: Fetal compromise during elective cesarean section. AM J Epidemiol 107:299-310, 1978. Broman SH, Nichols PL, Kennedy WA: Preschool IQ: Prenatal and Early Developmental Correlates. Hillside, New Jersey, L. Erlbaum Associates, 1975. Gaberts HA, Bryson MJ, Stenchever MA: The effect of cesarean section on respiratory distress in the presence of a mature lecithin/sphingomyelin ratio. Am J Obstet Gynecol 116:366-368, 1973. Cassady G: Effect of cesarean section on neonatal body water spaces. N Eng. J Med 285:887-891, 1971. Bland RD, Bressack MA, McMillan DD: Labor decreases the lung water content of newborn rabbits. Am J Obstet Gynecol 135:364-367, 197%. Milner AD, Saunders RA, Hopkin IE: Effects of delivery by cesarean sectino on lung mechanics and lung volume in the human neonate. Arch Dis Child 53:545-548, 1978. Fredrick J, Butler NR: Hyal ine-membrane disease. Lancet 2: 768-769, 1972. Callen P, Goldsworthy S, Graves L, et al.: Mode of delivery and the lecithin/sphingomyelin ratio. Brit.J Obstet Gynaecol 86:965-986, 1979. Kjellmer I, Magno R, Karlsson K: Anesthesia for cesarean section I: Effects on the respiratory adaptation of the newborn in elective cesarean section. Acta Anaesthesiol Scand 18:48-57, 1974. Chapter XIII - Dystocia 319 INTRODUCTION The purpose of this section of the report is to describe dystocia, a major clinical management problem in obstetrics, and its relationship to the changing cesarean birth rate. DEFINITIONS The term dystocia comes from the Greek roots dys, meaning abnormal, and toko, meaning childbirth or labor. Thus abnormal labor, or dystocia, is characterized by abnormal progress in labor. Three distinct types of labor abnormalities occur either as isolated events or as combinations of labor events. These include: 1. abnormalities of the maternal birth canal which may form an obstacle to descent of the fetal presenting part; 2. abnormalities in presentation or position of the fetus, or related to congenital anomalies of fetal development; and 3. abnormalities of the forces of labor, including uterine contractions which occur either infrequently or with insufficient strength to overcome the normal resistance of the maternal birth canal. It is clear from this broad definition that dystocia is a very complex, highly inclusive concept. One widely used American textbook of obstetrics’ devotes over 60 consecutive pages to a discussion of dystocia, in addition to including numerous references throughout the remainder of the text. That detailed a discussion is beyond the scope of this presentation. Rather, the focus will be specifically on the relation- ship of dystocia to cesarean birth. 320 DYSTOCIA AND CESAREAN BIRTH As noted throughout this report, dystocia is a frequently cited indication for cesarean birth. In a recent overview, the final diagnoses explaining admissions of cesarean birth patients were listed for 1,527 U.S. Professional Activities Survey (PAS) hospitals and 171 Canadian PAS hospitals for the period from January through December 1974. Nearly 130,000 abdominally delivered pregnancies were surveyed. Extracting all diagnoses which would fit within the broad concept of dystocia, as listed above, yields an estimate that dystocia was the indication for approximately 43% of the cesarean births surveyed. Included among the diagnoses categorized as dystocia were fetopelvic disproportion, prolonged labor, persistent Sai posterior, abnormally small maternal pelvis, excess sized fetus, primary uterine inertia, prolonged first stage, transverse arrest of descent, contracted midpelvis, cervical dystocia, arrest of active labor, abnormal fetal position, arrest of active phase, and prolonged second stage of labor. This interpretation would indicate that dystocia was the most common indication in the surveyed group for cesarean delivery. A similar perspective comparing the experiences of five institutions for the changing indications for cesarean birth was recently published. These specific hospital reports were selected because they reported cesarean birth rates according to indication and over time in a format 4,5,6,7,8 Overall, cesarean birth for which allowed comparison. dystocia was found to account for the largest single part (approximately one-third) of the increase in cesarean birth rates. Repeat cesarean 321 births were found to represent 23.1% of the increase in cesarean births. Dystocia accounted for approximately one-quarter of all tie cesarean deliveries performed and was second only to repeat cesarean birth as an operative indication. In previous sections of this report, the more current national CPHA and New York City experiences are entirely consistent with the above noted materials. The special significance of this consistency is that these experiences relate to general populations and are not dependent on questionnaire responses from individual hospitals, as for example are the reports from teaching hospitals noted in the introduction. In addition, the CPHA data show not only that dystocia is a common indication for cesarean birth, but also that the "diagnosis" of dystocia, or at least the diagnoses which are subsumed under this heading, are being made more frequently in current practice. DYSTOCIA - SPECIFIC CONDITIONS AND MANAGEMENT PROBLEMS The exceptional breadth of the concept of dystocia has been noted. It is not possible to explore each component in depth. Rather, specific examples of dystocia and their relationships to abdominal delivery will be presented. AN ANATOMIC CONCEPT OF DYSTOCIA: ABNORMALITIES OF THE BIRTH CANAL Abnormalities of the birth canal that interfere with descent of the fetal presenting part may be divided into abnormalities in the soft tissue and in the bony pelvis. Soft tissue dystocia is not commonly encountered, but may follow a broad range of specific problems,’ including vulvar atresia (for 322 example secondary to condylomata accuminata), vaginal septa, cervical stenosis, acute anterior flexion of the uterus (for example as may be observed in the grand multipara), uterine sacculation, myomata uteri, ovarian masses, pelvic kidney and bladder distention. Based upon the previously cited survey of PAS hospitals, these problems together probably account for less than 1% of all cesarean births. 2 Abnormalities of the bony pelvis may account for a somewhat greater proportion of abdominal deliveries.? This issue is complicated by the fact that the size of the pelvis and its relationship to the size of the infant to be delivered must be judged on a clinical basis, thus giving rise to the concept of fetopelvic disproportion. Typically, the size of the maternal pelvis is estimated clinically by manual exam- ination as a routine part of antenatal obstetrical care. During clinical pelvimetry, the anteroposterior diameters of the pelvic inlet, the shape of the sacrum, the prominence of the ischial spines (which mark the transverse diameter of the midpelvis), and the capacity of the outlet may be estimated. However, on clinical manual examination it is not possible to directly estimate the transverse diameter of the inlet or the capacity of the midpelvis. X-ray pelvimetry has been utilized when clinical pelvimetry indicates that the maternal pelvis may be small and in instances of malpresentation or arrest of labor. 10 Viewing x-ray pelvimetry films to define the pelvic shape and the measurements of the diameters of the inlet, midpelvis and outlet may be useful; however, this technique is of little assistance in accurately evaluating fetal size.!! Ultrasound determination of the fetal biparietal 323 diameter and fetal abdominal circumference may be more helpful in detecting the large fetus, but the reliability of this method may also be quest ioned 12 and at this writing has not been verified. At least in part because pelvic size must be estimated along with its relationship to the size of the fetus (and this is relatively inaccurate), x-ray pelvimetry is less commonly used today than in the past. X-ray pelvimetry use has also diminished because of a desire to limit fetal exposure to radiation. This diminution in use is demonstrated by noting that of 28 references in a chapter concerning pelvic contraction in the latest edition of an obstetric textbook, only one reference dates from the 1970's, one from the 1960's, and the majority of references relate to work prior to 1950 and some prior to the turn of the century. 1° Nonetheless, the concept of fetopelvic disproportion persists as an important concomitant of abnormal labor progress. FETAL ABNORMALITIES AND DYSTOCIA Fetal abnormalities associated with dystocia may be broken down into those cases in which the major problem is one of fetal position or presentation and those in which there is an intrinsic abnormality of the fetus which produces abnormal descent during labor. Of the malpositions and malpresentations, breech presentation is by far the most common, occurring in 3 to 4% of all delivered patients. Breech presentation, and other malpresentations or positions account for approximately 10% of the indications for cesarean delivery currently.2?? Breech presentation has been found to account for approximately 15-20% of the increase in cesarean births in five surveyed studies,’ 324 and in the materials presented elsewhere based on the CPHA and New York City data. The recent increase in utilization of the abdominal route for delivery of fetuses presenting by the breech is discussed elsewhere in this document and will not be elaborated on here. The breech presentation is discussed by itself in Chapter XV and not as a part of the subject of dystocia. Several of the other fetal abnormalities of presentation and position are discussed here in some detail. While each of these is a rare complication, the goal of the discussion is to provide specific examples of difficult intrapartum situations, for which the most approp- riate management is often cesarean delivery. MALPRESENTATIONS There are a number of clinical associations with transverse lie of the fetus. These include premature onset of labor, multiparity (specially grand multiparity), pendulous abdomen with anterior displacement of the uterus, congenital abnormality of the uterus, fetal malformation, 16,17,18,19 Apeunate fetopelvic disproportion and placenta previa. assessment of fetal presentation and position becomes increasingly important as pregnancy progresses and is particularly so in early 1abor. 20 When transverse lie is identified late in pregnancy, predispos- ing factors, such as those mentioned above, are sought. Gentle external version has been recommended to convert a transverse or oblique lie to a longitudinal lie in the presence of intact membranes. ?22 In early labor, particularly in the grand multipara, spontaneous conversion from transverse or oblique to longitudinal lie may be observed as labor begins. 325 If, however, labor continues with a fetus in transverse lie, vaginal delivery of an undamaged fetus is not possible. Should the fetal membranes rupture during labor in the presence of a transverse lie, prolapse of the umbilical cord may occur. An additional major complication is prolapse of a fetal arm with wedging of the shoulder and arm into the pelvis; this produces obstructed labor, and if unrelieved, rupture of the uterus may occur with death of both the mother and fetus. Transverse lie of a viable fetus which does not convert spontaneously to longitudinal lie by the time of evaluation in early labor is best managed by immediate cesarean delivery. 16,18,19,22,23 Internal podalic version and extraction as an alternate method for birth may result not only in trauma to the fetus with high perinatal mortality and morbidity, but may also result in rupture of the uterus.’ It is not recommended as an elective procedure in modern obstetric practice. BROW, FACE AND COMPOUND PRESENTATIONS Together, these malpresentations account for less than 1% of all vaginal deliveries, but nonetheless have received extensive attention in the obstetric literature 24-36 Brow presentation is usually unstable, converting either by flexion to a vertex (occiput) presentation or by extension to a face presentation in approximately two-thirds of cases.>’ If the brow does not convert spontaneously but persists, except in the small fetus engagement is impossible, unless marked moulding, which shortens the long occipitomental diameter, occurs. Generally the prognosis for vaginal delivery is poor and in the majority of cases with viable fetuses, cesarean delivery is warranted. 27-32 326 Face presentation is often associated with fetopelvic disproportion. Inlet contraction has been reported in as many as 39.4% of the cases. 2’ On this basis, in the presence of a face presentation careful evaluation of fetopelvic relationships is appropriate. Correct identification of 33,34 since whether the chin is anterior or posterior is crucial, delivery with the fetal chin toward the maternal back (mentum posterior) is not possible without rotation. With mentum posterior the fetal head has been extended as far as is possible. In this situation, abdominal delivery is indicated. The situation with compound presentations is different from that with brow and face presentations. Compound presentations of the fetal vertex and hand have been found to have an excellent prognosis for vaginal delivery.>? Other compound presentations, such as vertex and foot, are recognized as less favorable and more safely delivered abdominally. >? The above descriptions are presented as examples of many kinds of abnormalities of fetal position which require individual assessment upon their discovery, but which in their totality do not account for a large portion of the dystocia category. MACROSOMIA Macrosomia is a term used to indicate an excessive sized fetus. The definition of macrosomia in the literature varies with individual reports. The lower weight for macrosomia has been set at 4,082 grams,>’ 4,100 grams, >° 4,500 grams,’ or 10 pounds. 327 Regardless of the precise definition, macrosomia is recognized as being associated with a range of maternal and fetal complications, including postpartum hemorrhage, prolonged second stage of labor, 38,39 Severe neonatal depression, shoulder dystocia, and asphyxia. neurologic damage, perinatal mortality and childhood mortality have also been reported. 0 In view of the potential maternal/fetal trauma associated with this condition, cesarean delivery rates approaching 25% have been reported and the increased use of cesarean delivery in the presence of macrosomia has been suggested in order to decrease maternal and fetal morbidity.” More recent data is reviewed in the New York City experience for fetuses weighing more than 4000 grams (Chapter IX). The problem here involves the anterospective recognition of dystocia relating to excessive size of the fetus and the assessment of fetal-pelvic relationships. Although macrosomia is suggested by abdominal size, accurate fetal weight assessment in this group is notoriously poor. While ultrasound has been suggested for clinical use, it has limitations. In the macrosomic infant one must consider shoulder growth increases and not head growth alone. In addition, the use of ultrasonography during labor, on an emergency basis, is often conducted under less than appropriate circumstances and by less experienced personnel. A FUNCTIONAL CLASSIFICATION OF DYSTOCIA: THE FORCES OF LABOR An Introduction to the Classification Examination of the listings of indications for cesarean birth shows that abnormal forces of labor are cited infrequently (1% or less) as an indication for operative delivery.? Yet, clinical experience and 328 the literature indicate that this is not a rare problem. For example, the use of oxytocin has been recommended in the absence of fetopelvic disproportion as treatment for certain types of labor dysfunction which have been reported to occur in from 5 to 10% of labors. 41742 This apparent discrepancy is at least partially explained by the fact that there are currently two quite different ways of viewing abnormalities of uterine contractility. Classically, uterine dysfunction has been viewed as being either hypertonic or hypotonic. 4? Hypertonic inertia has been characterized as occurring during the latent phase of labor, as being painful to the patient, and as associated with fetal distress early in its course. Hypertonic labor is said not to respond favorably to the use of oxytocin. The use of sedation may be helpful. On the other hand, hypotonic inertia has been characterized as occurring secondarily, and in the active phase of labor. Hypotonic labor is generally not painful and is said to be less frequently associated with fetal distress, and to be responsive to oxytocin administration. The usefulness of this characterization of labor progress has 44,45 For example, based on a prospective study of been questioned. 1,000 consecutive primigravida deliveries, amniotomy followed by oxytocin infusion was advocated to simulate the progress of normal labor, unless normal labor was already evident. The total cesarean delivery rate was 4%, along with an intrapartum stillborn rate of 3 per 1,000 and a neonatal death rate of 4 per 1,000. This study is presented only as an example of the classification problem; however, the concept is questioned that there is 2 valid therapeutic distinction between hypotonic and hypertonic uterine inertia. % 329 An alternative conceptualization of normal and abnormal labor progress is based upon graphic representation of labor progress as a process occurring through time, and with statistical analysis aimed 41,42,46-49 The onset at defining abnormally slow progress. of labor is'defined historically by the onset of uterine contractions. The time, dilatation and station at each vaginal examination are recorded graphically on the square ruled cartesian coordinates, with 1 cm representing 1 hour, as well as 1 cm of cervical dilatation (0-10 cm) and 1 cm of descent (-5 to +5 station). Criteria for the phases of both dilatation of the cervix and descent of the fetal vertex have been published, as have criteria for the six major dysfunctional labor patterns, termed prolonged latent phase, protracted active phase dilatation, secondary arrest of dilatation, prolonged deceleration phase, protracted descent, and arrest of descent, 20-34 A detailed discussion of this method of both conceptualizing labor progress and diagnosing abnormalities of labor progress is beyond the scope of this discussion. However, it is important to note that this type of quan- titative assessment of labor progress has led to a more "functional" approach to labor diagnosis and management. The implications of this statement are detailed in the following section. It is also noted that there is still continuing discussion about the use of the graphic representation of labor. DYSTOCIA DEFINED FUNCTIONALLY Evaluation of the impact of a functional concept of labor progress 330 and labor dysfunction requires interpretations of the clinical practice of obstetrics in the United States that is not easily documented by literature citation. Functional definitions of abnormal labor progress, pioneered by Emanuel Friedman, are typically based upon a concept that the slowest progress experienced by a population of laboring gravidas is abnormal. Precise mathematical limits may be achieved. For example, protracted active phase dilatation is defined as cervical dilatation progressing at less than 1.2 cm per hour in nulliparous patients and less than 1.5 cm per hour in multiparous patients. While precise criteria have not been applied uniformly on all obstetric services, the concept that slow progress constitutes abnormal progress permeates current obstetric thinking, and although less easily documented may also conceptualize the patient's expectations. Thus, delivery for all patients in less than 24 hours has been advocated, as has intervention after two to four hours of poor progress in active 1abor.”® Evidence from the literature to support the value of a functional approach to labor diagnosis and intrapartum care can be advanced. The results obtained by 0'Drisco11%4 have been cited earlier in this report. Similar favorable outcomes have been obtained in the United States.’ Also pertinent to this current discussion of dystocia and cesarean birth has been the association of specific dysfunctional labor patterns (secondary arrest of dilatation, protracted descent and arrested descent) with an increased incidence of cesarean births.’>~38 For specific dysfunctional labor patterns, this increase in abdominal delivery appears warranted. For example, arrest of descent of the fetal vertex has been found to be associated with fetopelvic disproportion in 52% of 331 the cases.”’ Vaginal delivery, regardless of whether spontaneous or by midforceps, in association with protracted descent and cephalopelvic disproportion has been found to be associated with a perinatal mortality rate of greater than 120 per 1,000, compared with a 0 perinatal mortality rate for cesarean birth under the same circunstances.”® Moreover, secondary arrest of dilatation, prolonged deceleration phase and arrest of descent have been associated with a significant increase in abnormal neurobehavioral development at ages 3 and 4 in a series of 656 children.”’ Based upon data such as those presented here, the rationale for utilizing functional definitions of dystocia justifies careful considera- tion. It is also noted that the materials reported here are based almost entirely on work of one group of investigators. DYSTOCIA AND LUMBAR EPIDURAL ANESTHESIA It has been suggested that more frequent use of lumbar epidural analgesia during labor may, through its effects on the forces of labor, contribute to the increase in cesarean births. In none of the published studies of the effects of this anesthesia on labor and delivery has that outcome been well documented either in controlled or prospectively randomized studies. However, an increase in the rate of forceps use has been documented. A yet unreported study 50 of 1,955 patients from five hospitals in England and Ireland, 282 (14%) of whom received epidural block during labor and 1673 of whom did not, failed to show a difference in route of delivery. There still continues to be debate in medical circles about epidural anesthesia altering progress during labor. 332 DYSTOCIA AND INFANT MORBIDITY As discussed more completely in the introductory chapter on Fetal Considerations, infant morbidity resulting from birth trauma must be examined with respect to dystocia. However, there is a paucity of reports relating specific functional classifications of labor to infant outcomes. The mechanical interventions, such as high forceps, have long since been abandoned, along with the reputed maternal and infant morbidity which followed these procedures. As noted in the New York City experience, the incidence of all forceps use has diminished almost in parallel with a concomitant rise in the cesarean birth rate. However, despite its importance in evaluating the effect of the change in obstetric practice, we do not have infant morbidity information. This lack of infant developmental information is persistent throughout this report. SUMMARY 1. Dystocia as a definition is an umbrella-like term covering a broad range of clinical entities which may produce abnormal labor progress. 2. The term dystocia includes groups of both anatomically and functionally defined abnormal labor patterns. 3. The term dystocia may at times be used in so general or non- specific a manner that it does not meet the concept that a medical diagnosis should be a bridge leading to appropriate treatment. 4. It is likely that the differences between the frequency with which dystocia is cited as an indication for cesarean birth, 333 and the frequencies with which specific indications are cited, has accounted for this problem of definition. The indications listed for abdominal delivery for patients with these problems are often included under categories such as fetopelvic disproportion and failure to progress during labor. The increased cesarean birth rate associated with the category dystocia, and its position as a common and increasingly frequent indication, warrant concern and attention. The New York City experience, as well as numerous literature reviews, support this conclusion. As noted in the New York City experience, the diagnosis of dystocia is concentrated in the more mature (over 2500 gms) infant birth category. In that group, there is no clear survival advantage among cesarean births as compared with vaginal births with dystocia. Further, the maternal mortality ratio for dystocia is 41.9 deaths per 100,000 cesarean births as compared with 11.1 deaths per 100,000 vaginal births (see CPHA data in Chapter X - Maternal Mortality and Morbidity). Studies of infant neurologic development in relation to different methods of clinical obstetrical management of patients with the diagnosis of dystocia are rare and inadequate. 334 BIBLIOGRAPHY 10. 11. 12. 13. 14. Williams, J.W.: Obstetrics, 15th edition, edited by J.A. Pritchard and P.C. MacDonald. Appleton-Centruy-Crofts, New York, N.Y. , 1976, p. 656. Marieskind, H.I.: An evaluation of cesarean section in the United States. Final report submitted to Department of Health, Education and Welfare, June 1979, pp. 16-18. Bottoms, S.F. Rosen, M.G., Sokol, R.J.: The increase in the cesarean birth rate. N.Engl. J. Med. 302:559-563, 1980. Hibbard, L.T.: Changing trends in cesarean section. Am.J. Obstet. Gynecol 125: 798-804, 1976. Mann, L.I. Gallant, J.: Modern indications for cesarean section. Am.J. Obstet Gynecol. 135:437-441, 1979. Haddad H. Lundy, L.E.: Changing indications for cesarean section: a 38- year experience at a community hospital. Obstet.Gynecol 51:133-137, 1978. Gabert, H.A., Stenchever, M.A.: The results of a five-year study of continuous fetal monitoring on an obstetric service. Obstet Gynecol 50:275-279, 1977. Hughey, M.J. LaPata R.E., McElin, T.W., Lussky, R.: The effect of fetal monitoring on the incidence of cesarean section. Obstet Gynecol 49:513-518, 1977. Williams, J.W. Obstetrics, 15th edition, edited by J.A. Pritchard and P.C. MacDonald. Appleton-Century-Crofts, New York, N.Y. 1976, pp. 716-726. Friedman, E.A.: Labor management updated. J. Repro Med. 20:59-60. 1978. Friedman, E.A.: Evaluation and manageemnt of pelvic dystocia. Contemp. Ob.Gyn. 7:(5):155-161, 1976. Scher E.: Evaluation of cephalometry by ultrasound in breech presentation. Am.J. Obstet. Gynecol. 103: 1125-1130, 1969. Williams, J.W.: Obstetrics, 15th edition, edited by J.A. Pritchard and P.C. McDonald. Appleton-Century-Crofts, New York, N.Y. 1976, p.715. Friedman, E.A.: Arrest. disorders in Labor: Clinical Evaluation and Management, 2nd edition. Appleton-Century-Crofts, New York, N.Y. 1978, pp.102-123. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 335 Rovinsky, J.J. Miller, J.A. Kaplan, S.: Management of breech presen- tation at term. Am J. Obstet. Gynecol. 115:497-513, 1973. Bhowmik, R.N. Transverse lie. A review of 50 cases. J.Ind Med. Assoc. 49:432-435, 1967. Johnson, C.E.: Transverse presentation of fetus. J.Am. Med. Assoc. 187:642-646, 1974. Kawathekar P., Kasturilal, Srinivas P., Sudha, G.: Etiology and trends in the management of transverse lie. Am.J. Obstet. Gynecol. 117:39-44, 1973. Wood, E.D. Forster, F.M.C.: Oblique and transverse foetal lie. J. Obstet. Gyneco. Brit. Emp. 66:75-81, 1959. Wilson, L.A. Updike, G.B., Thronton, W.N., Brown, D.J.: The management of transverse presentation. Am.J. Obstet. Gynecol. 74:1257-1265, 1957. Ranney. B. : The gentle art of external cephalic version. Am. J. Obstet. Gynecol. 116:239-251, 1973. Harris, B.A. Epperson, J.W.W..: An analysis of 131 cases of transverse presentation. Am. J. Obstet. Gynecol. 59:1105-1111, 1950. Yates, M.J. Transverse feotal lie in labour. J.Obstet. Gynecol. Brit. Comm. 71:245-248, 1964. Posner, L.B. Rubin, E.J. Posner, A.C.: Face and brow presentations. A continuing study. Obstet. Gynecol. 21:745-749, 1963. Hellman, L.M. Epperson, J.W.W. Connally, F.: Face and brow presen- tation. The experience of the Johns Hopkins Hospital, 1896 to 1948. Am.J. Obstet. Gynecol. 59:831-842, 1950. Meltzer, R.M. Sachtleben, M.R. Friedman, E.A.: Brow presentation. Am. J. Obstet. Gynecol. 100:255-263, 1968. : Levy, D.L.: Persistent brow presentation: A new approach to manage- ment. South Med. J. 69:191-192, 1976. Voigt, J.C.: Brow and face presentation. Internat. Surg. 48:83-89, 1967. Kovacs, S.G.: Brow presentation, Royal Hospital for Women, Pad- dington, 1950-1965, and reveiw of literature. Med. J. Austral. 2:820-824, 1970 Ingolfsson, A.: Brow presentations. Acta Obstet. Gynaecol. Scand. 48:486-496, 1969. 2. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. 43. 44. 45. 336 Bednoff. S.L. Thomas, B.E. Brow presentation. N.Y.State J. Med. 67:803-805, 1967. Skalley, T.W. Kramer, T.F. : Brow presentation. Obstet. Gynecol. 15:616-620, 1960. Reddoch, J.W.: Face presentation. A study of 160 cases. Am.J. Obstet. Gynecol. 56:86-99, 1948. Prevedourakis, C.N.: Face presentation. Am.J. Obstet. Gynecol. 94: 1092-1097, 1966. Cruikshank, D.P. White, C.A.: Obstetric malpresentations: Twenty years' experience. Am.J. Obstet. Gynecol.116,1097-1104, 1973. Weissberg, S.M. O'Leary, J.A.: Compound presentation of the fetus. Obstet. Gynecol. 41:60-64, 1973. Posner, A.C. Friedman, S., Posner, L.B.: The large fetus. Obstet. Gynecol. 5:268-278, 1955. Golditch, I.M., Kirkman, K.: The large fetus. Obstet. Gynecol. Survey 34:137-139, 1979. Parks, D.G. Ziel, H.K.: Macrosomia. A proposed indication for primary cesarean section. Obstet. Gynecol. 52: 407-409, 1978. Sack, R.J. The large infant. Am.J. Obstet. Gynecol. 104:195-204, 1969. Friedman, E.A. Arrest disorders, in Labor: Clinical Evaluation and Management, 2nd edition. Appleton-Century-Crofts, New York, N.Y. 1978, pp. 102-123. Sokol, R.J., Stojkov, J. Chik, L, Rosen, M.G.: Normal and abnormal labor progress: I. A quantitative assessment and survey of the literature. J. Repro. Med. 18:47-53, 1977. Williams, J.W.: Obstetrics, 15th edition, edited by J.A. Pritchard and P.C. MacDonald. Appleton-Century-Crofts, New York, N.Y., 1976, pp. 658-663. O'Driscoll, K. et.al.: Prevention of prolonged labour. Brit. Med. J. 2:477-480, 1969. Barber, H.R. et al.: Views, augmented labor. Obstet. Gynecol. 39:933-941, 1972. 46. 47. 48. 49. 50. 51. 52. 53. 54. 55. 56. 57. 58. 59. 337 Friedman, E.A.: Labor management updated. J. Repro. Med. 20:59-60,1978. Friedman, E.A.: Patterns of labor as indicators of risk. Clin. Obstet. Gynecol. 16:172-183, 1973. Studd J. et.al.: Identification of high risk labours by labour nomogam. Brit. Med.J. 2:545-547, 1975. Philpott, R.H. Castle, W.M.: Cervicographs in the management of labour in primigravidae. J.Obstet. Gynecol. Brit. Comm. 79:592, 1972. Friedman, E.A.: "Labor: Clinical Evaluation & Management," 2nd edition. Appleton-Century-Crofts, New York, N.Y. 1978. Sokol, R.J. Nussbaum, R.S. Chik, L. Rosen, M.G.: Computer diagnosis of labor progression: I. Development of an on-line interactive digital computer program for the diagnosis of normal and abnormal cervical dilatation patterns. J. Repro. Med. 11:149-153, 1973. Sokol, R.J., Nussbaum, R.S., Chik, L. Rosen, M.G. : Computer diagnosis of labor progression: II. Application of an on-line interactive computer program in 45 high-risk labors. J. Repro. Med. 11:154-158, 1973. Sokol, R.J. Nussbaum, R.S. Chik, L. Rosen, M.G.: Computer diagnosis of labor progression: IV. An on-line interactive digital computer subroutine for evaluating descent of the fetal presenting part during labor. J. Repro. Med. 13:177-182, 1974. Sokol, R.J.,Nussbaum, R.S., Chik, L. Rosen, M.G.: Computer diagnosis of labor progression: V. Reliability of programmed analysis of descent of the fetal presenting part. J. Repro. Med. 13:183-186, 1974. Friedman. E.A., Niswander, K.R. Sachtleben, M..R. Ashworth, M: Dysfunctional labor: X. Delivery outcome. Amer. J. Obstet. Gynecol. 106:219-226, 1970. Friedman, E.A.: Station of the fetal presenting part: V. Protracted descent patterns. Obstet. Gynecol. 36:558-567, 1970. Friedman, E.A.: Station of the fetal presenting part: VI. Arrest of descent in nulliparas. Obstet. Gynecol. 47:129-136, 1976. Bottoms, S.F. ,Sokol, R.J., Rosen, M.G.: Short arrest of cervical dilatation: A risk for maternal/fetal/infant morbidity. Submitted for publication. Friedman, E.A., Sachtleben, M.R. Bresky, P.A. Dysfunctional labor: XII. Long term effects on infant. Am.J. Obstet. Gynecol. 127:779, 1977. 60. 338 Stredd, J.W.W., Crawford, J.S., Drignan, N.M. Rowbotham, C.J.F, Hughes, A.0.,: The effect of lumbar epidural analgesia upon cervimetric progress and the outcome of spontaneous labor. A personal communcation. Chapter XIV - Repeat Cesarean Birth 341 INTRODUCTION Noted frequently in the deliberations of this Task Force, and important among the factors leading to the increase in the cesarean birth rate in the United States, is the usual practice to deliver by repeat operation all pregnant women who have previously undergone a cesarean birth. '?2 Although this clinical practice is widespread, it is not all inclusive. The major question being asked is whether labor or elective cesarean birth is safer for the mother and fetus in pregnancy after the first cesarean birth. Controversy continues in this poorly studied, always present and hotly debated issue. The available data will be examined in this chapter. It must be emphasized, however, that most of the studies are old and may not have direct relevance to modern obstetrical and neonatal practices. ORIGINS OF THE POLICY "ONCE A CESAREAN, ALWAYS A CESAREAN" In a presentation before the New York Medical Society in 1916° Edwin Craigin said that the extension of cesarean birth to conditions other than dystocia from contracted pelvis or tumors should be "excep- tional and infrequent." He made it clear that "the usual rule is, once a cesarean, always a cesarean." At that time cesarean birth rates were less than 1% and most cesarean births were of the classical variety. Recorded more completely in Chapter III of this report, the transition to modern operative methods began with the introduction of transverse division of the anterior uterine wall at the level of the internal 4 os. The technique was first developed by Kehrer in 1881, but later reintroduced by Munro Kerr in 1921.7 Improved anesthetic techniques, 342 blood transfusions and antibiotics increased the safety of the cesarean operation. However, it was the adoption of the transverse lower segment operation that revolutionized the management of labor and delivery.® Today over 90% of cesarean operations are of the transverse low cervical type. 725 Despite these operative changes the dictum "once a cesarean, always a cesarean" continued as a stated policy in many institutions. This policy was not then, and is not today universal. There are several institutions in the United States where individualization of care with a trial of labor in a significant number of prior cesarean patients may geeur, 1011 In Europe many obstetrical services plan a trial of labor in the majority of patients with previous cesarean deliveries, 121 15:14 The practice of repeating the cesarean has been justified by two general propositions. The first proposition relates to maternal and perinatal mortality and morbidity. Rupture of the cesarean scar may occur during labor, and there is no way to predict the behavior of any uterine scar during 1abor.%7 Obstetricians are familiar with the visible evidence of scar weakness at the time of surgery, in the form of thinning of the myometrium in the scar area, or amniotic membranes protruding through the myometrium as a "window" or partial separation. Uterine rupture poses risks of severe hemorrhage, hysterectomy and sterility, and death for the mother, and oF anoxia and death for the fetus. In the second proposition, planned repeat cesarean operation has been supported 2,15-97 op. by the low operative mortality of the surgical procedure. safer the procedure became, the easier it became to make a decision to perform the cesarean. 343 THE MAGNITUDE OF THE PROBLEM As presented in detail in Chapter VIII, based on data from CPHA records, repeat cesareans contributed 27% of the overall rise in cesarean delivery rates between 1970 and 1978. In 1978 previous cesarean birth accounted for about 30% of all cesarean deliveries. Also in 1978, 98.9% of all pregnant women with a previous cesarean were delivered operatively. Since a substantial proportion of cesarean deliveries are in women who have not yet completed their families, it seems certain that the policy "once a cesarean, always a cesarean" will lead to continued increases in cesarean delivery rates. THE PROBLEMS IN STUDIES ASSESSING RUPTURE OF THE UTERINE SCAR Most of the studies of maternal and perinatal mortality following rupture of the uterus antedate modern surgical support services and neonatal intensive care units. In addition, the data are often based on rupture of the vertical scar. from classical cesarean delivery, now largely replaced by a transverse scar in modern obstetrics.>® In a recent review of the literature on rupture of the uterus following pelvic surgery, maternal mortality ranged from 0 to 26%, and perinatal mortality ranged from O to 100%2°. However, the reports reviewed in that article dated back to 1945 and may include patient data from as early as 1900. In this problem it is important to differentiate maternal and perinatal mortality by the site of previous incision (corporal or low segment), by vertical or transverse incision, and by type and definition of rupture (complete, incomplete), as well as by the recentness of the series and the associated medical problems. For example, the higher 344 incidence of rupture and the high maternal and perinatal mortality rates following uterine ruptures of the classical cesarean scar, should be separated from the lower incidence of rupture and much lower mortality rates following rupture of a transverse low segment uterine scar.” Most reports provide overall mortality data, because the numbers of cases in the divided categories are too small to be dealt with individually. 2? Fetal and neonatal mortality information provided is scanty, and in these reports neonatal mortality specific to a ruptured lower segment scar alone is rarely identified. THE CLASSIFICATIONS OF UTERINE RUPTURE There are several anatomical classifications of uterine rupture.’ Attempts have also been made to grade the severity of the rupture.”?2°126 A silent scar rupture* is classified as a completely asymptomatic rupture. Advancing grades of uterine scar rupture include those with clinical signs pointing to rupture, and those with maternal deterioration including shock. Using this system, Dewhurst 2 found that of twenty-eight uterine scar ruptures associated with maternal shock, twenty-five occurred in patients with previous low segment incisions (including low vertical). Of nineteen classical scar ruptures prior to labor, three were silent, and sixteen had clinical signs and symptoms. Of eleven lower segment ruptures prior to labor, nine were silent, and two showed clinical signs of rupture. In contrast, in another report >2 the silent or asymptomatic rupture category included rupture of a scar not diagnosed or suspected * Note that heretofore the term rupture has been used synonymously with separations of all kinds). 345 prior to operation, but with no evidence of shock, hemorrhage at the site of dehiscence, fetal or maternal mortality and no need for hysterectomy. The incomplete (or occult) uterine rupture does not extend through the entire thickness of the uterus and its peritoneal cover . 2 The imcomplete rupture is a dehiscence (myometrial separation) with little or no bleeding, gradual in occurrence, usually painless, and without extrusion of the fetus from the uterus. As noted, a complete (true) uterine rupture may be sudden, painful and a catastrophic event. 2’ Most of the dangers of uterine rupture are attributable to the rapid or as often described "explosive" complete rupture of the classical midline uterine incision. Over 90% of the ruptures following low trans- verse uterine incisions are "silent" and # incomplete”, 577126+31 Transverse low segment scar ruptures of varying severity may occur in a subsequent pregnancy or labor at rates reported from 0.1 to 1.5%.60% 10-15,25,26,31~22 Most of the reports give uterine rupture incidences between 0.25-0.50% . In a thorough English language literature review, shy 13 found no instances of maternal mortality in association with rupture of low transverse cesarean scars. THE CLASSICAL COMPARED WITH THE LOW TRANSVERSE SCAR RUPTURES The Classical Cesarean Rupture of the uterus during labor following the classical cesarean is more frequent than uterine rupture following a low transverse cesar- 26,27 Ne ea Risk of a classical scar rupture in a subsequent pregnancy 9,26,27 may vary from 0-9%. Rupture may also occur suddenly during the 346 course of pregnancy, prior to ad and before an elective repeat 26,39,40,41 po rhuret? reported cesarean birth would be scheduled. 2.2% ruptured classical scars in 762 prior classical cesarean pregnancies. However, if the patients were in labor, 4.7% of the scars ruptured. For 1530 pregnancies with previous low transverse cesarean section, the same author found uterine scar ruptures: in 0.5%. Of these, 0.8% ruptured during labor, and 1.2% were found ruptured following vaginal delivery. Rupture of the body of the uterus before or during labor may be life threatening to the mother because of the associated hemorrhage and shock. It is usually fatal to the fetus, which is often extruded into the maternal abdomen at that time. According to Dewhurst , 26 the maternal mortality associated with rupture of a classical cesarean scar is 5%. This figure was obtained from his review of the literature and reports published | between 1948 and 1956. Although modern obstetrical practices may reduce this risk considerably, there may still be a much higher maternal mortality risk than that for elective repeat cesarean of 20-70/100,000 +22 and 18/100,000 in the CPHA data presented in this report. In addition to mortality, there is a relatively high maternal morbidity, and fetal mortality and morbidity, associated with a ruptured 6,9,26,38 classical cesarean scar. For example, hysterectomy may be necessary to control hemorrhage, with consequent sterility. Today, most authors suggest that a repeat cesarean birth should be planned for all patients with a previous classical or inverted T shaped* cesarean soar®r7138 6,9,38,39 or low vertical incision and in all cases where the type of previous . 27 cesarean is unknown. * NOTE: The T-shaped incision results from beginning the surgery as a low transverse incision, but needing more room and extending the incision vertically. Thus we have the term "inverted T". 347 The Low Vertical Cesarean Unfortunately, even in the older literature there is very little data on the relative risk of uterine rupture of a vertical low segment scar. Donnelly and Franzoni reported on a thirty year experience of labor trial (1931-1961) at the Margaret Hague Maternity Hospital in New Jersey. Fifty percent of the patients with a previous cesarean delivered vaginally. The authors found a total of twenty-six cesarean scar ruptures. Ten occurred before the onset of labor, and six ruptures occurred in patients with previous classical or low vertical incisions. The remaining four ruptures occurred in patients with a previous history of two or more cesarean operations. The authors suggested mandatory repeat cesarean births for all patients with more than one previous cesarean or with previous classical or low vertical uterine incisions. Douglas’ reported on the experience at the New York Lying-In Hospital between 1933 and 1972 when vaginal delivery following cesarean was acceptable. More than 33% of cesarean patients delivered vaginally during the next pregnancy. Douglas suggested that the low vertical incision carried a risk comparable to that of the classical operation. Palerme and Friedman’ found an incidence of rupture of 2.2% in the classical uterine scars, 1.3 % in lower segment vertical scars and 0.7% in lower segment transverse scars. It is suggested that the distinc- tion between the risks for rupture of lower segment transverse and vertical scars is based on the relatively frequent extension of the lower 348 segment vertical incision into the upper segment of the uterus. F132,42 In many reports, lower segment vertical and transverse scar ruptures are not considered separately. The Lower Segment Transverse Cesarean In contrast to the classical scar, rupture of a lower segment trans- verse scar occurs less frequently during the course of pregnancy. 126129:32,41 Rupture may occur during labor, but in general a slow thinning of the myometrium at the scar site occurs. A partial scar separation (dehiscence) occurs with development of an opening in the myometrium through which amniotic membrances may be 6,7,9 visible. This may be asymptomatic. The fetus is rarely extruded into the abdominal cavity.51 2 Fetal mortality is lower than in the 9,26,40 classical rupture. Other injuries, such as rupture of the bladder requiring surgical repair, and vesicovaginal fistula, were report- . . . 6,29 ed in earlier series. TRIAL OF LABOR FOLLOWING CESAREAN BIRTH 9-11,19,32,38,43,44 In the United States and in other coun- 12,13,27,314%1,45-48 it is an acceptable practice to allow patients tries, who have had a previous lower segment transverse cesarean to labor if there are no recurrent indications for cesarean birth. Guidelines for allowing this to take place are varied, and include the absence of a recurrent indication for cesarean birth, an engaged vertex at labor onset, and a 6,10,11 normal and progressive labor. Some hospitals have required that the patient must have had only one previous cesarean, and that the previous 349 postoperative course had been without febrile morbidity, 1247 In contrast other authors have noted that previous infection did not 6,12,47 | Nn some series 19,32,43,48 prejudice the outcome in the next pregnancy. patients who underwent a cesarean for cephalopelvic disproportion were allowed a trial of labor if no dystocia was evident in the current pregnancy. In some series physicians induced or augmented labor with onybogin, 120 13:27:31,43,45,47,48 It has been suggested that rupture of the uterus following a pre- vious cesarean per formed during labor for the diagnosis of cephalopelvic disproportion is less frequent than that following cesarean delivery for other indications. 2 Reasoning in this case is that the lower uterine segment will have been thinned out, and thus the incision, placed well within the lower uterine segment, will be less likely to rupture, as when compared with the cesarean performed when little labor has taken place 3152 In the trials of labor series, cesarean birth has been repeated most often for arrest of labor, or poor progress in labor, or electronic evidence of fetal distress,’ 11145 Prompt operation has been carried out if vaginal bleeding, abdominal pain or other indications of impending uterine rupture were present. As noted earlier Douglas’ reported on a 32 year experience at The New York Hospital. Uterine rupture occurred on average one time in 1407 deliveries. A total of 84 ruptures occurred in 32 years. There were 60 spontaneous ruptures; 25 ruptures followed classical cesarean delivery and 29 followed low transverse cesareans; the remainder occurred for varied reasons. 350 There were no maternal deaths following rupture in all types of cesarean incisions. During the same period there were three maternal deaths attributable to elective repeat cesarean delivery. The ruptures after low transverse cesarean were in association with a neglected transverse lie of the fetus. During that time, at the New York Hospital, including both clinic and private practice, 33 percent of patients with previous cesarean births delivered vaginally. In a more recent report, Gibbe™® found that the frequency of low transverse uterine scar ruptures (including windows, dehiscences and frank ruptures) was the same in patients undergoing elective repeat cesarean and patients undergoing a trial of labor and vaginal delivery. Others have reported similar Findings. 5+% ADDITIONAL FACTORS TO BE CONSIDERED IN PATIENTS WITH PREVIOUS CESAREAN The basic issues relating to uterine rupture both before and during labor have already been presented. Many of the other issues to be considered in choosing the mode of delivery are discussed in other sections of this report. Among them are included the problems of anesthesia for mother and fetus, blood loss and transfusion requirements, general postoperative complications (both early and late), prolonged patient recovery time in the hospital, post=- operative infections, economic costs of surgery and the later costs in patient delay in return to work, and the problems of iatrogenic prematurity. More difficult to quantify but important in this same discussion are the benefits of a successful labor, the additional behavioral risks of a failed trial of labor, and finally the convenience of knowing when pregnancy will be terminated in an elective repeat cesarean birth. 351 MATERNAL AND PERINATAL MORTALITY Maternal mortality is a rare event. Maternal mortality is higher following cesarean birth than following vaginal delivery. Part of the overall mortality rate may be attributed to the conditions requiring the cesarean birth and part of the mortality rate is due to the operative 17,21 The general maternal figures procedure and its complications. have been discussed separately in this report in Chapters VIII, IX and X. However, clinical studies comparing maternal mortality from repeat cesarean birth with maternal mortality following a trial of labor in women with previous cesarean births are pertinent to this section. Unfortunately most studies are retrospective, old, nonrandomized, uncontrolled and usually involve very small numbers of patients. It may be difficult or impossible to perform the large prospective randomized controlled studies needed to obtain statistical significance for compara- tive maternal mortality figures, since with decreasing maternal mortality these studies will of necessity need to be extremely large. Paverstein®® examined the available data in a literature review and calculated a maternal mortality rate from uterine rupture of a low segment scar in labor of 2.5/100,000 pregnancies with a previous low transverse cesarean and 100/100,000 pregnancies from elective repeat cesarean birth. In another report, a review of the large series in the literature showed no maternal deaths in patients with low segment scar rupbures oY Again these comparisons are based on old data in uncontrolled retrosective studies. As noted in Chapter VIII, the maternal mortality rates from elective repeat cesarean at present are far lower (18/100,000 births). 352 Recently Shy et alt did a thorough review of the English literature on this subject in order to obtain data from which a decision analysis management scheme might be constructed. These authors investigated elective cesarean births and trials of labor. Hypothetical cohorts of 10,000 women with previous low transverse cesarean births were assumed. Based on numbers derived from the literature in the trial of labor group, 6,623 patients would have delivered vaginally. Uterine rupture would have occurred in 73 patients in labor. The relative risk of maternal mortality in the repeat cesarean group was 1.2 times that of the labor trial group. For the 10,000 patients with elective repeat cesarean this would mean an excess of 0.7 maternal deaths. However, if the prob- ability of vaginal delivery in a trial of labor was estimated to be very low, the advantages in terms of decreased maternal death rates disappeared. One problem with this hypothetical analysis is that it assumes that maternal mortality from elective repeat cesarean is the same as maternal mortality of these patients in labor. The data on that issue was not available to the authors in this report. An attempt was made to extract information from the literature on mortality specifically due to rupture of a low transverse scar (Table I). Only a few of the recent series provide data regarding four important items of information: (1) number of ruptures in the series, (2) number of hyster- ectomies, (3) maternal mortality and (4) perinatal mortality due to low segment rupture. This information is needed in order to permit comparisons between patients who have had elective repeat cesarean births and patients who have undergone labor trial. The same four items are necessary for 353 labor trial patients who have delivered vaginally and for those who required delivery by repeat cesarean birth. Most series contain only a small number of low segment ruptures, and 25,26,27,30,48 The confidential most report no maternal mortality. report of maternal mortality for England and Wales (1975) listed only one maternal death secondary to rupture of a low segment scar. While rupture of the low segment scar occurs infrequently, there is considerable perinatal mortality recorded in some series in which it is possible to identify mortality statistics (Table I). In a recent report by Gibbs, *’ in 1,558 patients with previous transverse lower segment cesarean birth scars, 366 patients had elective repeat cesarean deliveries and 1,192 patients were suitable candidates for a trial of labor. Of this latter group 746 delivered vaginally, and 446 patients required repeat cesarean delivery. There was no perinatal mortality due to a ruptured uterus. There were six patients with uterine rupture in the labor trial, and two patients required hysterectomy. Other trials of labor with no fetal loss due to rupture of low transverse segment scars include those of Saldana, |? Cosgrove, ** Morevwood, 27 (one fetal loss due to nuchal cord), Douglas, >> Riva,20 Birnbaum, 28 and Allshbadia.”> Table II lists a series of reports of vaginal delivery following previous cesarean birth. Trials of labor in which information is provided concerning elective and nonelective repeat cesarean delivery, and in most instances information regarding uterine rupture and maternal and perinatal mortality, are listed in Table III. With recent advances in perinatal care, including 354 electronic fetal monitoring (not used in nearly all the reported litera- ture on this subject), intrapartum fetal deaths are rare (< 1/1,000) for all patients. ® shy, 18 in his decision analysis of perinatal mortality, found that of all perinatal deaths predicted for women undergoing trial of labor after a previous cesarean, only 9.2% were related to uterine rupture. The estimated perinatal mortality attributable to uterine rupture in trial of labor was nine deaths for the cohort of 10,000 women with prior cesarean. These estimations are obtained from reviews of older literature. With modern obstetrical care these numbers may be expected to be lower. With decision analysis the expected perinatal mortality in a planned elective repeat cesarean delivery is higher than that expected in a planned trial of labor in women with previous cesarean deliveries. If perinatal deaths due to iatrogenic prematurity are eliminated, peri- natal mortality would be very similar to that in women with trial of labor. 18 This in turn will change the analysis statistics. MATERNAL AND PERINATAL MORBIDITY Maternal morbidity may be higher following an emergency cesarean birth as compared with an elective repeat cesarean. 10 In order to adequately compare the morbidity between cesarean and trial of labor patients, an analysis of morbidity should include information with respect to (1) the cesarean birth without a trial labor, (2) the cesarean birth after unsuccessful trial of labor, and finally (3) the vaginal delivery following 4 trial of labor. Gibbs 5 in a recent report found that febrile morbidity was higher in the patients who delivered abdominally after a trial of labor. 355 Maternal morbidity, including transfusions, febrile morbidity, endometritis and wound infection, was lowest among the two-thirds of the trial of labor patients who delivered vaginally. Only three of 1558 gravidas suffered an unplanned loss of fertility. Uterine rupture occurred with similar frequency in all three groups (0.5-1%). One abdominal hysterectomy was per formed in each of the three groups. Abdominal hysterectomy is uncommon in patients undergoing trial of labor after previous low transverse cesarean delivery. Murphy 12 reported incidences of 5/2479 or approximately 1/500. Four out of the five uterine ruptures requiring hysterectomy occurred in grandmultiparous patients. The fifth rupture occurred in a patient who had dehiscence of the uterine scar which had been repaired during a previous repeat cesarean delivery, and that in the subsequent pregnancy required a hysterectomy. In the New York Lying-In Hospital’ out of all 84 uterine ruptures in patients delivered with previous cesarean scar, eight hysterectomies were per formed. All eight hysterectomies followed rupture of classical cesarean scars. Blood transfusions, endometritis, abdominal wound infections, thromboembolic phenomena, anesthetic complications, pyelonephritis, pneumonia, septicemia and other measures of maternal morbidity were less common in the group with vaginal delivery following previous low transverse cesarean birth than in the repeat cesarean group.819,10,33,43 It is noked that most reports did not compare the maternal morbidity for all the above morbidity criteria. The significance of the possible increase in maternal morbidity in cesarean birth patients following a 356 trial of labor (as reported by Merrill and Gibbs '0) needs careful evaluation. shy 18 in his decision analysis estimated that if the probability of a vaginal delivery in a trial of labor after previous cesarean delivery is low (less than 0.4467), the risk of maternal mortality may be greater with a trial of labor than with an elective repeat cesarean delivery. Unfortunately there are insufficient data in the literature for a similar analysis on maternal morbidity. SUMMARY 1. In the United States, following a previous cesarean birth, nearly all women undergo a repeat cesarean delivery of any subsequent pregnancy. 2. About 30% of all cesarean births in the United States today are performed for the indication of previous cesarean. 2 The practice of routine repeat cesarean began in the early 1900's when almost all cesarean births were by the classical technique. 4. Although the information was obtained at the beginning of this century, it would appear that maternal and perinatal mortality with vaginal delivery following a classical cesarean birth is higher than the maternal and perinatal mortality with a repeat cesarean birth. Be Today in the United States over 90% of the cesarean deliveries employ the low transverse technique. 6. With any uterine scar there is a small but definite risk for rupture in the next pregnancy. %- Ruptures of lower segment transverse uterine scars in the next pregnancy are uncommon, often incomplete, sometimes silent and not predictable. 10. 357 The literature review of uterine rupture indicates that the conse- quences following lower segment transverse incisions are less serious as compared with the classical cesarean scar. The literature on maternal and perinatal mortality resulting from trial of labor and vaginal delivery in patients with previous cesarean birth is often incomplete. The data on outcome of trial of labor in more recent times is limited. Prospective randomized studies of trials of labor as compared with repeat cesarean birth have not been performed. 358 TABLE I Mortality Due to Low Segment Cesarean Scar Rupture Maternal Mortality Perinatal Mortality Deaths/Ruptures % Dewhurst (26) 0 6/48 12 1/2% 0'Driscoll (41) 0 96/ 30% 920% Muller (49) 0 0/13 % Schrinsky (25) 0 1/9 1% Salzman (32) (Not Stated) 4/13 31% Donnelly (38) 0 1/8 12 1/2% Morewood (47) 0 0/0 (or 0/4 partial ruptures or dehiscences) McGarry (12) 0 1/1 100% * Perinatal deaths - numbers reported with no details and no information . on whether they were related to uterine scar ruptures. Murphy (13) O'Driscoll (41) Donnelly (38) Douglas (34) Salzman (32) 359 TABLE II Vaginal Delivery After Cesarean Birth Repeat cs _Cs Vag Rupt 2479(LSCS) 1099 1380 29 3798(LSCS) 1628 2170 30 2905(CL&LS) 1419(CL&LS) 1486 8 (LSCS) 2094(CL&LS) 1314 780 8 (LSCS) 4000(CL&LS) 13 {LSCS) * May not all be due to uterine rupture ** 2 maternal deaths; no uterine rupture; deaths unrelated to route of delivery Mat Peri Hyst Mort Mort Ej 0 5% 0 6% 0 1 ox* 0 Not 4 Listed # Gibbs (43) 1558 Saldana (11) 226 Morewood (47) 423 McGarry (12) 415 Jeffcoate (37) 1513 Allahbadia (35) 565 LCSC El Repeat 366 81 180 81 570 255 Trial of Labor After Previous Cesarean Birth TABLE III Trial Nig Rupt Hyst Mat Peri 1192 446 3 1 0 0 145 87 0 0 0 0 243 72 0(3d) © 0 0 334 92 0(3d) 0 0 943 126 10 0 310 9 0 0 0 *1 loss due to route of delivery not due to rupture d= dehiscence Vag 746 58 171 242 817 301 Rupt Hyst Mat PM 3 0 1 0 0 0 0 0 0 (1 nuchal cord) 1 Not Listed ox 09¢ 361 BIBLIOGRAPHY 1. 10. 1. 12. 13. 14. 15. 16. 17. Obstetrical Practices in the United States, 1978: Hearing before the Senate subcommitee on health and scientific research of the committee on human resources, United States Senate. Washington, D.C., Government Printing Office, 1978. Bottoms SF, Rosen MG, Sokol RJ: The increase in the cesarean birth rate. New Eng J Med, 302:559-563, March 6, 1980. Craigin, EB: Conservatism in obstetrics. N Y Med Journal: Vol. CIV, July 1, 1916, 1-3.. Kehrer FA: Ueber ien modifiziertes verfahren beim kaiserschnitte, Arch Gynaekol, 19:177,1882. Kerr, JMM, The lower uterine segment incision in conservative caesarean section. J Obstet Gynecol Br Emp, 28:475-487, 1921. Case BD, Corcoran R, Jeffcoate Sir Norman, Randle GH: Caesarean section and its place in modern obstetric practice. J Obstet and Gynaecol of the British Commonwealth. 78:203-214, 1971. Pritchard JA and MacDonald PC: Injuries to the birth canal. Williams Obstetrics 15th Ed. New York, Appleton-Centruy Crofts, 1976. 727-743. Lowe JA, Klassen DF, Loup RJ: Cesarean section in U.S. Pas Hospitals. PAS Report, 14: 1, 1976. Douglas RG, Stromme WD (Ed): Cesarean Section: Operative Obstetrics. Third Ed. Appleton-Century-Crofts, New York, pp. 618-675, 1976. Merrill BS, Gibbs CE: Planned vginal delivery following cesarean section. Obstet Gynecol, 52:50-52,1978. Saldana LR, Schulman H and Reuss L: Management of pregnancy after cesarean section. Am.J. Obstet.Gynecol.135:555-561, 1979. McGarry JA: The management of patients previously delivered by cesarean section. J Obstet Gynecol Brit Commonwealth, 76:137-143,1969. Murphy H: Delivery following caesarean section. Ten years' experience at the Rotunda Hospital, Dublin. J of the Irish Med Assoc, Vol. 69,No.20:533- 534,December 18,1976. British Births 1970, Vol 2: Obstetric care, ed. Chamberlain G, Phillio E, Howlett B. London Heinemann Medical Books, 1978, 135. Jones OH: Cesarean section in present-day obstetrics. Am.J. Obstet.Gynecol. 126: 521-530, 1976. Hinselmann M. Roemer VM, Ramzin M and Kaser 0: Maternal and neonatal risk at caesarean section. Contrib.Gynecol.Obstet., 3:125-129, 1977. Petitti D, Olson RO and Williams RL: Cesarean section in California-1960 through 1975. Am.J. Obstet.Gynecol. 133: 125-129, 1977. 18. 19. 20. 21. 22. 2%. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34 362 Shy K: Evaluation of elective cesarean section as a standard of care: an application of decision. Am J Obstet Gynecol (Accepted for publication). Schmitz HE, Gajewski CI: Vaginal delivery following cesarean section. Am J Obstet Gynecol, 61: 1232-1242, 1951. Riva HL and Teich JC: Vaginal delivery after cesarean section. Am. J. Obstet.Gynecol. 81: 501-510, 1961. Peel J and Chamberlain GVP: Cesarean section 1949-64, Journal of Obstet- rics and Gynaecology of the British Cmmonwealth, 75: 1282-1286, 1968. Evrard JR and Gold EM: Cesarean section and maternal mortality in Rhode Island. Obstetrics and Gynecology, 50: 594-597, 1977. Pauerstein CJ: Once a section, always a trial of labor? Obstet Gynecol 28: 273, 1966. Sloan D: Inconclusive conclusion. Amer J Obstet Gynecol, 101: 133-136,1968. Schrinsky DC and Benson RC: Rupture of the pregnant uterus. A review. Obstetrical and Gynecological Survey, 33: 217-232, 1978. Dewhurst CJ: The ruptured caesarean section scar Journal of Obstetrics and Gynaecology of the British Empire, 64: 113-118, 1957. Menon MKK: Rupture of the uterus. Journal of Obstetrics and Gynaecology of the British Empire, 69: 18-28, 1962. Birnbaum SJ: Postcesarean obstetrics: management of subsequent pregnancy. Obstetrics and Gynecology, 7: 611-618, 1956. Lawson JB and Ajabor LN: Ruptured caesarean section scar. Journal of Ob- stetrics and Gynaecology of the British Commonwealth, 75: 1296-1300, 1968. Ferguson RD and Reid DE: Rupture of the uterus: A twenty-year report from the Boston Lying-in Hospital, American Journal of Obstetrics and Gynecology, 76: 172-180, 1958. Klufio CA, ARkutu ARA, Bentsi-Enchill KK: The outcome of pregnancy and labour following previous caesarean section at the Korle Bu Teaching Hospital, Ghana Medical Journal, June, 1973, 150-160. Salzmann..B: Rupture of low segment cesarean section scars. Obstet Gynecol. 23: 460-466, 1964. Sutherst JR, Case BD: Caesarean section and its place in the active approach to delivery. Clinics in Obstet Gynaecol, Vol.2, No. 1: 241. Douglas RG, Birnbaum SJ and Macdonald FA: Pregnancy and labor following cesarean sectin. American Journal of Obstetrics and Gynecology, 86: 961-971, 1963. 25. 36. 37. 38. 32 40. 41. 42. 43. a4. 45. 46. 47. 48. 49. 50. 363 Allahbadia NK: Vaginal delivery following cesarean section. American Journal of Obstetrics and Gynecology, 85:241-249, 1963. Parer, JT: Fetal heart rate monitoring, Lancet, Sept 22, 1979, 632. Jeffcoate, TN: Caesarean section South African Journal of Obstetrics and Gynecology 16-21, 1969. Donnelly JP, Franzoni KT: Uterine rupture: a 30 year survey. Obstet Gynecol, 23:774-774,1964. Palerme GR, Friedman EA: Rupture of the gravid uterus in the third trimester. Am J Obstet Gynecol, 94: 571, 1966. McLane CM: Delivery through natural passages following cesarean section. Am J Obstet Gynecol, 20: 650, 1930. O'Driscoll K: Rupture of the uterus. Proceedings of the Royal Society of Medicine, 59: 65-66, 1966. Shreve RW, Russo IN: Rupture of the uterus. Gynecology and Obstetrics Vol. 2 Sciarra J. J. (Ed) Chapter 80,1-10, 1979. Gibbs CE. Planned vaginal delivery following cesarean section. Clin Obstet Gynecol, 23:507-515, June 980. Cosgrove RA: Management of pregnancy and delivery following cesarean section. Journal American Medical Association, 145: 884-888, 1961. Kuah KB. Labour and delivery after caesarean section. Aust N Z J Obstet Gynaecol. 10:145, 1970. Baldwin WF: The repeat caesarean section. A study of 616 cases from the Vancouver area. Canadian Medical Association Journal, 77:329-335, 1957. Morewood GA, O'Sullivan MJ, McConney J: Vaginal delivery after cesarean section. Obstet Gynecol. 42:589-595, 1973. Browne ADH, McGrath J: Vaginal delivery after previous cesarean section. J Obstet Gynaecol Brit Comwlth, 72: 557-563, 1965. Muller PF, Heiser W and Graham W: Repeat cesarean section. American Journal of Obstetrics and Gynecology, 81:867-876, 1961. Editorial: Should childbirth be a cutting experience? Lancet 1980,1: 406. Chapter XV - The Problem of the Breech Presentation 367 INTRODUCTION The epidemiologic data relating to breech presentation has been presented in Chapter IX, The New York City Experience. In this chapter the literature is reviewed to present the many different clinical obstetrical problems inherent in considering the mode of delivery for the fetus in breech presentation. As noted earlier, breech presentation constitutes one of the four major factors responsible for the rapidly increasing rate of cesarean birth in the United States.]2 The reason most often cited for the increased rate of cesarean delivery for breech presentation is evidence obtained from retrospective studies that neonatal and perinatal mortality and morbidity tates” 5 and subsequent neurologic donomnalities > are significantly higher in breech presentations than in cephalic presentations. This is particularly evident when breech delivery is by the vaginal route. Prematurity, malformations, associated complications such as placenta previa, and the risk of trauma and/or asphyxia inherent in the breech delivery are all factors contributing to this increased risk. However, even when corrected for the increased incidence of prematurity and congenital abnormalities among breech deliveries, mortality and morbidity rates are still greater for breech than for cephalic births. For example, Brenner and sssocites’ assessed the dangers of breech delivery. In a retrospective study, 1,016 consecutive singleton breech deliveries were compared with 29,343 non-breech singleton 368 deliveries during the years 1962 through 1969 at MacDonald House in Cleveland, Ohio. The overall perinatal mortality rate for breech delivery was 25.4% as compared with 2.6% for non-breech birth. At every stage of gestation, even when infants with congenital abnormalities incompatible with life were excluded, antepartum, intrapartum and neonatal deaths were significantly greater among breech deliveries when compared with nonbreech deliveries. Excluding fetal deaths prior to the onset of labor, the perinatal mortality rate for breech fetuses of 32 weeks gestation or greater was 3.2% for those delivered vaginally, while it was zero for those delivered by cesarean. While these numbers seem to speak clearly in favor of cesarean births, retrospective reports such as this have inher- ent study design problems including nonrandomized reasons for the choices for route of birth. Analysis of studies of breech delivery is also made difficult by the increased incidence of breech presentation in the lowest birth weight categories where unfavorable outcomes may be due to many factors other than mode of delivery. Other problems include the different types of breech presentation (frank, complete, single or double footling, etc.), the increased incidence of congenital anomalies associated with breech presentation, and the influence of maternal pelvic size on ease of vaginal breech delivery. Furthermore, physician choice based on expected fetal viability may affect outcome:in the lowest birth weight groups. If the physician expects that a fetus may be viable, treatment is different and outcome is improved. Thus the problem of assessing outcome in the breech presentation is complex. 369 THE PREMATURE BREECH Because of the effect of prematurity on fetal outcome, it is helpful to differentiate between the premature breech and the term breech in assessing the role of cesarean birth in breech delivery. Problems associated with vaginal delivery which are special to the premature breech include (1) traumatic birth injuries from incomplete cervical dilatation with entrapment of the relatively large aftercoming head, (2) increased vulnerability of the brain to both trauma and asphyxia, and (3) the increased incidence of umbilical cord accidents. To avoid these complications many investigators have suggested that cesarean birth should be the delivery method of choice. 10-12 However, there are no randomized and controlled prospective studies comparing vaginal vs. abdominal delivery of the breech presentation fetus weighing less than 2500 grams. Inherent difficulties with the reported retrospective studies include the unknown circumstances surrounding the decision to deliver a premature breech by the vaginal route, and the unknown methods used to monitor labor and conduct delivery (i.e. types of anesthesia, use of Piper forceps, electronic monitoring, etc.). In a recent editorial, Cruikshank and Pitkin? reviewed several retrospective studies bearing on the question of how the premature breech should be delivered and concluded that there was no proof for the concept that cesarean birth was the optimal method for delivery. Since this editorial, Duenhoelter and associates 1B have reported a paired 370 controlled but still retrospective study of 88 singleton fetuses weighing between 1000 ‘and 2499 grams and presenting as breech. Excluded from this study were cases with obstetric complications known to influence perinatal morbidity and mortality. Seven of the 44 fetuses who were delivered vaginally died (15.9%) compared to one of 44 (2.3%) delivered by cesarean. Asphyxia was more frequent in the vaginal than in the abdominal delivery group and vaginal delivery was more commonly associated with birth trauma and intracranial hemorrhage. Another recent study by Ingemarsson and associates’ suggested that cesarean delivery would significantly lower both death and long term morbidity in premature infants presenting as breeches. These investigators conducted a prospective study evaluating the frequency of developmental and neurologic abnormalities in 42 consecutive premature breech infants delivered by cesarean in Sweden during the years 1975 and 1976. Long term follow-up findings in these infants were compared with a control group of 48 infants presenting as breech and delivered vaginally in the years 1971-1974. Abdominal delivery significantly reduced the frequency of severe prolonged asphyxia. Neonatal mortality was reduced from 14.6% to 4.8%. At 12 months of age, 24% of those infants delivered vaginally had developmental or neurological abnormalities as compared with 2.5% of those delivered by cesarean. Although this is a prospective study for the cesarean delivered breech, it is retrospective for the vaginally delivered breech. In addition, as the authors point out, obstetrical practices and newborn care had changed during the two sequen- tial time periods of the study. 371 Finally, there is some suggestive evidence to indicate that mortal- ity and morbidity for the premature breech delivered vaginally may not 2,%4-16 4, , retrospective be the same for all weight categories. study, Bowes, et al.2 reported that there was no difference in survival between cesarean and vaginally delivered premature fetuses presenting as breech and weighing between 1501 and 2500 grams, whereas for the very low birth weight infant (less than 1501 grams) cesarean appeared to be safer than vaginal delivery. The New York City data indicate that in the ten year period, 1967-1977, large decreases occurred in neonatal mortality among infants in the breech presentation weighing less than 2501 grams. These decreases accompanied large increases in the cesarean delivery rate among this group. In the same period, however, there were decreases in the neonatal mortality rate of all infants weighing less than 2501 grams, regardless of presentation. Thus there is the possibility that other conditions besides the management by cesarean delivery contributed to lowered mortality among breech presentations. Further, in 1976-1977, in New York City, neonatal mortality across 500 gram birth weight groups less than 2501 grams was not consistently lower SO infants in the breech presentation delivered by primary cesarean birth compared with those delivered vaginally. THE TERM BREECH Rovinsky and associates’ at Mount Sinai Hospital in New York retrospectively analyzed the pregnancy outcomes of 2,145 cases of term singleton breech presentations delivered during the years 1953 through 372 1970. Term delivery was defined as the delivery of an infant weighing 2500 grams or more. The 3.17% perinatal mortality rate for the term breech infants was approximately 4 times greater than the 0.84% perinatal mortality rate for vertex presentations at term. Breech presentation and/or delivery was thought to be an important factor in one-third of the perinatal deaths (24 cases). Of these perinatal deaths, intrauterine asphyxia accounted for 13, traumatic delivery for 8, and pulmonary complications for 3 deaths. There were no perinatal deaths attributable to either the breech presentation or the breech delivery among the 425 infants delivered by cesarean birth, although overall neonatal traumatic morbidity was still 5 times higher than for vertex presentations. The authors noted that mortality and morbidity rates from trauma were higher when less experienced physicians conducted the delivery. From this study, Rovinsky and associates concluded that in retrospect the deaths of 17 infants at term or about 1% of all term breech infants would have been prevented by cesarean birth. Rovinsky, et al.? also addressed the specific problems of umbil- ical cord prolapse and of fetal distress of undetermined etiology as they related to the type of breech presentation. When both these problems were combined as "asphyxia", some degree of intrauterine asphyxia occurred in approximately 10% of all term breech deliveries. This complication was twice as frequent in the complete or footling breech (17%) as compared to the frank breech (8%). The associated perinatal mortality rate was twice as high in the complete breech, 80.5 vs. 45.1 per 1000 deliveries for the frank breech. 373 More recently, Lyons and Papsin’’ through careful selection of cases for vaginal delivery achieved a corrected perinatal mortality rate of zero for 213 breech deliveries of infants weighing over 2500 grams. In this series, cesarean delivery was performed in 58% of all breech presentations. Perinatal morbidity was greater for vaginal delivery (6.7%) when compared with cesarean birth (0.8%). Morbidity included one infant with a fractured humerus, one baby with seizures during the neonatal period, 2 babies with cerebral palsy and 2 with low Apgar scores who were normal at discharge. Only one infant delivered by cesarean birth demonstrated morbidity, and this was a low five-minute Apgar score. Maternal morbidity was 7.9% in the vaginal group compared to 23.4% in the abdominal deliveries. Collea and colleagues!’ have recently reported similar results from a prospective randomized study of women in labor at term with frank breech presentations. Of 115 women who were randomly selected as candidates for vaginal delivery, 52 or 45% were promptly excluded and delivered by cesarean birth because of possible pelvic disproportion based on x-ray pelvimetry. Three women delivered vaginally before x-ray pelvimetry could be obtained. One of these 3 women delivered an infant who died of lethal congenital anomalies. This was the only perinatal death in the study. Of the remaining 60 patients, 49 delivered vaginally and 2 of these infants sustained injury to the brachial plexus. The other 11 patients were delivered by cesarean, 9 for failure to progress in labor and 2 for acute fetal distress. Of the 93 women randomized to the elective cesarean group, 5 delivered vaginally without complications 374 before cesarean birth could be accomplished. There were no maternal deaths, but 73 or 49.3% of the 140 women delivered by cesarean experienced morbidity (14 required blood transfusions, and 2 required hysterectomy). Only 4 (6.7%) of the 60 women delivered vaginally had postpartum morbidity. In summary, these authors concluded that (1) carefully selected cases of term frank breech presentation can be delivered vaginally with a minimum of risk for both mother and infant, and (2) although perinatal morbidity occurs with vaginal delivery, the significant maternal complications of elective cesarean birth make cesarean birth for all term frank breech infants an unattractive policy. This view is supported by the New York City experience. There, in the face of large shifts to cesarean delivery of infants in the breech presentation weighing 2501 grams or more, there was overall no decrease in neonatal mortality during that 10 year experience. BREECH PRESENTATION AND A HYPEREXTENDED HEAD In the past decade several studies have documented the fetal risks of vaginal delivery of the fetus when presenting as a breech with marked hyperextension of the fetal head. Caterini and gssociates'® analyzed the pregnancy outcome of 108 fetuses with this complication (101 from a review of the literature and 7 of their own) and found that 13.7% of 73 infants delivered vaginally died, as compared with no deaths in those infants delivered by cesarean birth. In addition there was a total of 15 or 20.6% medullar or vertebral injuries and 5 meningeal hemorrhages in those infants delivered vaginally. Because vaginal delivery may result in considerable injury to the spinal cord, as reemphasized by Abrams and 375 associates'’ and Bhagwanani and associates, 2 radiologic evidence of marked hyperextension of the fetal head after labor has been established is considered to be a firm indication for cesarean birth by most investigators. SUMMARY 1. A breech birth via either the vaginal or abdominal route is associated with an increase in both morbidity and mortality when compared with vertex presentation. When considering the route for delivery of the fetus presenting as breech, problems relating to fetal maturity, congenital anomalies, fetal size, type of breech presentation, and pelvic size unk e considered. Most studies of infant morbidity and mortality associated with vaginal delivery of the breech are retrospective in nature. Controlled prospective and randomized prospective studies are uncommon. Debate surrounding the method of delivery for the fetus presenting as breech continues and is influenced by the described complexities and lack of definitive information on later infant development. It is apparent from a literature review that the choice for cesarean birth is complicated by the additional maternal morbidity and mortality of the operative procedure when compared with vaginal delivery. It is also apparent that most reviews of breech births suggest that abdominal delivery may be associated with less risk to the premature fetus. This issue remains less clear with respect to the term 7. 376 frank breech delivery. For many of the above reasons, there appears to be a continuing trend toward delivery of breech presentations by cesarean birth. 377 BIBLIOGRAPHY 1. 10. 1. 12. Hibbard, L.T.: Changing trends in cesarean section. Am. J. Obstet. Gynecol. 125:798-803, 1976. Bowes, W.A., Taylor, E.S., O'Brien, M., and Bowes, C.: Breech Delivery: Evaluation of the method of delivery on perinatal results and maternal morbidity. Am. J. Obstet. Gynecol. 135:965-970, 1970. Brenner, W.E., Bruce, R.D., and Hendricks, C.H.: The character- istics and perils of breech presentation. Am. J. Obstet. Gynecol. 118:700-709, 1974. Rovinsky, J.J., Miller, J.A., and Kaplan, S.: Management of breech presentation at term. Am. J. Obstet. Gynecol. 115:497-513, 1973. Franu, S.: Fetal mortality and morbidity following breech delivery. Acta Obstet. Gynecol. 56(S), 1976. - Kauppila, 0.: The perinatal mortality on breech deliveries and observations on affecting factors. Acta Obstet. Gynecol. Scand. 33(8), 1975. Ingemarsson, 1., Westgren, M., and Svenningsen, W.W.: Long-term follow-up of preterm infants in breech presentation delivered by cesarean section: A Prospective study. Lancet 2:172-175, 1978. Alexopoulos, K.A.: The importance of breech delivery in the path- ogenesis of brain damage: End results of a long-term follow-up. Clin. Ped. 12:248-249, 1973. Fianu, S. and Jackson, I.: Minimal brain dysfuction in children born in breech presentation. Acta Obstet. Gynecol. Scand. 58: 295-299, 1979. Duenhoelter, J.H., Wells, C.E., Reisch, J.S., Santos-Ramos, R., and Jimenez, J.M.: A paired controlled study of vaginal and abdominal delivery of the low birth weight breech fetus. Obstet. Gynecol. 54:310-313, 1979. Lyons, E.R. and Papsin, F.R.: Cesarean section in the management of breech presentation. Am. J. Obstet. Gynecol. 130:558-561, 1978. Galdenberg, R.L. and Nelson, K.G.: The premature breech. Am. J. Obstet. Gynecol. 127:240-244, 1977. 13. 14. 15. 16. 17. 18. 19. 20. 378 Cruikshank, D.P. and Pitkin, R.M.: Delivery of the premature breech. Editorial. Obstet. Gynecol. 50:367-369, 1977. Mann, L.I. and Gallant, J.M.: Modern management of the breech delivery. Am. J. Obstet. Gynecol. 134:611-614, 1979. Karp, L.E., Dorney, J.R., McCarthy, T., Meis, P.J., and Hall, M.: The premature breech: Trial of labor or cesarean section? Obstet. Gynecol. 53:88-92, 1979. Milligan, J.E. and Shennan, A.T.: Perinatal management and outcome in the infant weighing 1000 to 2000 grams. Am. J. Obstet. Gynecol. 136:269-272, 1980. Collea, J.V., Chein, C., and Quilligan, E.J.: The randomized management of term frank breech presentation: A study of 208 cases. Am. J. Obstet. Gynecol. 137:235-241, 1980. Caterin, H., Langer, A., Sama, J.C., Devanson, M., and Pelosi, M.A.: Fetal risk in hyperextension of the fetal head in breech presentation. Am. J. Obstet. Gynecol. 123:632-636, 1975. Abrams, I.F., Bresman, M.J., Zuckerman, J.J., Fischer, E.G., and Strand, R.: Cervical cord injuries secondary to hyperextension of the head in breech presentations. Obstet. Gynecol. 41:369-378, 1973. Bhagwanani, S.G., Price, H.V., Laurence, K.M., and Ginz, B.: Risks and prevention of cervical cord injury in the management of breech presentation with hyperextension of the head. Am. J. Obstet. Gynecol. 115:1159-1161, 1973. Chapter XVI - Fetal Distress 381 A CLINICAL DISCUSSION OF FETAL DISTRESS AND CESAREAN BIRTH BACKGROUND At times fetal distress may require an emergency cesarean birth. Alberman reports that 30% of stillbirths and early neonatal deaths may be attributable to intrapartum vents.) More recent research indicates that the number of infants damaged during labor and delivery is far less than was indicated by earlier case-control studies. 1° Between 20 and 40% of cerebral palsy, and 10% of severe mental retardation are currently attributable to intrapartum factors. ? In addition to its neurologic effects (see also Chapter V), intrapartum asphyxia has also been associated with respiratory failure,r?r% 7s 2510, 71 coagulation 14,15,16 myocardial failure, 12,13 renal dysfunction, abnormalities, and metabolic abnormalities. The mag- nitude of these problems is difficult to quantify. Thus, intrapartum events continue to be an important focus for the prevention of fetal death and damage. THE DEFINITION OF FETAL DISTRESS Fetal distress during labor is a condition resulting from inadequate fetal oxygen supply and carbon dioxide removal, which produce fetal acidosis. Operationally, fetal distress is defined by clinical signs found during labor. These may include: (1) passage of or the presence of meconium; (2) bradycardia (fetal heart rate <100 beats per minute); 382 (3) absence of or diminished beat-to-beat variability during electronic fetal heart rate monitoring; (4) late fetal heart rate decelerations; (5) severe variable fetal heart rate decelerations; and (6) two consecutive scalp blood pH determinations less than 7.25 (in the presence of a normal maternal acid-base status). It is clear that the diagnosis of fetal distress during labor is not easily made clinically, or with the use of any single physiologic variable or predictor. In some instances infants predicted to be normal may have in fact experienced fetal distress and are depressed at birth. On the other hand, some infants predicted to be distressed appear normal at time of birth. Part of this lack of sensitivity and specificity may relate to the available monitoring techniques. Some of this predictive failure may also relate to the process of patient treatment when fetal distress is suspected. For example, if treatment of the suspected cause of fetal distress is appropriate, the correction of that distress may restore the fetus to a normal or nondistressed state. The fetus or neonate then appears normal, and the predictive test appears in error. Thus, the question arises - was this a failure in predictive techniques, or a success in the intervention procedure? The diagnosis of fetal distress must also be influenced by the maternal and fetal antenatal course. For example, fetuses that are growth retarded in utero are more at risk for fetal distress during labor as a result of this pre-existing stress. 383 Deciding to intervene during labor by means of a cesarean birth to alleviate the fetal distress requires careful attention to all available information. However, when failure of in utero treatment efforts is evident, and the fetus cannot be delivered safely via the vaginal route, an emergency cesarean may be performed. Allowing the fetus to remain in utero under conditions of continuing fetal distress increases the risk for fetal death or damage. In certain conditions (placenta previa, abruptio placenta, prolapsed umbilical cord) the risk for fetal jeopardy may be so overwhelming that the delivery must be performed even before all the confirmatory diagnostic measurements may be made. In such instances, even the utilization of appropriate diagnostic techniques will not always insure successful perinatal outcome. Outcome after intrapartum asphyxia may be strongly influenced by the vulnerability of the fetus, as for example in the case of the low birth weight fetus which is more vulnerable to asphyxia than the term fetus. 17718 THE PROBLEM OF PROSPECTIVE DIAGNOSIS OF FETAL DISTRESS As noted earlier, the issue of fetal distress and monitoring has been thoroughly reviewed recently by the NICHD Task Force on Predictors of Fetal Distress.2 A brief review is included here by way of making this report more understandable and complete. Electronic fetal heart rate monitoring has emerged as the most effec- tive screening technique available for detecting the fetus which is either 384 already asphyxiated or at risk for intrapartum rypoxia. 12748,21,22 Heart rate interpretation can be divided into "normal" and "abnormal" patterns. The strength of the normal pattern is that it signifies a well-oxygenated fetus with a high degree of accuracy. In contrast, the abnormal patterns are not as readily interpreted, because in a large number of cases the fetus with an "abnormal" 2” pattern is, in fact, delivered in normal condition. Certain recorded fetal heart rate decelerative patterns suggest stress to that fetus. If the fetal heart rate beat-to-beat variability remains normal, the fetus is usually vigorous at delivery. In the face of a heart rate pattern associated with loss of beat-to-beat variability, the fetus is more likely to be distressed. This pattern is managed appropriately by using fetal scalp blood sampling to provide more precise information on fetal status, or by rapid delivery.2? An abnormal pattern with absent heart rate variability and profound heart rate decelerations can be termed a sinister pattern; under such conditions fetuses are generally depressed at birth, so immediate delivery is indicated. Little additional information may be gained by scalp blood sampling. Another example in which immediate delivery may be indicated is the fetus with evidence of intrauterine growth retardation and abnormal fetal heart rate patterns appearing early during labor. Such patterns are ominous and immediate delivery under those circumstances is indicated. In this instance the appearance of intrapartum distress in a fetus already at risk suggests that the fetus cannot tolerate the process of labor. 385 During labor fetal tachycardia or bradycardia or decreased heart rate variability as isolated signs are not necessarily indications of fetal distress or hypoxia. These signs assume more ominous significance if they are associated with periodic late or severe variable FHR decelera- tions. In either event, if possible, a fetal blood sample should be obtained in an effort to define the fetal condition more accurately. 2? Interven- tion for prolonged FHR deceleration should be considered in the face of progressive acidosis as determined by serial fetal scalp blood sampling and/or the persistent absence of variability of the heart rate. Meconium staining of the amniotic fluid is suggestive, but rarely 25,26,27 Its presence should be used as diagnostic, of acute hypoxia. an indication for fetal heart rate monitoring and/or scalp blood sampling to determine the existence of asphyxia. In addition, because of the risk of meconium aspiration, the obstetrician should be certain that adequately trained personnel and all required equipment for neonatal resuscitation are present in the delivery room, whether the delivery is accomplished by the abdominal or vaginal route. The fetal condition may also be altered or compromised by a Variety of non-asphyxial related insults such as physical trauma, maternally administered drugs, or the presence of an in utero infection. These events may not be reflected in the fetal heart rate pattern or scalp pH. INTERVENTIONS FOR FETAL DISTRESS Fetal distress may occasionally demand immediate operative delivery, but there is usually time to attempt intrauterine resuscitation. Operative intervention for fetal distress can be justified when all avenues of 386 correction have been explored and found not to be effective. The indication for operative intervention in the case of fetal asphyxia is not simply the presence of distress, but rather the presence of nonremediable distress. If the potentially harmful situation can be altered, the fetus may be expected to recover in utero. Maneuvers for intrauterine resuscitation include institution of maternal oxygen inhalation, maternal positional changes, and intravenous hydrat ion.28 If oxytocin is being used, another resuscitative measure may be to turn the infusion off. While these maneuvers for intrauterine resuscitation are being carried out, the patient may be prepared for operative delivery. The success of intrauterine resuscitation can be assessed in ongoing fashion by observing improvements in the fetal heart rate patterns or obtaining fetal scalp blood pH. In the present state of our knowledge, it is impossible to establish any rigid guidelines for delivery based solely on fetal heart rate pattern and pH. In this very brief review, use of fetal scalp blood sampling has been suggested as a means of more accurately identifying fetal distress. However, this technique requires not only a skill learned with experi- ence, but also a knowledge of acid-base problems in mother and fetus. Most importantly, the use of this technique requires hospital and delivery room support systems which are rarely available. Thus, fetal scalp blood sampling, while useful, is infrequently used at the present time. CESAREAN BIRTH OR MID-FORCEPS BIRTH Delivery of an asphyxiated fetus often requires a choice between cesarean and mid-forceps delivery. Although each case must be judged 387 individually, more recently a cesarean birth appears to have been favored over the mid-forceps (see Chapter IX - New York City Experience). It is implied that it may not be appropriate to employ a potentially traumatic procedure to a fetus already compromised by asphyxia. The question of how Hach hypoxia or asphyxia can be tolerated by the human fetus before irreversible brain damage occurs cannot be answered at this time. Present goals are to minimize hypoxic insults to the fetus and the mother. CLINICAL STUDIES OF THE CONTRIBUTION OF FETAL DISTRESS TO THE RISING CESAREAN BIRTH RATE As noted in the PAS data (see Chapter VIII) fetal distress as an indication for primary cesarean delivery has contributed approximately 15% of the increase in the rate of primary cesarean birth from 1970 to 1978. Haverkamp and colleagues, 2 in a study of high risk patients, reported a cesarean birth rate for fetal distress that was 7.4% in the patients managed by continuous electronic fetal heart rate monitoring as opposed to 1.2% in those patients managed by intermittent auscultation of the fetal heart rate. By contrast, Renou and associates’C found no significant increase in cesarean births in a monitored group of high risk patients compared with nonmonitored control patients. Mann and Galiant’! reported an increase in the primary cesarean birth rate for fetal distress associated with the introduction of electronic fetal heart rate monitoring in their hospital. Of interest in this study was the reduction in this rate from 24.4% to 11.7% when fetal scalp pH sampling was performed after ominous decelerations were noted. This 11.7% rate for primary cesarean birth due to fetal distress represented 1.3% of the total 388 deliveries in the last year of their study, and was the lowest rate recorded from their hospital in the past ten years. Zallar and Quilligan®2 reported on the obstetric experience at Los Angeles County, University of Southern California Medical Center for the years 1970, 1974 and 1976 in relation to fetal distress as an indication for cesarean births. One hundred and thirty-four of the 1,119 primary cesareans (12%) were performed for fetal distress. Ninety- two of these were performed for observed changes in the fetal heart rate. Forty-three cesarean births were done with the diagnosis of late decelerations. Periodic changes in decreased baseline variability of the fetal heart rate accounted for 39% of the diagnoses of fetal distress in this group. Scalp sampling appeared to clarify the diagnosis of fetal distress and led to a reduction in unnecessary cesarean births. The percentage of infants delivered by cesarean birth for fetal distress was about 1% of the total deliveries. The incidence of cesarean birth for fetal distress was low, and had remained constant during the past 7 years. ELECTRONIC FETAL MONITORING AND CESAREAN DELIVERY RATES Electronic fetal monitoring is often cited as a major contributor 3313435 thus, an this section, to the rise in cesarean birth rates. studies of the association of use of the electronic fetal monitor and rises in cesarean delivery are reviewed. 389 The temporal association of the introduction and widespread use of the electronic fetal monitor and the rise in cesarean delivery rates probably accounts for this idea. However, several a wat have pointed out that there have been many other recent changes in pregnancy management that might also account for the rise in cesarean delivery rates. Determining the contribution of each of these changes and of electronic fetal monitoring to the rise in cesarean delivery rates is a difficult task. The NICHD Task Force on Predictors of Fetal Distress’ examined the subject of electronic fetal monitoring and cesarean delivery rates in detail. That Task Force concluded that the increasing use of both procedures was "not necessarily reflective of a cause and effect." In the following section of this report, the studies on which their conclusion was based are reviewed. In addition, an attempt is made to derive a numerical estimate of the magnitude of the contribution of use of electronic fetal monitoring to the rise in cesarean delivery rates. The series of studies t32 described below address the subject of the association of electronic fetal monitoring and cesarean delivery rates. Most of these studies are of five types: randomized clinical trials’t21; studies that describe changes in the cesarean delivery rate over time in a setting in which electronic fetal monitoring was introduced at a point in time and subsequently used in almost all deliveries (Time Series [42-44 ’ I) studies that describe differences in the cesarean delivery rate over time in a setting in which use of fetal monitoring increased 390 20,45-47 gradually (Time Series II); studies that describe differences in the cesarean delivery rate in monitored and unmonitored labors at a 21,46,48-50 _ single institution or in a circumscribed geographic area; nd 51,52 analytic studies. The eighteenth 37 is a review of articles in which cesarean delivery rates were given by indication. The results of 20,21,38-52 17 of the studies are summarized in Table I. PROSPECTIVE ELECTRONIC MONITORING STUDIES The findings of the four randomized clinical trials’ are consistent. Each found a higher cesarean delivery rate in the electronic- ally monitored group. In Kelso's study?! of low risk pregnancies, the difference in cesarean delivery rate between clectronically monitored and electronically unmonitored women was five percent. In Renou's study? of high risk pregnancies, the difference was about 11 percent. Havercamp’? showed that the effect of electronic fetal monitoring on the cesarean delivery rate may be reduced by use of fetal scalp blood pH. In this study, the cesarean delivery rate was 6.6 percent in those who were not electronically monitored, 11.0 in those electronically monitored who also had fetal pH determination in the event of "fetal distress", and 16.5 in the electronically monitored group without fetal pH. Taken together, this is evidence for a direct effect of fetal monitoring on the cesarean delivery rate. The magnitude of the increase in cesarean delivery rates associated with electronic fetal monitoring in these four studies, five to ten percent, is probably higher than in other settings, as will be shown in the following section of the review. 391 RETROSPECTIVE ELECTRONIC MONITORING STUDIES Findings in the second group of studies, 32-44 all of which compare cesarean delivery rates between two periods, one when there was no electronic fetal monitoring and another when it was used in almost all pregnancies, were also consistent. Each found the cesarean delivery rate increased slightly after introduction and universal use of the electronic fetal monitor. In two, 42746 the cesarean delivery rate continued to rise after introduc- tion of the electronic fetal monitor although the percentage of elec- tronically monitored deliveries did not change. The increase in cesarean delivery rates, even after stabilization of the rate of electronic fetal monitoring, has two explanations. First, it is possible that the initial year of electronic fetal monitor- ing does not reflect the full effect of electronic fetal monitoring. on the cesarean delivery rate. Perhaps interpretation of its results are conservative at first. If true, later years are a better indicator of the "true" effect of fetal monitoring. The alternative explanation is that continued increases in the cesarean delivery rate in the period after universal use are due to more frequent use of cesarean delivery for indications such as breech, dystocia, etc. It is not possible to defin- itely decide between these two explanations. However, the fact that each of the three studies, done in different places at different times, found approximately the same magnitude of increase in cesarean delivery rate in the first year after its introduction and universal use support the second explanation. Taken together, these studies suggest that the fetal 392 monitor alone increased the cesarean delivery rate by about 0.5 to 1.0 percent. The findings of the third group of studies are not consistent. They report the cesarean delivery rate over a period of time when the rate of electronic fetal monitoring gradually increased. Johnstone’ found that the cesarean delivery rate in Sheffield, Scotland, changed little over a three year period when the rate of electronic fetal monitoring increased by an unspecified amount. Similarly, Paul? showed that, in a large Los Angeles teaching hospital which pioneered the use of the electronic fetal monitor, the primary cesarean delivery rate remained constant in a five year period when the percentage of electronically monitored births increased from 18 to 32. Shenker Zl and vughey™? on the other hand, found that cesarean delivery rates increased by 2% and 4.3%, respectively, in five year periods when the percentages of elec- tronically monitored births increased gradually from about 4 to 88. The periods of time and the initial and final rates of electronic fetal monitoring differed between the four studies. This may help explain their inconsistencies. They may represent a biased experience or the effects of electronic fetal monitoring on cesarean delivery rates may differ between institutions. Longer experience with the electronic fetal monitor may be associated with lower rates of cesarean delivery at a given electronic fetal monitoring rate. Thus, because these studies represent highly select samples for which other factors cannot be con- trolled, the overall effect of electronic fetal monitoring on cesarean delivery rates cannot be inferred from them. 393 The two analytic studies®? 32 use multivariate statistical techniques to examine the effect of electronic fetal monitoring on cesarean delivery after control for other variables. Williams”! showed that in 323 California hospitals, the percentage of electronically monitored births was significantly associated with the hospitals' cesarean delivery rate even after control by linear regression for other variables related to the cesarean delivery rate. The hospitals' cesarean delivery rate was also significantly correlated with the proportion of obstetrician-attended deliveries, nonprofit ownership and the presence of a neonatal intensive care unit. This suggests that the percentage of births that are electronically monitored may be a proxy for other factors related to obstetrical practice. For example, hospitals with high rates of elec- tronic fetal monitoring may more quickly adopt practices as well as technologies. In these hospitals, the higher cesarean delivery rate might be due to these practices rather than directly to the use of the electronic fetal monitor. Neutra’> used multiple linear regression to study the relation of electronic fetal monitoring to the cesarean delivery rate in a group of 14,484 deliveries classified by risk. Parity, malpresentation and arrest of labor were associated with both electronic monitoring and cesarean delivery. In the analysis, these were controlled by stratifica- tion (see Table II). In nid raras without malpresentation or arrested labor, who comprised 78% of all nulliparas and 38% of the whole group, the cesarean delivery rate was not significantly different between the electronically monitored and electronically unmonitored. On the other 394 hand, in multiparas without malpresentation or arrested labor, who comprised 91% of all multiparas and 46% of the whole group, the cesarean delivery rate in the electronically monitored was three times that of the electronically unmonitored. In the remaining nulliparas the cesarean delivery rate was signifi- cantly different only for those with malpresentation alone. Here it was almost twice as high in the electronically unmonitored women. However, this result may be a result of obstetrical decision to "automatically" (i.e., before time for decision to electronically monitor) perform a cesarean delivery in these women, most of whose infants are in the breech presentation. In the remaining multiparas, the cesarean delivery rate was significantly higher in electronically monitored women with arrested labor. This study group is from a single, specialized hospital. Thus, the generalizability of the results are in question. In it, electronic fetal monitoring in the absence of other conditions associated with cesarean delivery was related to an increased cesarean delivery rate only in multiparas without malpresentation or arrested labor. The eighteenth study’ reviewed published articles in which cesarean delivery rates were given by indication. The authors concluded that fetal distress as an indication for cesarean delivery accounted for 13.2% of the rise in cesarean delivery rates. The contribution of electronic fetal monitoring to direct increases in the cesarean delivery rate probably does not exceed this. The overall increase in cesarean delivery rate in this review was 8%. Thus, the authors conclude that electronic 395 fetal monitoring increased the cesarean delivery rate by a maximum of one percentage point. The analysis of CPHA and New York City data (Chapters VIII and IX) on the contribution of fetal distress as a complication to rises in cesarean delivery rates also showed that it contributed about one percentage point to the rise in cesarean delivery rates over the decade. To the extent that the fetal monitor may increase cesarean delivery rates through increases in the diagnosis of fetal distress, this is a maximum estimate of its effect. SUMMARY bse Fetal distress is a diagnosis relating to many problems with poten- tial for morbidity. 2+ The diagnosis of fetal distress during the antenatal or intrapartum period is now made more frequently on the basis of new information and new technology. Ds This diagnosis is made in 1% of all births, and accounts for 10% of cesarean births and 15% of the increase in the cesarean birth rates (see CPHA data). 4. The precise diagnosis of fetal distress is still limited despite the availability of electronic fetal monitoring and fetal scalp blood sampling. Sie Intrapartum resuscitative intervention techniques, when successful, diminish the incidence of cesarean births for fetal distress. 6. Intrapartum resuscitative techniques, when successful, alter the effects of fetal distress. Therefore the infant's condition at birth may be normal despite an intrapartum diagnosis of fetal distress. 396 TABLE I SUMMARY OF FINDINGS OF STUDIcS OF RELATION OF FETAL MONITORING AND CESAREAN BIRTH RATES A. Risk Cesarean Birth Rate(% Randomized trial Place Status Unmonitored Monitored (38) Havercamp (1976) Denver high 6.6 16.5 (39) Havercamp )1978) Denver high 5.6 17.6% (40) Renou (1976) Australia high 13.7 22.3 (41) Kelso (1978) Scotland low 4.4 9:5 B. Cesarean Rate (%) Descriptive: Before 1st Yr.After Overall in Time Series I** Place Monitor Monitor Monitored Period (42) Gabert (1977) Utah 3.24 4.24 8.0# (43) Edington (1975)## London 5.61 6.14# NA (44) Lee (1976) Connecticut 7.3 7.7 10.4 C. Cesarean Birth Rate (% Change in fetal Descriptive: 1st repor- Latest repor- monitoring rate Time Series II** Place ed year ted year 1st to latest yr. (45) Johnstone (1978) Scotland 7. 7.5 NA (46) Paul (1977) Los Angeles 6.41 6.61 +14,0% (20) Shenker (1975) New York 4.5 6.5 +76.6% (47) Hughey (1977) Illinois 2.6 6.9 +81.0% D. Descriptive: Institution or Who Cesarean Birth Rate(%) Area Place Monitored Unmonitored Monitored (21) Amato (1977) Cincinnati unselected 6.14 8.64 (48) Kelly (1973) Baltimore high risk 8.3 18.0 (49) Tutera (1975) Kansas City high rask 4.8 10.14# (46) Paul (1977) Los Angeles high risk 3.0 16.04 (50) Koh (1975) Canada high risk 6.4 12.5 E. Analytic Place Findings (51) Williams (1979) California Rate oi" fetal monitoring was significantly related to variation in cesarean birth rate between hospitals after control by regress- ion for other variables. (52) Neutra (1979) Boston See text. * cesarean birth rate in monitored group with fetal scalp sampling 11.0% ** see text # primary cesarean section rate ## fetal pH routinely used NA not available 397 TABLE II CESAREAN BIRTH RATES ACCCRDING TO CLINICAL RISK FACTORS AND FETAL MONITORING Arrested C.B. Rate* Significance+ Malpresentation Labor Monitored Number (Per 1000) (P Value) Nulliparas No No No 2530 66 N.S. Yes 3009 58 No Yes No 963 376 N.S. Yes 262 371 Yes No No 163 556 0.002 Yes 89 293 Yes Yes No 23 818%* N.S. Yes 31 667% Multiparas No No No 3918 8 : 0.001 Yes 2814 26 No Yes No 129 135 0.036 Yes 271 275 Yes No No 148 264 N.S. Yes 105 208 Yes Yes No 1 4734+ N.S. Yes 18 625++ * Cesarean birth rate, adjusted for year of delivzry, using entire series as standard. + Two-tail p-value based on standard error of adjisted rate of difference; N.S., no significance, p >0.05. ** Adjusted rat: for study years excluding 1974 data because of insufficient sample size. ++ Adjusted rat: for study years excluding 1973 and 1975 because of insufficient sample size. (FROM NEUTRA, ET AL.) 398 BIBLIOGRAPHY 1 1b. 10. 11. 12. 13. Alberman, E.: Factors influencing perinatal wastage. Clin. Obstet. Gynecol. 1:1-7, 1974. Illingwirth, S.I: Why Blame the Obstetrician? A review. Brit. Med. J. p. 797-780, March 24, 1970. Antenatal Diagnosis. Report of Consensus Development Conference, Sec. III, p. 23, National Institutes of Child Health and Human Development Conference, March 5-7, 1979, Bethesda, Maryland. Myers, R.E.: Experimental models of perinatal brain damage: Relevance to human pathology in Gluch, L., editor. Intrauterine asphyxia and the developing brain. Chicago, 1977 Yearbook Medical Publishers, Inc., pp. 37-97. Cruz, A.C., Buhi, E.C., Birk, S.A., Spellacy, W.N.: Respiratory distress syndrome with mature lecithin/sphingomyelin ratios. Am. J. Obstet. Gynecol. 126:70, 1978. Merritt, I.A., Farrell, P.M.: Diminished pulmonary lecithin synthe- sis in acidosis: Experimental findings as related to respiratory distress syndrome. Pediat. 57:32-40, 1976. Hutchinson, A.A., and Russell,G.: Effective pulmonary auxillary blood flow in infants with birth asphyxia. Aeta Pediat. Scand. 65:669, 1976. Peckham, G.J. and Fox, W.W.: Physiologic factors affecting pulmon- ary artery pressure in infants with persistent pulmonary hyperten- sion. J. Pediat. 93:1005, 1978. Donnelly, W.H., et al: Ischemic papillary muscle necrosis in stressed newborn infants. J. Pediat. 96:295, 1980. Dauber, I.M., Krauss, A.N., Symchycn, P.S., Auld, PAM.: Renal failure following prenatal anoxia. J. Pediat. 88:851, 1976. Drago, J.R.: Perinatal asphyxia and renal failure in neonatal patients. J. Urol. 118:80,1976. Daniels, S.S., and James, L.S.: Abnormal renal function in the newborn infant. J. Pediat. 88:856, 1976. Chadd, M.A.: Coagulation defects in hypoxic full-term newborn infants. Brit. Med. J. 4:516, 1971. Edelund, H. and Finnstrom, D.: Fibrin degradation products and plasminogen in newborn infants with respiratory disturbances and postnatal asphyxia. Aeta Pediat. Scand. 61:661, 1972. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 399 Shelby, H.J.: Glycogen reserves and their changes at birth and in anoxia. Brit. Med. Bull. 17:137, 1961. Tsang, R.C., et al: Neonatal hypocalcemia in infants with birth asphyxia. J. Pediat. 84:428, 1974. Svenningsen, N.W., Aronson, A.S.: Postnatal development of renal concentration capacity as estimated by 1) DAVP Test in normal and asphyxiated neonatis. Biol. Neonate 25:230, 1974. Lebenfield, A., Parkhurst, E.: A study of the association of factors of pregnancy and parturition with the development of cere- bral palsy: A preliminary report: Am. J. Hg. 53:262, 1951. Nelson, K.B., Broman, S.H.: Perinatal risk factors in children with serious motor and mental handicaps. Annals of Neurology 2:371, 1977. Edington, P.T., Sebanda, J., Beard, R.W.: Influence on clinical practice of routine intrapartum fetal monitoring. Brit. Med. J. 3: 341, 1975. Shenker, L., Post, R.C., Seiler, J.S.: Routine electronic monitor- ing of fetal heart rate and uterine activity during labor. Obstet. Gynecol. 46:185, 1975. Amato, J.L.: Fetal monitoring in a Community Hospital: A statis- tical analysis. Obstet. Gynecol. 122:750, 1975. Neutra, R.R., Fienberg, S.E., Greenlund, S., Friedman, E.A.: Effect of fetal monitoring on the incidence of neonatal decibel rates. N. Eng. J. Med. 299:324, 1978. Schifrin, B.S., Dame, L.: Fetal heart patterns and prediction of Apgar score. JAMA 219:13-22, 1972. Wood, C.: Fetal scalp sampling: Its place in management. Seminars in Perinatology, Editors, Oliver, T.K. and Kirschbaum. Greene and Stratton, Publishers, Vol. II, No. 2:969, 1978. Fuyijura, T., Klionsky, B.: The significance of meconium staining. Am. J. Obstet. Gynecol. 121:45, 1975. Barkam, K.: Amnioscopy, meconium and fetal well being. J. Obstet. Gynecol., Brit. Commonwealth, 76:412, 1969. Miller, F.C., Sacks, D.A., Yeh, S.: Significance of meconium during labor. Am. J. Obstet. Gynecol. 122:573, 1975. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 400 Cohen, W.R. and Schifrin, B.S.: Diagnosis and management of fetal distress during labor. Seminars in Perinatology., Editors, Oliver, T.R. and Kirschbaum. Greene and Stratton, Publishers. Vol. II, No. 2:155, 1978. Haverkamp, A.D., Thompson, H.E., McFee, J.L., Certulo, C.: The evaluation of continuous fetal heart rate monitoring in high risk pregnancy. Am. J. Obstet. Gynecol. 125:310, 1976. Renou, P., Chang, A., Anderson, I., Wood, C.: Controlled trial of fetal intensive care. Am. J. Obstet. Gynecol. 126:470, 1976. Mann, L.F. and Gallant, S.: Modern indications for cesarean section. Am. J. Obstet. Gynecol. 135:437, 1979. Zalar, R.W., Jr., and Quilligan, E.J.: The influence of scalp sampling on the cesarean section rate for fetal distress. Am. J. Obstet. Gynecol. 135:239, 1979. Obstetrical Practices in the United States, 1978. Hearing before Subcommittee on Health and Scientific Research of the Committee on Human Resources, United States Senate. (This publication is obtained by writing to the U.S. Government Printing Office, Washing- ton,D.C. 20402). Marieskind, H.I.: An evaluation of cesarean section in the United States. Report submitted to the Assistant Secretary for. Planning and Evaluation, Department of Health, Education and Welfare, June, 1979. Placek, P.J. and Toffel, S.M.: Demographic variation in cesarean delivery rates: United States, 1970-1978. In press, Health, United States, U.S. Dept. of Health and Human Services, National Center for Health Statistics, 1980. Jones, 0.: Cesarean section in present-day obstetrics. Presiden- tial address. Am. J. Obstet. Gynecol. 125:798, 1976. Bottoms, S.F., Rosen, M.G., Sokol, R.J.: The increase in the cesarean birth rate. N. Eng. J. Med. 302:559-563, 1980. Havercamp, A.D., Thompson, H.E., McFee, J.G., Cetrulo, C.: The evaluation of continuous fetal heart rate monitoring in high risk pregnancy. Am. J. Obstet.Gynecol. 125:310-317, 1976. Havercamp, A.D., Orleans, M., Langendoerfor, S., McFee, J., Murphy, J., Thompson, H.: A controlled trial of the differential effects of intrapartum fetal monitoring. Am. J. Obstet. Gynecol. 134:399-412, 1973. 40. 41. 42. 43. 44. 45. 46. 47. 48. 49. 50. 51. 52. 401 Renou, P., Chang, A., Anderson, I., Wood,C.: Controlled trial of fetal intensive care. Am. J. Obstet.Gynecol. 126:470-476, 1976. Kelso, 1.M., Parsons, R.J., Lawrence, G.F., Arora, S.S., Edmonds, D.K., Cooke, I.D.: An assessment of continuous fetal heart rate monitoring in labor: A randomized trial. Am. J. Obstet.Gynecol. 131:526-532, 1978. Gabert, H.A., Stenchever, M.A.: The results of a five year study of continuous fetal monitoring on an obstetric service. Obstet. Gynecol. 50:275-279, 1977. Edington, P.T., Sibanda, J., Beard, R.W.: Influence on clinical practice of routine intrapartum fetal monitoring. Brit. Med. J. 3:341-343, 1975. Lee, W.K., Baggish, M. S.: The effect of unselected fetal monitor- ing. Obstet. Gynecol. 47:516-520, 1976. Johnstone, F.D., Campbell, D.M., Hughes, G.J.: Antepartal care: Has continuous intrapartum monitoring made any impact on fetal outcome? Lancet 1:1298-1300, 1978. Paul, R.H., Huey, J.R., Yaeger, C.F.: Clinical fetal monitoring - Its effect on cesarean section rate and perinatal mortality: Five year trends. Postgraduate Med. 61:160-166, 1977. Hughey, M.J., LaPata, R.E., McElin, T.W., Lussky, E.: The effect of fetal monitoring on the incidence of cesarean section. Obstet. Gynecol. 49:513-518, 1977. Kelly, U.C., Kulkarni, D.: Experience with fetal monitoring in a community hospital. Obstet. Gynecol. 41:818-824, 1973. Tutera, G., Newman, R.L.: Fetal monitoring: Its effect on the perinatal mortality and cesarean section rates and its complications. Am. J. Obstet. Gynecol. 122:750-754, 1975. Koh, K.S., Greves, D., Yung,S., Peddle, L.J.: Experience with fetal monitoring in a university teaching hospital. Canad. Med. Assoc. J. 112:455-562, 1975. Williams, R.L., Hawes, W.E.: Cesarean section, fetal monitoring, and perinatal mortality in California. Am. J. Public Health 69: 867-870, 1979. Neutra, R., Greenland, S., Friedman, E.A.: The effect of monitor- ing on cesarean section rates. Obstet. Gynecol., in press. Chapter XVII - Other Maternal and Fetal Indications for Cesarean Birth 405 INTRODUCTION In previous chapters we have discussed the major diagnoses assoc- iated with the rise in cesarean birth rates. In this chapter we present examples of some of the many "other" diagnoses often, but not always, associated with a cesarean birth. It is of interest to note that while there are a multiplicity of titles, these many diagnostic indications rank far behind dystocia, repeat cesarean birth, breech presentation and fetal distress as reasons for cesarean birth rate changes. These indications often occur in life endangering situations for mother or for fetus. On occasion the presence of these medical problems requires decisions to be made at a point in time when the risks from that problem for one patient of this two-patient situation far outweigh the risks for the other. It is impossible to present all medical situations here; these are more appropriately discussed in a textbook. However, in order to give the reader an understanding of the breadth of this category, a number of specific examples are presented. MATERNAL DIABETES This is an example of an illness that may lead to cesarean birth because of maternal or fetal indications. In one report, cesarean birth occurred in 75% of diabetic patients.) In the past these diabetic mothers were almost all delivered by cesarean between the 36th and 37th week of gestation to avoid intrauterine fetal death that frequently occurred if pregnancy went beyond 38 weeks gestation. With a more adequate understanding of the necessary medical care for the pregnant diabetic, outcomes for mothers and fetuses have improved. Important 406 advances in the medical management of the fetus have occurred with the use of new laboratory tests such as antepartum electronic monitoring (non-stress test, oxytocin challenge test) and the amniotic fluid tests of fetal lung maturity (lecithin/sphingomyelin and phosphatidyl-glycerol tests). These parallel medical advances in patient care have led to diabetic pregnancies being extended closer to full term, and some diabetic women are delivering vaginally following spontaneous onset of labor or being induced with the use of oxytocin. | This illness, diabetes, may also be looked at as an example of a need for improved techniques for induction of labor. Preterm delivery of the diabetic mother is often resistant to oxytocin stimulation of labor, with cesarean delivery being performed as a consequence of unsuccessful induction. BIBLIOGRAPHY 1 White, P.: Diabetes mellitus in pregnancy. Clinics in Perinatology Vol. 1:2, 331-347, Sept. 1976. MATERNAL CARDIAC DISEASE (ACQUIRED AND CONGENITAL) This set of maternal illnesses is presented as an example of a medical illness which should not alter normal obstetrical care. If a cesarean were to be performed, it would be performed for obstetrical indications. Maternal cardiac disease occurs in about 1% of pregnancies. Rheumatic heart disease previously accounted for the majority of cases, but recently congenital heart disease (corrected and uncorrected) 407 has become the more prevalent group as medical and surgical care for both groups has improved. The conclusion of most studies is that pregnant cardiac patients should be allowed to deliver vaginally, with the second stage shortened by the use of forceps. Cesarean delivery should be reserved for obstetrical complications. 172159%41316,7 For women who have had a myocardial infarction, management of delivery is not conclusively established. The number of cases is small. Some physicians favor cesarean delivery when a myocardial infarction has occurred; others Peel vaginal delivery poses no problems as long as the patient has recovered satisfactorily from the infarction. 11H BIBLIOGRAPHY 1s Burrow, G.N., and Ferres, T.F.: Medical Complications During Pregnancy. Philadelphia, W.B. Saunders Company, 124-129, 141-143, 1975. 2. Pritchard, J.A. and MacDonald, P.C.: Williams Obstetrics, 15th Edition. New York, Appleton-Century-Crofts, 608-609, 611 613-614, 614-615, 1976. 3. Batson, G.A.: Cyanotic congenital heart disease and pregnancy. J. Obstet. Gynecol. Brit. Commwlth. 81:549-553, 1974. 4. Kenmure, A.C.F., and Cameron, A.J.V.: Congenital complete heart block in pregnancy. Br. Heart J. 29:910912, 1967. 54 Turner, Gillian M., Oakley, Celia A., and Dixon, H.G.: Manage- ment of pregnancy complicated by hypertrophic obstructive cardio- myopathy. Br. Med. J. 281-284, 1968. 6. Neilson, Graeme, Galia, E.G., and Blunt, Alan: Congenital heart disease and pregnancy. Med. J. Aust. 1086-1088, 1970. 7. Ellis, I.D.: Pregnancy and delivery after mitral valvotomy. J. Obstet. Gynecol. Brit. Commwlth. 74:24-27, 1967. 8. Husaine, M.H.: Myocardial infarction during pregnancy: Report of two cases with a review of the literature. Postgraduate Medical Journal 47:660-665, 1971. 408 9. Listo, Matti, and Bjorkenheim, Gosta: Myocardial infarction during delivery. Acta. Obstet. et Gynecol Scandinav. 45:268-278, 1966. MATERNAL GENITAL HERPES This maternal medical illness is presented as an example of an infection which is relatively harmless to the mother. However, if during labor the fetus is exposed to the virus during vaginal birth, infection may be lethal. Therefore in the presence of an active genital infection, a cesarean birth is performed for fetal indications. Herpes simplex virus (HSV) infections have been cited as one of the most rapidly increasing venereal diseases. Genital infections of the cervix, labia or vagina with HSV type II are prevalent. About 10 percent of genital infections occur with HSV type I. The type I HSV usually infects a non-genital site. Herpes II antibody is present in about 10% of the sexually active population. The number of women who come to term with active cervical genital herpes is estimated to be from 0.5 to 1.5 percent. ] HSV infection of the newborn is associated with a case fatality rate of 60 percent. At least 40 percent of the neonatal survivors have 2,3 Positive maternal significant neurological or ocular sequelae. vaginal cultures for HSV can be found in about 90 percent of neonatal infections. Many of the maternal genital infections are asymptomatic. The risk of neonatal infection is highest in the vaginally delivered infants whose mothers have active infection or who are culture positive at delivery. The HSV virus normally does not cross the placenta or affect the fetus prior to labor. However, once the fetal membranes have 409 been ruptured, risk for fetal infection rapidly rises, > A pregnant patient with a history of recurrent genital herpes, or with active disease in that pregnancy, should be monitored with vaginal viral cultures and cervical pap smears, beginning at about 32 weeks of gestation. The monitoring should be repeated every second visit through tern.” In order to avoid fetal infection, labor in the presence of a positive HSV culture or cervical smear within the past week should be promptly terminated by cesarean birth before membranes rupture. BIBLIOGRAPHY 1. Nahmias, A.J., Josey, W.E., Naib, Z.M.: Significance of herpes simplex virus infection during pregnancy. Clin. Obstet. Gynec. 15:929-938, 1972. 2. Nahmias, A.J., Alford, C.A., Korones, S.B.: Infection of the newborn with herpes virus hominis. Adv. Pediatr. 17:185-226, 1971. Se Nahmias, A.J., Josey, W.E., Naib, Z.M., Free, M.C., Fernandez, R.J., Wheeler, J.H.: Perinatal risk associated with maternal genital herpes simplex virus infection. Am. J. Obstet. Gynecol. 110:825-834, 1971. 4. Amstey, M.S.: Management of pregnancy complicated by genital herpes virus infection. Obstet. Gynecol. 37:515-520, 1971. Sw Light, I.G., Linnemann, C.C.,Jr.: Neonatal herpes simplex infection following delivery by cesarean section. Obstet. Gynecol. 44:496-499, 1974. 6. Amstey, M.S.: Management of pregnancy complicated by genital herpes virus infection. Obstet. Gynecol. 37:515-520, 1971. MULTIPLE PREGNANCY Multiple pregnancy, with twin pregnancy as the example, is presented as an indication for cesarean birth which is changing. This management 410 represents a trend away from the mechanical intervention forms of obstet- rics, in a manner similar to that seen in the changing forceps use as reported in Chapter IX. Since twin pregnancies only occur in about one in ninety gestations, any change in practice will not markedly alter the cesarean birth rates. However, there appears to be a rising incidence of cesarean births in the presence of multiple gestation. Cesarean birth for multiple pregnancy is indicated for a number of obstetrical complications. If the twins present in labor in oblique lie or if the first twin presents other than longitudinally, cesarean birth is indicated. If the presenting twin is breech, a cesarean birth is often chosen for delivery. This is particularly true if the labor is premature. In another example, if the second twin is in the breech position and is much larger than the first fetus, then cesarean birth may be performed. BIBLIOGRAPHY 1. Petitti, D., Oslon, R.0., Williams, R.L.: Cesarean section in California, 1960-1970. Am. J. Obstet. Gynecol. 133:391-397, 1979.: 2. Hibbard, L.T.: Changing trends in cesarean section. Am. J. Obstet. Gynecol. 125:798, 1976. ERYTHROBLASTOSIS FETALIS (RH HEMOLYTIC DISEASE) This fetal illness is presented as a fetal indication for cesarean birth for a condition which is harmless for the mother, but potentially fatal for the fetus if not delivered. However, since the incidence of erythroblastosis is now falling due to new methods of prevention of maternal sensitization, (i.e. the administration of blocking antibodies to the unsensitized mother following delivery), it is also presented as a 411 medical condition which will be seen less frequently among the cesarean birth diagnoses. Analysis of amniotic fluid for bilirubin concentrations to assess the severity of intrauterine fetal hemolysis is indicated in an Rh negative mother who becomes sensitized prior to the 36th week of pregnancy. When a very elevated amniotic fluid bilirubin is documented, life-threatening fetal anemia can be anticipated, and some intervention may be indicated. Delivery of the fetus is appropriate when the gestational age of the fetus predicts an extrauterine mortality rate which is less than the mortality rate from continued intrauterine management (i.e. intra- uterine transfusion). Infants with erythroblastosis fetalis (particularly when complicated by hydrops) have a high incidence of asphyxia. Obstetrical intervention should minimize intrauterine stress which might contribute to asphyxia. When early delivery (<36 weeks) is necessary, cesarean delivery is usually indicated. BIBLIOGRAPHY 1. Phibbs, R.H., Johnson, P., Kitterman, J.A., Gregory, G.A., and Tooley, W.H.: Cardiorespiratory status of erythroblastotic infants. 1) Relationship of gestational age, severity of hemolytic djsease, and birth asphyxia to idiopathic respiratory distress syndrome and survival. Pediat. 49:5-14, 1972. MATERNAL LIFE ENDANGERING CONDITIONS There are a number of examples of medical situations when continu- ation of the pregnancy may lead to permanent injury or death of the 412 mother. In these cases a cesarean birth may be the only method for delivery. As one example, in the case of increasing maternal hyperten- sion and eclampsia, the disease may only be controlled after birth. The answer to terminate the pregnancy is straightforward since fetal death will inevitably follow maternal death; therefore, there may be no choice. In a second example, chronic pyelonephritis with impending renal failure, continuation of the pregnancy, if not endangering maternal life, may permanently damage her kidneys. The greater medical risk here is to the mother. However, the degree of prematurity will affect fetal survival. The ethical issues involved in this decision are discussed more completely in Chapter XX. SUMMARY 1s There are many diagnoses in this category of other maternal and fetal indications for cesarean birth. 2. These indications rank well behind the individually discussed categories of dystocia, repeat cesarean birth, breech presenta- tion, and fetal distress in their contributions to the rising cesarean birth rate. i Since many of these situations arise in the preterm time period, stimulation of labor with presently available techniques is often ineffective, necessitating cesarean delivery. 413 SECTION IV - BEHAVIORAL STUDIES RELATING TO CESAREAN BIRTH Information is presented in these two chapters which relates to the effects on mother and child of this different method of birth. When available, short term and long term studies are included. Information is also presented in the form of ideas with respect to how the behavioral environment surrounding cesarean birth may be improved. Chapter XVIII - Effects on Mother and Family Chapter XIX - Effects on Infant Development Chapter XVIII - Effects on Mother and Family 417 INTRODUCTION Emotional responses to planned and unplanned cesarean births vary widely and depend on several factors. These factors include preparation the parents may have received prior to the acute events, their prior expectations about their birthing experience, past childbearing exper- iences, their experiences with disappointment and loss, and the support and sensitivity of the caregivers. During the same time period in which cesarean rates have been rising, parent expectations about birth have also been changing. Factors such as prepared childbirth, participation of the father in the birth experience, reduction in the amount of maternal analgesic used for birth, and emphasis on "gentle birth" and early parent-infant contact for "bonding", in addition to the consumer movement in health in general, have all contributed to a revolution in attitudes for many parents today. The inevitable corollary has been a parallel disappointment if the birth events did not go as planned or desired. THE DIFFERENT EXPERIENCES OF CESAREAN BIRTH PARENTS In nursing, childbirth education, and lay literatures increasing attention has been paid to the emotional needs of cesarean parents. Writers have described maternal responses which may include fear of surgery, pain, death, or anesthesia for herself; fears for the baby's well being; relief at the end of labor and the birth of her baby; feelings of "powerlessness", loss of autonomy, and self esteem lowered; loss of feelings of femininity; change in body image, feelings of not being "whole"; jealousy of other women; extended ego constriction; difficulty in integrating the labor experience; difficulty in establishing feelings 418 of closeness with the infant and in the "claiming" of the infant as her own; blame of the infant; fears of another delivery; grieving behaviors, including denial, anger, self-blame, and depression; and finally, guilt at experiencing these negative feelings at a time when the mother believes she is supposed to feel happiness at the birth of a healthy Sifapt 2720 Although researchers have examined parental responses to premature delivery, stillbirth, or birth of a deformed child, until recently cesarean births have received less attention in the professional or the parent-infant attachment literature. Research evidence regarding the psychological impact of a cesarean on parents or on family interaction is fragmentary and preliminary at best. The reports are primarily descrip- tive, involve small numbers, and are largely confined to middle class, caucasian families. In addition, due to the mother's physical limita- tions and needs, as well as the baby's often altered responsiveness, the benefits of maternal infant interaction that have been attributed to early infant contact following vaginal birth may be made more difficult to achieve after a cesarean birth. The question of the infant's respon- siveness is discussed in the section on longitudinal infant develomental effects (Chapter XIX). INITIAL MATERNAL INFANT CONTACT Cesarean mothers may often be prevented from seeing their infants at the moment of birth because of anesthesia or sedation or at least by the presence of a physical barrier. Frequently cesarean infants may spend 24 hours or more under observation in a nursery, and are unavailable to 419 their mothers during this time. The initial mother infant contact may come at a time when a mother is either in a good deal of pain, or groggy from medication. Furthermore, the pain, effects of medication, fatigue, difficulty in moving around, and dependency that mother may experience following major adbdominal surgery all combine to make the cesarean birth considerably more difficult. THE EXPERIENCES IN THE NON CESAREAN SITUATION Because of the paucity of the cesarean literature, analogies for the cesarean birth must often be drawn from other writers who have discussed mothers' responses to the birth experience. Sugarman suggests that surgical birth or birth under general anesthesia leaves some women with a sense of uncertainty about whether or not they have had a baby or about their roles in the birth.2 For some there is often a sense of having failed or having been cheated out of the expected normal birth experience. In addition, when a woman is forced into a passive, helpless sick role, her self-esteem may suffer. Some years ago, Kaplan and Mason reported that mothers of premature infants may feel biologically incompetent . 2 In studying the effect of denying early mother infant interaction on maternal self-confidence, ° Seashore, et al., found that primiparae without early contact displayed less self confidence than either multiparae or primiparae with early infant contact?’ Those mothers with initial low self confidence, including multiparae, were most vulnerable to the effects of separation, and interaction between these two factors was statistically significant. Seashore suggests that to the extent that the mother feels responsible 420 for the failure of the birth process, these feelings of inadequacy may generalize to her confidence in her ability to provide for the postpartum needs of her infant. Furthermore, the separation tends to reinforce these doubts. Barbero, Morris, and Reford, in reporting their work with failure-to-thrive infants, suggest that identification of the newborn as part of the mother's good self-image is a necessary process for a thriving mother-baby unit. 28 When the mother's ego is threatened, the baby becomes the locus of maternal self-doubts, and a threat to the mother. Conversely, when a mother's hunger for self-esteem is met, she is then able to nurture her baby and meet his/her needs. In a survey of attitudes toward their birthing experience, Willmuth found that for a sample of prepared, vaginally delivered women, the most important factor related to positive attitudes was a sense of control, of participating in decision making and actively in the birth rather than as a passive object of care. The Johns Hopkins First Pregnancy Study, a longitudinal study of 120 couples interviewed before and after giving birth between 1973 and 1976, also attempted to identify variables leading up to or predicting positive feelings about the birth experience. Again, control of the situation was a strong __ EXPERIENCES OF CESAREAN BIRTH MOTHERS Affonso and Stichler conducted a pilot study of 105 cesarean mothers, assessing emotional reactions after cesarean birth. 27% Questionnaires were administered between the second and fourth postoperative days. During the period before surgery, but after the decision had been made, 92% of the mothers reported feeling fear, 50% reported dissatisfaction, 421 anger, or depression, and 30% felt relief at the end of labor. Almost 90% reported fears related to self, and 53% fears for the baby. Forty- two percent of the mothers expressed a need for reassurance, for verbal communication, or for touch in the operating room prior to anesthesia. Explanations from professionals were the most commonly reported help in preparing for the cesarean. Almost half of the mothers recalled altered perceptions of their bodies and of time in the operating room. All mothers vividly remembered uncomfortable preoperative procedures. In the recovery room, all respondents had wanted their husbands or another support person with them. Although 70% of the mothers felt relief that surgery was over, 33% felt concerns and fears about their roles as mother and wife, and 25% about the long recovery period. All women commented on physical pain and difficulties in the postpartum period. The majority of the women felt a cesarean was harder than a vaginal birth. Women commonly exhibited grieving behaviors. Over half the patients studied felt that their husbands had experienced disappoint- ment, worry, and concern, and had needed more explanations. No compar- ison was made with the feelings of women delivering vaginally. In another pilot study of nine mothers after an unexpected cesarean Marut found these mothers had difficulty integrating their labor and delivery exper iences. 1° Many mothers were preoccupied with resolving what had happened to them, and were unable to focus on their infant. Those who had been awake and .had had sensory contact with their infants in the delivery room reported closer feelings to the infant. With Mercer, Marut conducted a follow up study of the feelings of 20 primiparae 422 who had undergone an unexpected Cesarean, comparing them with 30 primiparae delivering vaginally. V? Open-ended interviews and a questionnaire on attitudes toward childbirth were administered in the first 48 hours after delivery. All women had had normal pregnancies, and had anticipated vaginal delivery. Background variables such as age, race, marital status, postpartum complications, attendance at prenatal classes, method of infant feeding, and infants' sex, birthweight, and Apgar scores, were all similar. The mean length of labor was longer for the cesarean group. All of the vaginally delivered women had had a support person with them during labor and delivery, while 25% of the cesarean group were alone in labor, and 33% were alone at delivery. Cesarean mothers had less positive perceptions of their birth experiences than did the controls (p <.01). Factors revealing signifi- cant differences included control during delivery, worry about baby's condition, and time of initial mother-infant contact, confirming some of the observations cited above. Marginally significant were fear during delivery, memories of labor as painful, and extent to which the exper- ience met expectations. Satisfaction with the delivery was linked to feelings of confidence, pleasant feeling states, and perceived control. Women who had had regional anesthesia experienced their cesareans more positively than did those who had had general anesthesia. Cesarean mothers were significantly more hesitant to name their infants (p=.005); cesarean mothers asleep for the birth were more hesitant than those who had been awake. 423 Interview data indicated that the presence of a support person contributed to overall satisfaction with the birth. Vaginally delivered mothers reported more of a sense of reality and of feeling positive about an effective labor. These feelings contributed to an increase (for vaginally delivered mothers) or a decrease (for Cesarean mothers) in self-esteem. Vaginally delivered mothers predominantly expressed concern for their infants, while cesarean mothers reflected more hostility toward their infants. Positive comments on the delivery far overshadowed negative comments on fatigue and pain from vaginally delivered mothers. Only one of these mothers mentioned feeling she was a failure. Of the 20 cesarean delivered mothers, 18 described the birth as a '"shock] a "big disappointment," and "totally different from what I planned." Three- fourths expressed feelings of "torture" and "fears of death." Although discussing their experiences in detail, they expressed a lack of contin- uity and feelings of incompleteness. When they felt they had lost control, they expressed harsh criticism of themselves, their babies, and others. A support person to act as advocate was seen as valuable. In the delivery room the father was seen as a protector, and as someone to welcome the baby as the mother had wanted to. Postpartum, cesarean mothers expressed a need for time to recover physically and emotionally before undertaking mothering tasks, and a lack of understanding from others. They perceived their births as "abnormal" and as having social stigma. Unfortunately, this study failed to control for three possible confounding variables, including length of labor, amount of pain per- ceived, or presence of a support person. Three surveys of postpartum adjustment also found that those parents experiencing a cesarean birth had a more difficult adjustment in the early 424 postpartum period. Six of the 40 families observed and interviewed at about five months of age by Peterson, et al. had had cesareans.”2 These families reported more problems with both physical discomfort and infant feedings in the initial adaptation period. Of 89 families followed during pregnancy and the first year of life by Grossman, et al., 21 had cesarean births.” These mothers tended to adapt less well to birth and the initial postpartum period. Postoperative pain and physical limitations, as well as anxiety about the infant, were associated with anxiety and depression among mothers in the first week postpartum. Of the 120 families interviewed in the Johns Hopkins First Pregnancy Study, 20 experienced cesarean deliveries.”® As reported by Doering and Entwistle, these mothers described more difficulty with physical symptoms after birth and a slower recovery. Ashu women varied widely in how soon they first fed their babies, all those who waited more than 48 hours had cesarean births. In addition, cesarean mothers rated the birth more negatively, averaging a rating of 2.6 (on a scale with 1 as very negative, 7 as very positive, 4 as neutral), as compared with 5.0 for vaginally delivered women (p<.001). This negative effect of the cesarean on feelings about the birth persisted even when controlled for the use of anesthesia.” A sub-sample of responding cesarean fathers rated the birth 2.0, while other fathers rated it slightly positive. Cesarean mothers also reported feeling more seriously depressed postpartum (p<.05). There was a trend for cesarean mothers to be more likely to discontinue breastfeeding, more ambivalent about caring for their newborns, and less likely to mention the baby as a source of happiness in their marriage. It also appeared that the impact of other negative events, 425 such as the baby's crying or weight gain, seemed to be greater on cesarean mothers than on others. Unlike the other two surveys, the Doering and Entwistle data did not include observations in addition to interviews. All three studies may have involved a possible self selection bias, and included primarily middle-class, caucasian, two-parent families. These long term infant developmental studies are discussed more completely in the following chapter (XIX - Effects on Infant Development). Joy reported very few statistically significant differences in maternal attachment after cesarean and vaginal deliveries. Of a total of 189 women who completed questionnaires in the last trimester of pregnancy and again at one month postpartum, 40 or 22% had cesareans. All women studied were relatively advantaged socioeconomicelly, and delivered in hospitals where services were provided at little or no cost. Virtually all the mothers had attended prenatal classes and were prepared almost exclusively for a vaginal delivery. Most vaginally delivered women were awake, had a support person with them, and had contact with their infants soon after birth. In contrast, most cesarean mothers had general anesthesia, and were separated for a period of time from their infants. Differences in items covering areas of attachment, cohpetence in caregiving, and emotional state were not systematic, and about evenly divided in each group. However, there was a marginally significant tendency for cesarean mothers to describe themselves as more depressed (p<.06). PREDICTORS FOR CHILD ABUSE Recent studies have focused attention on the possible association with child abuse and neglect of antepartum and intrapartum events, 426 including cesarean birth. Lyneho compared 25 abused children with 35 of their nonabused siblings. She found that 12 abused children had had abnormal labor and deliveries, compared to 2 nonabused children. The difference was significant at the .001 level. Cesarean delivery was included in this category, but exact figures for cesareans in the two groups are not presented. In general these families had characteristics which have been associated with child abuse and neglect by other investi- gators. In a second study, Lynch and Roberts”’ compared 50 abused children with 50 controls consisting of the next birth at the same institution. They found that 22 of the abused and 17 of the nonabused children had had abnormal labors and deliveries. There were 8 abused children and 4 controls who had been delivered by cesarean. Neither of these differences are statistically significant. Both of these studies are based on small numbers. They are sugges- tive, and highlight an area in which further research is needed. Attempts to clarify any possible association of complications of pregnancy and birth with child abuse and neglect will be very difficult, however, since children reported as abused may be more likely to come from socio- economic backgrounds which also put their mothers at high risk of obstet- rical complications. ‘FAMILY CENTERED MATERNITY CARE As the number of cesarean births has increased so have the attempts to make the birth experience a more positive one for parents.’ 14 Family centered maternity/newborn care was defined by the Interprofes- sional Task Force on Health Care of Women and Children as management that 427 comprises the delivery of safe quality health practice while recognizing, focusing on, and adapting to both the physical and psychosocial needs of the client patient, the family, and the newborn. 35 The emphasis is on the provision of maternal and newborn health care which fosters family unity while maintaining physical safety. The Task Force acknowledged: - That the family is the basic unit of society. - That the family is viewed as a whole unit within which each member is an individual enjoying recognition and entitled to consideration. - That childbearing and child rearing are unique and important functions of the family. - That childbearing is an experience that is appropriate and bene- ficial for the family to share as a unit. - That childbearing is a developmental opportunity and/or a situa- tional crisis during which the family members benefit from the supporting solidarity of the family unit. Extending family centered maternity care to families has often been difficult. As Stichler and Affonso point out, aspects of the birth experience such as rooming-in, contact with the newborn immediately after birth, and sharing the experience with a mate are often given to vaginally delivered women, and may be felt as a loss and grieved for by cesarean parents. > Thus, parental and professional efforts to effect change in the care of cesarean families have focused on allowing the father to be at the mother's side during the birth itself, and increasing parent contact with the newborn, especially immediately after the birth. Parents have requested that hospitals abandon routine observation of cesarean infants for a 12-24 hour period in a special care nursery, since the new cesarean mother can have no contact with her infant during this time. Increasingly, hospitals are moving to a policy of individual 428 assessment of cesarean newborns. This allows most infants to go immedi- ately to the regular nursery in the mother's postpartum unit. Thus, although the mother may be largely confined to her bed during the first 24 hours, the infant may be brought to her as often as she wishes. With due attention to the infant's body temperature, the infant may remain in the delivery room until surgery is completed, sipaoidlly 0 the father is present. If the mother desires, she may hold and breast feed her infant as soon as the surgery is completed, when she is usually more comfortable. The Interprofessional Task Force on Health Care of Women and Children has stated that recovery rooms should allow for the option of allowing the infant to be with the mother and support person for a time period after delivery, and "where feasible, sash cesarean section patients may be allowed the same option, 38 FATHERS IN THE OPERATING ROOM A controversial change, which has received considerable consumer pressure, has been the issue of allowing the father to be present for the cesarean itself. In general, fears about adverse consequences of the fathers' attendance at cesarean birth have been similar to former fears about fathers' presence for vaginal deliveries. These questions include the potential for increased infection, fathers' fainting, lack of space in crowded operating rooms, interference with teaching programs, or increased malpractice charges. Experience in institutions that have instituted this practice has not indicated major problems. No adverse effects have been reported. In general, the father, dressed in appropri- ate scrub gear, enters when the surgery is about to begin, and is seated 429 on a stool by the mother's head, where he remains. In 1976 the Committee on Obstetrics: Maternal and Fetal Medicine of the American College of Obstetricians and Gynecologists stated that "The Committee cannot per- ceive strong medical indications or contraindications to the presence of fathers in the operating suite 2 More recently the opinion was reaffirmed with the additional note that the "presence of the father or other support person may be psychologically helpful to the mother." Whether or not the father's presence at birth is beneficial is difficult to demonstrate. Greenberg and Morris, studying the reactions of 30 first time fathers of normal infants, all born by uncomplicated spontaneous vaginal deliveries, found no highly significant differences between the 15 who were present for the birth and the 15 who were not . 30 However, fathers who were present believed they could distinguish their baby from others more readily than fathers who were absent. They repeat- edly and spontaneously spoke of "when you see your child born, you know it's yours," a connecting or "hooking" that was not mentioned by fathers who were not present for the birth.. There was also a trend for fathers who were present to be more comfortable holding the baby. In the study cited above, Petersen found cesarean fathers, none of whom were present for the birth, had substantially less positive feelings about the birth, as compared with fathers of vaginally delivered infants, most of whom had shared in the birth (p<.01).%2 Cesarean fathers mentioned relief and disappointment, while other fathers were generally very positive, even ecstatic. This difference may have been due to the fact that cesareans were performed in the A of complications which may have been frightening to the father. 430 Grossman, et al. >, and Doering and Entwistle" also found that involvement in labor and delivery seemed to facilitate the father's positive evaluation of the birth experience. In the latter data, the only fathers who rated the birth as "very negative" had been absent from the delivery room. When the father had been present for the birth, 94% of women, including three who had cesareans, and a similar proportion of the men felt positively about his participation. None were negative. However, when the father had been absent, 45% of mothers and 88% of fathers felt negatively about this exclusion. As before, these findings in part reflect a selection bias in both who chose to participate in the interviews, and which fathers chose to be present for the birth. Nolan, Gainer, and Van Bonn examined the joint effects of the father's presence at cesarean birth, and postpartum teaching about the 41542 Sixty-six women experiencing both primary and repeat procedure. cesareans were included. Selection to receive teaching on the third postpartum day was made randomly; except for the first 18, fathers were assigned on other grounds. There were no problems with the father's presence, no increase in infection or operative complications, no changes in resident or student training, and no fathers fainted or interfered. Hospital stay was about the same for all four groups. There was a substantial difference in the type of anesthesia used; most women with husbands present were awake, and most women with husbands absent were asleep. It is not clear on what basis choices of anesthesia were made. Use of postpartum pain medication was reduced when the father had been present. This effect reached statistical significance following postpar- tum teaching, and the greatest reduction in pain medication occurred in the group who had received both types of psychological support. 431 Mothers with the father present consistently expressed a higher average satisfaction score immediately after the delivery and three days later. This effect reached statistical significance among those women who received teaching. Specific components of the score which did reach statistical significance following the father's inclusion were less loneliness after delivery, more joy at delivery, and less fears for the baby's health in the postpartum period. The great majority of mothers whose husbands were present found the husband overwhelmingly supportive and his presence positive. Fathers who were present felt involved, that they had played an important role, and that they had been a source of strength and emotional support. All mothers and fathers in the father present group would want him there again. In fact, the majority of the father absent group, both mothers and fathers, stated they would want him there another time. Postpartum teaching about cesarean delivery had uniformly and reliably positive effects on the mother's physical and emotional responses to the birth. The intention had been to demonstrate the presence or absence of harm, rather than benefit, with the father's presence. Nonetheless, his involvement at the time of birth, while in no way compromising medical care or causing problems, showed consistently positive, and in some cases reliably so, effects on the mothers’ CESPONSS, Although these numbers were quite small, a subsequent series of over 300 fathers attending cesareans at the same hospital has not produced problems, including no malpractice charges. Both Joy? and Grossman’ have suggested that better prenatal preparation for the possibility of a cesarean delivery might reduce the anxiety, depression, and disappointment that they found may follow an 432 unexpected cesarean birth. Doering and Entwistle found that for the vaginally delivered women in their sample there was a positive associa- tion between the extent of prenatal preparation and their rating of the birth exper lenge. 0 However, for cesarean mothers, there was no such correlation. Thus parents have called upon childbirth educators to include better preparation for cesarean delivery in prepared childbirth 7,10,43,44 classes. In addition, many cesarean support and childbirth education groups, as well as provider institutions, have begun cesarean childbirth classes for parents anticipating a cesarean pirth.’?7111:12 These classes aim not only to provide information and to alleviate anxiety for mothers, but also to prepare fathers who will be present in the operating room. A number of writers have attempted to raise the sensitivity of caregivers and to suggest ways providers may improve the cesarean birth experience. 12114 16,18,19,20,22,25,44,45 In addition to better preparation for parents, there is a need for better preparation for nursing staff and other caregivers to meet the needs of cesarean parents, through training programs and education. This would be especially important before policy changes, such as allow- ing fathers to be present for cesareans, are implemented. SUMMARY 1. Research evidence concerning the emotional or psychological impact of a cesarean birth on the parents, as well as the benefits of education and preparation, is limited and has many methodological problems. 433 A number of writers have reported negative resonses to a cesarean birth among women. These include fear, disappointment, anger, lowered self-esteem, and a sense of loss of control. In part these reactions may reflect the disparity between prior expectations of birth and the actual experience. In part they may represent a reaction to the presence of the complications or crisis which necessitated the cesarean. Not all parents have negative emotional responses, and the influences on how parents react to the birth experience are many and varied. Efforts to extend the concepts of family centered maternity care to the cesarean family have been an attempt to make the cesarean birth experience a more positive and satisfying one for parents. Negoti- ating close contact among family members has usually been more difficult for new cesarean parents than others. Changes have been advocated principally in two areas: abandoning routine separation of the normal cesarean newborn in a special care nursery, and allowing the father or surrogate to be present for the cesarean. Although fears of adverse effects have been widespread, no evidence of harm from the father's participation has been reported. Other suggestions that have been made to improve cesarean birth experiences have been better parent prenatal preparation through traditional and cesarean childbirth classes, and improved sensi- tivity of nurses through training programs and education. 434 BIBLIOGRAPHY 1. De 10. 1. 12. 13. Grace, Jeanne T.: Good Grief: Coming to Terms with the Childbirth Experience. JOGN Nursing 7 (1): 18-24, 1978. Affonso, Dyanne: "Missing Pieces'"--A Study of Postpartum Feelings. Birth and the Family Journal 4(4): 159-164, 1977. Affonso, Dyanne and Stichler, Jaynelle: Cesarean Birth: Women's Reactions. American Journal of Nursing, 468-470, March 1980. Affonso, Dyanne and Stichler, Jaynelle: Exploratory Study of Women's Reactions to Having a Cesarean Birth. Birth and the Family Journal 5(2): 88-94, 1978. Bampton, Betsy A. and Mancini, Joan M.: The Cesarean Section Patient Is a New Mother Too. JOGN Nursing 2(4): 58-61, 1973. Cane, Aleta and Shearer, Beth: Frankly Speaking: a pamphlet for Cesarean couples. Second edition. Boston, C/SEC, Inc., 1978. Cohen, Nancy Wainer: Minimizing Emotional Sequellae of Cesarean Childbirth. Birth and the Family Journal 4(3): 114-119, 1977. Conner, Beth Shearer: Family centered cesarean birth--Supporting families through planned & unplanned cesarean birth. In Simkin, Penny and Reinke, Carla (Eds.: Kaleidoscope of Childbearing: Preparation, Birth and Nurturing (Highlight of the Tenth Biennial Convention of the International Childbirth Education Association, Inc.). Seattle, the pennypress, 1978, pp. 43-45. Conner, Beth Shearer (Ed.): Manual for Setting Up Prepared Childbirth Classes for Cesarean Parents. Boston, C/SEC, Inc., 1977. Conner, Beth Shearer: Teaching About Cesarean Birth in Traditional Childbirth Classes, Birth and the Family Journal 4(3): 107-113, 1977. Donovan, Bonnie: The Cesarean Birth Experience. Boston, Beacon Press, 1977. Donovan, Bonnie and Allen, Ruth M.: The Cesarean Birth Method. JOGN Nursing 6(6): 37-48, 1977. Drucker, Cyndie Van Hook and Hoogerwerf, Arlene: Emotional Aspects of Cesarean Childbirth. In Stewart, D. and Stewart, L. (Eds.): Compulsory Hospitalization or Freedom of Choice in Childbirth? Marble Hill, MO, NAPSAC Reproductions, 1979. Vol. III, Ch. 62, pp. 825-830. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 2s. 27. 28. 435 Enkin, Murray W.: Having a Section Is Having a Baby. Birth and the Family Journal 4(3): 99-106, 1977. Hausknecht, Richard and Heilman, Joan R.: Having a Cesarean Baby. New York, E.P. Dutton, 1978. Hedahl, Kathleen J.: Cesarean Birth: A Real Family Affair. American Journal of Nursing, 471-472, March 1980. Hickernell, Barbara (Ed.): Cesarean Childbirth: A Handbook for Parents. Briarcliff Manor, NY, Westchester ASPO, 1978. Marut, Joanne Sullivan: The Special Needs of the Cesarean Mother. MCN: The American Journal of Maternal-Child Nursing 4: 202-206, 1978. Marut, Joanne Sullivan and Mercer, Ramona T.: Comparison of Primiparas' Perceptions of Vaginal and Cesarean Births. Nursing Research 28(5): 260-266, 1979. Mevs, Lois: The current status of cesarean section and today's maternity patient. JOGN Nursing 6: 44-47,1977. Rozdilsky, Mary Lou and Banet, Barbara: What Now? A Handbook for New Parents. New York, Charles Scribner's Sons, 1975. Ch. 1, pp. 16-22. Schlosser, S.: The emergency C-section patient: Why she needs help--What you can do. RN41: 53-57, 1978. Stichler, Jaynelle and Affonso, Dyanne: Cesarean Birth. American Journal of Nursing, 466-468, March 1980. Sugarman, Muriel: Paranatal Influences on Maternal-Infant Attachment. American Journal of Orthopsychiatry 47(3): 407-419, 1977. Wilson, Christine Coleman and Hovey, Wendy Roe: Cesarean Childbirth: A Handbook for Parents. Ann Arbor, 1977. (To be published in expanded version by Doubleday/Dolphin, 1980.) Kaplan, David M. and Mason, Edward W.: Maternal Reactions to Pre- mature birth viewed as an acute emotional disorder. Am. J. Ortho- psychiatry 30:539-552, 1960. Seashore, Marjorie J. et al.: The effects of denial of early mother- infant interactions on maternal self-confidence. J. of Personality and Social Psychology 26(3):369-378, 1973. Barbero, Giulio J., Morris, Marian G., and Reford, Margaret T.: Malidentification of mother-baby-father relationships expressed in infant failure to thrive. In The Neglected Battered Child Syndrome. New York, Child Welfare League of America, G17, 1963. 29. 30. 31. 22. 33. 34. 25. 36 27. 38. 39. 40. 41. 436 Willmuth, L. Ragan: Prepared childbirth and the concept of control. JOGN Nursing 4:38-41, 1975. Doering, Susan G.and Entwisle, Doris R.: The First Birth. Final Report to the National Institute of Mental Health, July, 1977. Doering, Susan G.: Paper presented to the meetings of the American Foundation for Maternal and Child Health, New York, November 1977 (unpublished). Petersen, Frank A., et al.: Cesarean Childbirth: The Importance of a Family Perspective. NICHD, 1979. Grossman, Frances K. et al.: Mothers, Fathers, and Babies: Adaptation to Pregnancy, Birth and Early Parenting. Jossey-Bass, in press. Doering, Susan G.: Personal communication, May 1980. Joy, Leslie A.: Ramifications of caesarean versus vaginal delivery. for the development of maternal attachment. Paper presented at the biennial meeting of the Society for Research in Child Development, San Francisco, March 1979. Lynch, Margaret A.: Ill-Health and Child Abuse. The Lancet, 317-319, August 16, 1975. Lynch, Margaret A. and Roberts, Jacqueline: Predicting child abuse: signs of bonding failure in the maternity hospital. Brit. Med. J. 1:624-626, 1977. Pl Interprofessional Task Force on Health Care of Women and Children: Joint Position Statement on the Development of Family Centeered Maternity/Newborn Care in Hospitals. June 1978. Shirley A. Shelton, Administrator, Practice Division, American College of Obstetricians and Gynecologists, personal communication February 19, 1980. Greenberg, Martin and Morris, Norman: Engrossment: The Newborn's Impact upon the Father. Am. J. of Orthopsychiatry 44(4)520-531, 1974. Gainer, Margaret and Van Bonn, Patricia: Two Factors Affecting the Cesarean Delivered Mother: Father's Presence at the Delivery and Postpartum Teaching. Ann Arbor, University of Michigan Press, 1977. 437 42. Nolan, George H., M.D., personal communication, November 9, 1979. 43, C/SEC, Inc.: Guidelines for Childbirth Instructors. 1976. 44. Conklin, Mary M.: Discussion Groups as Preparation for Cesarean Section JOGN Nursing 6(4): 52-54, 1977. 45. Reynolds, Cheryl B.: Updating Care of Cesarean Section Patients. JOGN Nursing 6(4): 48-51, 1977. Chapter XIX - Effects on Infant Development 441 INTRODUCTION Developmental studies on the effects of cesarean birth comprise a very small literature. Most of the published studies have assessed development only during the first few months following birth. In contrast there is an abundance of studies of the cesarean birth as a medical event. However there are many reasons for considering cesarean birth a nr with implications for the subsequent interactions of mother, father, and infant. The cesarean delivery may be extremely different from the antici- pated experience by parents, who have prepared themselves for a vaginal delivery with father present and with little or no medication. The often rapid decision to perform a cesarean may not allow the parents time to adjust to the change in plans. Separation of mother and father often takes place and there is less opportunity for these parents to interact with each other and with their child immediately following the delivery. In addition concerns have been addressed to the medications administered during cesarean delivery, questioning both long and short term central nervous system effects on the infant. Family effects of cesarean birth have been discussed in Chapter XVIII. However, for continuity of this theme, some of the materials will overlap with those already presented. Studies identified in the literature search addressed the following questions: (1) do the reactions and behaviors of parents differ during and after cesarean and vaginal deliveries? (2) what are the differences in parent infant interactions following the different childbirth 442 experiences? (3) what are the implications of cesarean delivery for the infant's development? and (4) does the impact of caesarean delivery differ in different social groups? A variety of methodologies were utilized in the studies, including assessment of mothers' medical status before, during, and after delivery, and of infants' medical status after the delivery; observations of parent- infant interaction in the hospital, laboratory and at home; measures of infant development and infant temperament; interviews with parents concerning the birth experiences and adaptations to parenthood; and measures of parental anxiety and depression. Except for one 5 year longitudinal follow up study by Ingemarsson, Westgren & Svenningsen’ and data from the Collaborative Perinatal Study reported by Broman, et a1?, the research located in the literature search had been limited to infant development through the first year of life. In addition most of these protocols involved very small numbers of infants with varying medical complications. Thus, since the sample sizes are often inadequate for the number of assessments made, several of the effects may be spurious findings. THE NEONATAL OUTCOMES Focusing on neonatal outcomes, vaginal and cesarean born infants were compared by Croghan et al. The subjects for this study were 24 Mother/Infant (M/I) dyads. The infants selected were later born healthy, full-term (>2500 gms) single births. The mothers ranged in ages from 20 to 30 years: Twelve infants (6 male, 6 female) were delivered by repeat cesarean. Twelve (6 male, 6 female) were delivered vaginally. 443 On the second day postpartum in the hospital room M/I interaction was observed during a 20 minute feeding session. Maternal behaviors rated during feeding included attentiveness, general sensitivity, frequency and quality of auditory and visual stimulation, quality of tactile stimulation, and quantity of functional .and nonfunctional handling. The infant behaviors coded included initial and predominant behavioral state; body position; eye contact; responsivity to auditory, visual and tactile stimulation; and responsivity to holding. In order to provide an independent assessment of infant responsivity and behavioral capabilities, the Brazelton Neonatal Behavior Assessment Scale (BNBAS) was administered on the third day. Preliminary analyses suggest group differences in infant responsivity and behavioral capabilities. As assessed by the BNBAS, infants in the cesarean group demonstrated greater motor maturity, stronger defensive behavior, and less of a need to be consoled. Infants delivered vaginally tended to be more alert, more responsive to animate visual and auditory stimuli and more prone to self-quieting behavior. Although these differences suggest that the cesarean group showed more mature attentional behavior, the differences are very few relative to the 57 items in the Brazelton scale, and may be related to chance. During feeding, infants in the cesarean group were more responsive to auditory stimuli and their mothers provided more auditory stimuli. Furthermore, in the cesarean group, the amount of auditory and visual stimuli presented by the mother correlated with responsivity to auditory 444 and visual stimuli during the observation period and during testing. In the vaginal delivery group, the mothers were more attentive to their infants during feeding situations, and also displayed more head and facial movement. Infant responsivity to holding and cuddliness scores on the BNBAS were correlated for this group. Since there were as many positive behaviors noted for each of the groups in different areas, a tentative conclusion made by the authors was that each type of delivery had positive effects. Statistically it is important to note that since the sample size was inadequate for the number of variables analyzed, several of the effects reported may be spurious. Focusing on the first month postpartum Gewirtz and his colleagues” compared cesarean and vaginally delivered infants and their parents for a variety of behavioral indices following early contact experiences. The subjects were from two middle socio-economic status (SES) white groups. One group was composed of 55 vaginally delivered infants and their mothers and families. The second group consisted of 39 infants and their parents following cesarean birth. Both groups were normal full term . infants, delivered under epidural anesthesia, and with no delivery complications for either infant or mother. During the first postpartum hour the vaginally delivered infants while still in the recovery room spent either 15 or 60 oo in interaction with their mothers. The infants were either swaddled and nested in their mother's arms, or naked and held in a ventral ventral position with head aligned on the mother's naked body. The cesarean infants lay in their isolettes in the special care nursery. [Their fathers remained either 5 or 60 minutes in inter- 445 action with them. Cesarean birth infants did not interact with their mothers until at least the 6th hour postpartum. Within the two delivery modes, mother/infant pairs were assigned at random to short or long interaction duration conditions, during the first postpartum hour. Therefore, the statistical design crossed the two modes of delivery with two contact durations (short vs. long). In this double- blind design, 11 parent and 11 infant behaviors were time sampled during two 15-minute periods. One period was during feeding and the other period was between feedings, on days 2-3 and day 28 postpartum. Infant behaviors were also assessed on day 2 by the Brazelton Scales, and again on day 28 by parent ratings. The results are recorded below. 1. BRAZELTON SCALE. For items on the Brazelton Scale multivariate analysis of variance (Manova) yielded reliable group differences. The means of vaginally delivered infants were higher than the cesarean delivered infant means on Plantar Grasp and Resistance of Left Arm. In contrast, cesarean infant means were higher than vaginal delivery infant means on Tonic Deviation, and for the ancillary descriptive variables, Predominant Behavioral State and Attractiveness. Again, there were few behavioral differences relative to the 57 Brazelton items. These 'investi- gators’ and Croghan et al’ might have more effectively used the four Brazelton summary scores in their analyses rather than individual items. Since group differences were noted on only a few of the 57 items, however, the groups would probably not differ on the four scores typically used to summarize performance. 446 2. INFANT INTERACTION BEHAVIOR. Across observation days 2-3 and day 28, an overall effect was detected for infant behavior in interaction with the mother. Cesarean infants exhibited higher rates for face to face looking at the mother and mouthing than did vaginally delivered infants. 3. MATERNAL INTERACTION BEHAVIORS. An interaction effect between treatment and day of observation was detected for maternal behaviors during interactions with their infant. Mothers in both groups exhibited more kissing and showing and telling about their infants by day 28 than at day 2-3. This change between 2 and 28 days was greater for cesarean than for vaginal delivery mothers. In contrast, the pattern of Finger Touching of the Infant was reversed with age. Both cesarean and vaginal- delivery mothers exhibited more mean finger touching on day 2-3 than on day 28. The mean change was again greater for cesarean than for vaginal delivery mothers. Since mean changes between the 2 and 28 day observations were analyzed rather than absolute amounts at each of these times, it is not clear whether cesarean mothers and infants showed greater changes simply because their day 2 activity levels were lower than the vaginal delivery group. Mothers of those infants who had interacted for longer duration with a parent rated themselves more satisfied with their child's personality. In this frame, an interesting result was detected within the cesarean group. When compared with mothers, the cesarean fathers rated themselves more satisfied with their child's personality. These data suggest that there is a relationship between amount of contact 447 with the infant in the neonatal period and expressed "satisfaction with personality" of the infant at one month. Thus, if the cesarean delivery father spent more time than the mother during the initial postpartum hours, it is not surprising that he might show more "satisfaction with personality" of the infant than the woliner at one month. Since there are no follow up data, it is not clear whether the effects they report are temporary or have any influence on development beyond the early postnatal period. The relatively positive effects noted by Gewirtz et a1? are in contrast to those reported by Entwistle. Although Entwistle's metho- dology is unclear and her analyses very preliminary, she reports the following for 20 cesarean couples (mothers and fathers): (1) "They viewed the whole childbirth experience slightly negatively"; (2) "They were more depressed postpartum"; (3) "Their babies cried more per 24 hours at 3 weeks postpartum". These findings are based on telephone interviews for which there are no confirmatory behavioral observations. In addition, there apparently was a self selection factor involved in the sampling which in itself may explain the cesarean delivery attitudes reported. This author notes, for example, "...the effects of couples' preparation in pregnancy (attendance at childbirth classes, reading articles and books, and the like) were markedly different according to whether or not there was a section". THE OUTCOMES FOR THE FIRST SIX MONTHS POST BIRTH Again, in contrast with Entwistle's data’ there is data from two 448 other groups®”’ who also focused on mothers' and fathers' responses to cesarean deliveries. In these studies, fathers were observed as well as interviewed. For example, Pederson and his colleagues’ looked at the behaviors of three members of the family (infant, mother, and father) over the first six months. The fathers reported positive effects. In a sample of 41 non-minority, two-parent families with a first born infant, there were 6 cesarean deliveries (a 15% rate); the balance underwent normal, vaginal deliveries. The two groups were similar in background and demographic variables. Families were studied between the infants' 5th and 6th months with interviews, home observations, assess- ments of the infant's temperament, and the Bayley Scales of Infant Development. No apparent differences were noted for infant temperament or infant mental and motor development during the first 6 months of life. Measures that distinguished the families on the basis of their childbirth exper- iences were concentrated in the father-infant and spouse interaction areas. Fathers of cesarean infants participated in a greater amount of caregiving activities and were rated as significantly more responsive to their infants' distress signals than fathers in the comparison group. Although concerned with their infants' physical needs, the fathers of cesarean-delivered infants showed no greater involvement for non-caregiving reasons. On 11 of 12 measures of social interaction, these fathers were numerically, but not significantly lower than fathers in the comparison group. Mothers and fathers of cesarean delivered infants were observed to communicate with each other more about matters concerning the baby 449 than in the vaginal delivery group. The mothers of cesarean delivered infants tended to direct more negative affect to their husbands than in the comparison group. The authors’ interpreted their results as providing evidence that the effects of a childbirth complication are distributed among all members of the family and are observable at least through the first half year of the infant's life. Higher involvement of the father in child care may have been fostered by the greater needs of the mother in the early post-delivery weeks. This influence may have affected the husband-wife interaction as well. A very similar study by Vietze and his colleagues’ also provides suggestive evidence for increased father involvement with cesarean delivered infants. Again, mother and father infant interactions were observed when their first born infants were six months old. Of 75 middle income families in the study, 17 families were delivered by cesarean while the other 58 were vaginal deliveries. Observations were carried out by observers blind to delivery status. Interactions were observed at home with two sessions of mother and infant, and one session of father and infant. In addition to the behaviorial observations, parents kept diaries of the infants' activities and companions, for a period of one week around the time of the observations. For purposes of analysis, the two mother sessions were combined. Analyses of the durations of behaviors produced by each parent and by the infants in interaction revealed several noteworthy findings. Fathers of infants delivered by cesarean spent significantly more time soothing 450 their babies, engaged in more general caretaking and were in closer proximity to their babies when compared with fathers of vaginally delivered infants. The cesarean delivery fathers also showed less vocalization and demonstration activities and their infants engaged in less motor activity when compared with the vaginally delivered group. Mothers who experienced cesarean deliveries spent more time stimulating their infants kinesthetically, but showed less time vocalizing to their infants than those who experienced normal deliveries. Other analyses compared fathers and mothers in relation to mode of delivery. These analyses supported those reports above. Contrasting mothers and fathers within the cesarean group, fathers soothed more than mothers. There were no differences between mothers and fathers in the vaginally delivered group. Mothers in the cesarean group vocalized more and were out of the room more than fathers. There were no differences between parents in the vaginal delivery group. Infants who were delivered by cesarean showed more distress in the presence of fathers than mothers, while the babies in the comparison group showed no such differences. The diaries revealed that fathers of infants in the cesarean group spent significantly more time alone with their infants than fathers in the vaginally delivered group. These results indicate that for babies delivered by cesarean, the fathers assumed more caregiving responsibility for their infants even at six months of age. However, they showed no greater involvement during non-caregiving interactions. Mothers who delivered by cesarean showed 451 higher levels of kinesthetic but lower levels of verbal stimulation than their vaginally delivered counterparts. The implications of these findings are discussed in terms of their impact on family organization and subsequent infant development. It is especially noteworthy that by six months there were few major differences in the infants' behavior regardless of mode of delivery. ONE YEAR FOLLOW UP STUDIES In a similar vein, Field and Wicmayer®?® reported group differences in early interactions as a function of mode of delivery. Their study in- volved a comparison between cesarean and vaginal deliveries, and a developmental follow up of the infants to age eight months. Their sample, unlike the previously described study samples of middle SES parents, involved lower SES, black mothers, 20 of whom delivered vagin- ally and 20 by cesarean birth. The neonates were full term (mean birth weight 3,237 grams) and had Apgar scores of 7 or above. Maternal age (mean age 20 years) and parity were evenly distributed among cesarean and vaginal deliveries. Multiple indications were cited for the emer- gency cesareans including secondary arrest of labor, disproportion, preeclampsia, fetal distress, and breech presentation. In addition, some of the cesarean mothers experienced antepartum or intrapartum hyperten- sion, toxemia or both illnesses. All cesarean delivery mothers were given nitrous oxide. Vaginal delivery mothers were given either no anesthesia or local regional anesthesia. Minimal medication was given during the vaginal deliveries. At four months post-delivery the cesarean mothers showed elevated diastolic blood pressures and higher or less optimal state trait 452 anxiety ratings. The cesarean delivered infants performed less optimally on the Denver adaptability items (tracking, reaching or grasping). Their mothers, however , rated them more optimally on the infant tempera- ment questionnaire. In addition, the cesarean mothers stated more realistic expectations of developmental milestones and, together with their infants, received more optimal face-to-face and feeding interaction ratings. At eight months the cesarean mothers showed higher systolic and diastolic blood pressures and the cesarean infants higher diastolic pressures. Analyses revealed no difference on the Caldwell. Home Assess- ment, the Bayley Mental Scale (M=113 for cesarean, M=109 for vaginal delivery infants), the Bayley Motor Scale (M=112 for cesarean, M=116 for vaginal delivery infants), or Bayley Infant Behavior Record. Once again, the cesarean mothers rated their infants' temperament more optimally. A slightly longer term follow up of the psychological sequelae of cesarean delivery occurred in the context of a project following 89 couples through pregnancy, birth, and early parenting 'C. All research participants were married. The couples were recruited for the study from the medical settings in which they were receiving prenatal care. They ranged in socioeconomic status from lower to upper SES with the majority being middle and upper middle. Out of 89 births, 21 (23.7%) were cesar- ean deliveries. The study included: (1) measures of infant health and develop- ment in the newborn period, at 2 and at 12 months; (2) interviews with the mother and father at 2 and 12 months postpartum concerning the birth, 453 adaptation to parenthood, and sense of comfort concerning self, spouse relationship, and parenting; (3) measures of parents' anxiety and depres- sion at 2 and 12 months; and (4) ratings from observations of maternal feeding behavior at 2 months, and mother-infant interaction at 2 and 12 months. The findings indicate that in this sample, infants delivered by cesarean tended to be heavier at birth, and to have slightly lower Apgar scores. [he mothers were given more medication during the process of delivery. At 2 months postpartum, for the sample as a whole and more strongly for first borns, infants born by cesarean delivery were physio- logically less mature and healthy, and had lower motor scores than babies delivered vaginally. Mothers who delivered by cesarean were judged as adapting less well to the labor and delivery in the early postpartum period, and were clear in their interviews concerning their negative reactions to the birth process. Although by 2 months postpartum there were no negative sequelae for the women who delivered by cesarean, they said in the interview that they were "still feeling the effects". An unexpected finding occurred in the couples whose infants were delivered surgically. The men seemed more involved in, and satisfied with, the arrangements they and their wives had made concerning parenting. The men were closer to their infants at 2 months postpartum than fathers with infants delivered without surgical intervention. They speculated that "men become more involved and more responsive to their wives and infants when their wives are:less able to cope, as women are after surgical delivery." The authors concluded: "There were no effects of a caesarean delivery by one year, suggesting that in well functioning 454 family units, such as the families in our study, the number and quality of resources are sufficient to overcome any negative impact of a compli- cated birth. Possibly in families with less adequate personal and inter- personal family resources, these effects could be lasting and destructive." The speculation of these authors about potentially "lasting and destructive" effects in families with less adequate personal and interpersonal family resources is not supported by the previously described data of Field and Widmayer®’’ on lower SES families. The Grossman’ study, in general, illustrates that despite reports of negative feelings about the cesarean delivery experience, there appear to be no negative effects on the behaviors of either the parents or the infants. The expression of negative feelings appears to be limited to the immediate postpartum period. A one year follow up of a much larger sample (N=158) compared the development of vaginal and cesarean delivered term and preterm twins . All of these infants were lower SES, and ethnicity was distributed 52% black, 18% white and 30% Hispanic. Although there were significant differences between the neonatal birth data and Brazelton scores of preterm and term twin pairs favoring the term twins, there were no differences as a function of vaginal or cesarean delivery. At four months there were no differences on interaction behaviors of the mother (e.g. verbal activity) or the infant (e.g. gaze aversion) as a function of delivery in the case of the term infant group. However, the interaction behaviors of the cesarean delivered preterm twins and their mothers were more optimal than those of the vaginally delivered preterm twins. These differences favoring the cesarean delivered preterm infants and mothers 455 persisted at twelve months on both interaction ratings and Bayley develop- mental scores. In addition, a comparision was made between twins within 8 pairs in which one twin was delivered vaginally and .the second twin, due to prolapsed umbilical cord and/or acute fetal distress, was delivered by cesarean. Although the cesarean delivered twin experienced more perinatal complications, there were no follow up differences between twins within pairs experiencing both types of delivery. LONGER TERM FOLLOW UP STUDIES As noted earlier, except for the one 5-year longitudinal follow up| and the Perinatal Collaborative Study, 2 the studies located in the literature search have followed development only though the first year of the infant's life. The longest follow up reported in the literature involved a comparison of cesarean versus vaginal delivery of breech infants, This comparison suggested a reduced frequency of severe prolonged asphyxia and neonatal mortality and more optimal developmental and neurological outcomes at 1-5 years for cesarean delivered breech infants. Unfortunately, these data cannot be generalized beyond the cesarean delivered breech infant. These authors provided no details on the nature of the developmental or neurological assessments. In the very large sample Collaborative Perinatal Study of 38,000 births, a correlation screen on delivery variables and 4 year IQ scores failed to reveal any relationship between type of delivery (vaginal or 2 cesarean) and outcome as measured by IQ scores’. 456 SUMMARY In grouping and summarizing these studies, a few generalizations can be made. 1. One of the most striking findings is the consistency across studies (with the exception of the Entwistle study)’ of the greater involvement of fathers with their cesarean delivery infants. This observation ranged from attitudes of greater satisfaction with the child's personality expressed by fathers, to fathers being more responsive to their infants' distress signals, to fathers engaging in more caregiving activities, to fathers spending more time with their infants. Several of these authors suggested that "men became more involved with their infants as their wives were less able to cope, as women are after surgical delivery." Since the latter is not a documented medical reality, that interpretation remains speculative. Two pieces of data absent from almost every study are the nature of the cesarean (emergency or elective) and the presence/absence of fathers in the delivery room. The cesarean may have been viewed as a crisis event which mobilized family support systems such as the father's involvement, may have altered the parents' perceptions of their infants' behaviors and temperament, and may have contributed to "special treatment" of the emergency delivered infant. A universally reported finding was the mother's less positive attitudes and greater anxieties regarding the birth process. Another observation that is less consistent but was noted in a few studies relates to infant behavior. Although higher delivery medication levels of the cesarean infants might suggest neonatal 457 depression, those studies assessing neonatal behavior did not reveal depressive effects. In fact, in the Gewirtz et al study’ the cesarean infants were noted to be in a more optimal state, to engage in more face-to-face looking, and to be rated more attractive by Brazelton examiners. The greater amounts of face-to-face looking persisted to 1 month. Similarly, in the Field and Widmayer study, 8? cesarean infants' interactions were rated as more optimal by examiners and their temperaments were rated as more optimal by their mothers. However, the infants were also noted in a few of the studies to show less optimal behavior, for example, less strong plantar grasp, engage in less motor activity, show less optimal performance on Denver adaptability stems®?® and show less optimal psychomotor development (Grossman). By and large, however, the infant develop- ment effects reported were minimal, and by 8-12 months there were virtually no delivery mode differences except for the case of those breech infants whose development significantly benefited by a 8,9 cesarean delivery, and the case of preterm twins whose development appeared to benefit from a cesarean delivery. 458 BIBLIOGRAPHY 10. Ingemarsson, I., Westgren, M. & Svenningsen, N.W. Long term follow up of preterm infants in breech presentation delivered by caesarean section: A prospective study. The Lancet 172-175, 1978. Broman, S. H., Nichols, P. L. & Kennedy, W. A. Preschool IQ: Prenatal and early develomental correlates. New York, Lawrence Erlbaum Associates, 1975. Croghan, N., Connors, K. & Franz, W. Vaginal vs. C-section delivery: Effects on neonatal behavior and mother-infant interaction. Paper presented at the International Conference on Infant Studies, New Haven, Connecticut, April, 1980. Gewirtz, J., Hollenbeck, A. & Sebris, S. L. Cesarean section and vaginally delivered infants and their parents compared during the first post-arrtum month. Paper presented at the International Conference on Infant Studies, New Haven, Connecticut, April, 1980. Entwistle, Unpublished Data, 1979. Pederson, F., Zaslow, M. Cain, R. & Anderson, B. Cesarean child- birth: The importance of a family perspective. Paper presented at the International conference on Infant Studies, New Haven, Connecticut, April, 1980. Vietze, P. M., MacTurk, R. H., McCarthy, M. E., Klein, R. P., & Yarrow, L Impact of mode of delivery on father and mother infant interaction at six months. Paper presented at the International Conference on Infant Studies, New Haven, Connecticut, April, 1980. Field, T. & Widmayer, S. Developmental follow up of infants delivered by cesarean section and general anesthesia. Infant Behavior and Development 1980, in press. Field, T. & Widmayer, S. Eight month follow up of infants delivered by cesarean section. Paper presented at the International Conference on Infant Studies, New Haven, Connecticut, April, 1980. Grossman, F. K. Psychological sequelae of cesarean delivery. Paper presented at the International Conference on Infant Studies, New Haven, Connecticut, April, 1980. 459 SECTION V - OTHER ISSUES RELATING TO CESAREAN BIRTH The next three chapters are grouped together in order to present significant and important medically related issues surrounding cesarean births. Chapter XX - Ethical Concerns Chapter XXI - Medicolegal Concerns Chapter XXII - Economic Concerns Chapter XX - Ethical Concerns 463 The ethical issues associated with the performance of the cesarean delivery are, for the most part, not specific to this — They are mainly issues shared with other specialized techniques and therapies, as well as with the general practice of the health professions. These issues include matters pertaining to the achievement and preservation of real and potential goals of patients as well as those of the health professionals, and methods for resolving conflicts between competing value claims. THE PRIORITY OF THE PATIENT By longstanding tradition the health professions are committed to providing the best possible care to patients, giving them priority over the professional's own self-interest, ] On this basis it would seem unethical to institute or to withhold a procedure if doing so might subject patients, in this case the mother and her fetus(s), to increased health risks, for such self-interest reasons as the health professional's convenience or increased monetary or other reward, or to provide opportunity for enhancing the professional's skill or competence, or even to protect the professional from legal action by the patients or their representatives. While each of these may be a reason for doing the procedure, each is a secondary reason and should not be allowed to take priority over the physician's higher purpose of fostering the health and well-being of the patient (s). On a scale of values, patient values will ordinarily take highest priority if for no other reason than the fact that in the 464 professional to patient relation, the patient is in a position of special vulnerability. It will always be difficult to judge whether an exceptional health professional is allowing a secondary value (that is, self-interest such as convenience, monetary or other reward, training experience, or mal- practice protection) to take first place in his/her judgment in placing patients at unnecessary risk. This is a question of personal conscience and motivation which may sometimes be hidden even from the professional (him) (her) self. It is important, however, that the professional be aware of the ideals and be reminded of the special temptations attendant upon the health-care provider role. The unnecessary risk - be run in either direction, of course, the non-performance of the cesarean as well as its performance. But the point remains, it is generally accepted that it is the patient's interest and not that of the health-care provider that must take precedence. THE DECISION-MAKING PROCESS: PATIENT AND PHYSICIAN INTERACTION Patient priority includes priority in the decision-making process. Patients ideally should have the final say in matters relative to their own persons. 273 This includes access to information, including avail- ability of facilities and personnel, upon which to base such decisions (informed consent}. It also includes the right to have representa- tives speak for the patient when the patient is unable to do so, the representative being someone who may be assumed to have the patient's best interest at heart.” This does not mean that the physician is a passive non-participant in the process, however, nor does it mean that 465 the patient or her agents may impose their decisions upon (him) (her). It is the physician's responsibility to counsel and inform, but it is also (his) (her) right to refuse to participate in a procedure with which (he) (she) does not CONES THE RIGHTS OF THE FETUS In the case of cesarean delivery there are almost always at least two patients involved--only one of which (the mother) may be able to speak for herself. Indeed this is the main feature that makes decision- making in cesarean birth unique ethically. The other patient. (fetus or fetuses) will always require that someone else make the decision for (him) (her) (them). Usually, but not necessarily, the mother will be assumed to be the surrogate who as the fetus(es)' best interest at heart. An exception to the above unique feature would be a case where one or the other of the patients has expired. When the dead individual is the fetus the issue involves largely a medical judgment as to the timing and the preferred procedure for removing the dead fetus from its uterine environment that will best safeguard the mother's health. Ordinarily this will not require a cesarean but may if the dead fetus presents a significant threat to the maternal physical or mental well- being and other methods of delivery prove unsuccessful. The issue would be reversed and become both acute and emergent in a situation involving the death of the mother only. In this case time would be of the essence during the brief period of continued fetal viability. An immediate delivery by post-mortem cesarean would usually 466 be indicated along with the use of whatever maternal cardiopulmonary aids may be available to assist in placental perfusion while the section is being performed, at least until sufficient time has elapsed to indicate irreversible fetal brain damage. The fetus in this situation is the primary subject of concern. In both of the above circumstances the point of ethical significance is that the demise of one patient does not obviate the necessity of serving the needs of the other. There are ordinarily at least two patients involved and each makes claims upon us independently so long as viability persists.’ This independence is further illustrated by situations where other persons than the patients may influence the decision. For example, in a case where a pregnant patient presents a history of giving birth to previous infants with congenital anomalies and is now carrying a pre- mature fetus who is showing evidence of fetal distress, whether to place the premature fetus at risk with an immediate delivery including a possible cesarean should not be decided by the previous anomalous fetuses but by its own independent needs, that is, by weighing its present distress against the risks of premature delivery. Only in situations where this fetus is considered to have serious, life-threatening congen- ital abnormality should fetal abnormality influence the decision. COMPETING MATERNAL AND FETAL INTERESTS In situations involving the competing interests of patients (i.e., mother vs. fetus(es)), for example where the institution of the procedure or its omission may benefit the one more than, or even at the expense 467 of, the other, the one at greatest risk will generally be given prece- dence in making the decision - providing that there is truly a benefit to be obtained.” Attempts will always be made, however, to maximize the benefits and minimize the risks for all patients involved. An example of such competition might be where a mother requests a medically non-indicated cesarean for reasons such as her convenience or unwillingness to experience ordinary physiologic delivery. If this places the fetus at increased risk, the fetus's interest will generally take precedence. A more serious example would be where advanced breast carcinoma or unremitting, severe pre-eclampsia in the pregnant mother would usually indicate speedy termination of the pregnancy but where fetal immaturity places the fetus at significant risk from a cesarean birth. If it is not possible in such cases to benefit both of the patients and one must be placed at greater risk for the sake of the other, in our society, the mother will generally be given preference’ because of her greater human investments, other children in the family, obligation to her spouse, to the larger community, etc. The fetus's investments are at this point still largely potential. Moreover, the mother by her actual personal and social association has accrued a measure of symbolic human identity not yet achieved by the unborn fetus. Decisions of this nature may also be influenced by the degree of benefit to be obtained by the person given priority. For example, in the case of the breast carcinoma, if the length and quality of the mother's life is not materially increased by granting her priority 468 in the decision process, it may seem illogical to do so. In any case the process should still conform to the general pattern of decision- making outlined above. EXCEPTIONS TO GENERAL RULES OF PRIORITY There are certain exceptions to this general rule. Some pregnant persons would grant priority to the fetus on theological and metaphysical grounds. The mother's choice in such a case should be honored, whether made directly or via individuals authorized to speak for her. A special case involving the religious beliefs of the maternal patient is presented by the pregnant Jehovah's Witness, who on religious grounds extends the 0ld Testament proscription against the ingestion of blood to receiving blood, or blood-product, transfusions. Given a situation where such belief on the part of the mother places both her and her fetus in jeopardy, for example where an emergency cesarean is indicated because of abruptio placenta, and where blood loss from the abruptio and from the ensuing surgery must be replaced by transfusion according to standard medical procedure, the physician may be placed in a difficult position. The mother's conscientious refusal to receive blood places both her and her fetus in peril. Generally it is agreed, in a society honoring personal freedom of decision, that the mother's rights in matters involving her own person are inviolable. But the question in this situation is, "does she have absolute rights over the life of her viable fetus?" Such absolute rights are generally denied by the larger society through its legal structure. The State is generally considered at some point to have 469 an overriding interest in preserving the life of fetuses. In this case the physician will be acting properly when he/she assumes that the State (through the courts) rather than the mother has the fetus's best interest at heart, and can do what is required to protect that interest. THE TEACHING ENVIRONMENT In some situations individual patient-risk may, on the above prin- ciples, be slightly increased for the general common good of all patients, as in a teaching hospital situation where the person actually performing the procedure, even though supervised, may not be the most highly quali- fied professional available. This is a training risk that must be accept- ed if future patient-interests are to be protected. But this additional risk should at all times be kept at a minimum through adequate supervision and assistance and should be taken only with informed, patient coopera- tion: 0 It is also clear that in any hospital this principle of teach- ing or training should not be relegated to any single category of patient, but applied equally in all patient situations. THE ISSUE OF FINANCIAL REIMBURSEMENT Finally, assuming as self-evident that the professional's own financial interest shall not be a primary factor in the decision whether or not to perform a cesarean, a word must be said about the ethics of health care costs. Even if it could be achieved that the risk/benefit ratio were no different for patients receiving cesarean delivery from those achieving normal delivery, the financial costs will nearly always be greater for the former due to the greater length of hospital stay, use of supplies, personnel, facilities, etc., - even if the obstetrician 470 does not increase his/her fees for services rendered. On this basis alone it might be unethical to select the operative procedure because of the general imperative to provide equity in health care distribution. This would be so particularly where third-party carriers (governmental agencies, insurance carriers, etc.) are involved. It would not seem fair to impose an additional financial burden on other segments of society, possibly to the point of reducing the amount of care available to other patients, where no clear benefit to the patient in question is to be realized. If there is actual, even if slight, increased risk attendant with the procedure this becomes even more pertinent. Further review of the economic issues involved in cesarean birth is provided in Chapter XXII. In addition, the data available on how cesarean birth varies in different practice situations is reviewed in Chapter VII. SUMMARY The above statements of ethical principle, as they relate to the performance of cesarean delivery, are not specific to this procedure. While not exhaustive they are consistent with generally established patterns governing the relationships between physicians and their patients. They are consistent with the profession's long-standing, if largely unwritten commitment to placing patients' interests above their own. They express the profession's recognition of patient's rights over their own bodies including the right to proxy when it comes to decision- making. They recognize the rights of the unborn as well as those of the 471 mother. They also take into account developing sensitivities in a social climate where personal, legal and financial considerations are increasingly pressuring for greater responsibility and clarity in medical ethical matters. They are here set forth as part of that ongoing process. 7s 472 BIBLIOGRAPHY This is not as obvious from the various historic documents express- ing the ethics of the medical profession as might be presumed. The famous Hippocratic Oath says no such thing. There are allusions to such a notion in a variety of ancient medical codes some of which do not lie directly in the ancestral stream of western medicine. The Indian Oath of Initiation of Ceraka Samhita (1st century A.D.?) says, "Thou shalt not desert or injure thy patient for the sake of thy life or thy living." (Quoted in the Encyclopedia of Bioethics, New York, The Free Press, 1978, p. 1732). A leading Persian figure in medicine and ethics, Holy Abbas (Ahwazi) wrote in the first chapter of his work on the ethics of medicine (10th century A.D.), "A physician is to prudently treat his patients with food and medicine out of good and spiritual motives not for the sake of gain." (Quoted in Ibid., p 1735). An Islamic Persian by the name of Kholasah Al Hekmah wrote in 1770 A.D. regarding the physician's ethical duties, "He must be content, grateful, generous and magnan- imous, and never covetous, greedy, ravenous or jealous." (Quoted in Ibid., p. 1737). The famed Prayer of the Jewish Moses Maimonides, which along with the Hippocratic Oath is the best known of the older statements on medical ethics, says in one passage, "Do not allow thirst for profit, ambition for renown and admiration, to interfere with my profession." (Quoted in Ibid., p. 1737). The forerunner of Western medicine's codes of ethics, the rules and requlations prepared by the Royal College of Physicians of London in the early 16th century has virtually nothing to say about the patient. This omission seems to be downplayed by the historian of the Royal College, Sir George Clark, who says that the members "... had precepts and principles generally accepted and considered to be morally binding," and implies that among these was the impera- tive that the physician should have as his overriding aim the welfare of the patient. (Clark, G., A History of the Royal College Physicians of London, Vol., 1, Oxford, Clarendon Press, 1964, Pp. 19-36.) The code of ethics drawn up by the AMA in 1847, borrowing heavily from the earlier work of Thomas Percival of England seems to promote mainly the good of the profession and its organization, though it does state that "the good of the patient is the sole object in view." (Encyclopedia of Bioethics, 1742.) 473 The World Medical Association's Declaration of Geneva in 1948 said among other things, "the health of my patient will be my first consideration". (Ibid., p. 1749). The International Code of Medical Ethics developed by that same body in 1949 included the statement, "A doctor must practice his profession uninfluenced by motives of profit." This was echoed in the AMA's Principles of Medical Ethics prepared that same year. "The prime object of the medical profession is to render service to humanity; reward or financial gain is a subordinate consideration." (Principles of Medical Ethics of the American Medical Association, 535 North Dearborn Street, Chicago 10, Ill., 1949, p. 3.) It also said, "The benefit of the patient is of first importance." (Ibid., p. 13.) This reflects a growing articulation of the modern concept of profession vs. trade or craft. A profession, according to Bledstein (Bledstein, B., The Rise of Professionalism, New York, W.W. Norton, 1976, p. 87.) "...embraces an ethic of service which (requires) that dedication to a client's interest take precedence over personal profit, when the two happen to come into conflict." In spite of this lack of explicit articulation in the traditional codes, the principle is well established as an unwritten rule of conduct for most ethical physicians. There are voices currently calling for the inclusion of this principle in the written codes. See, for example, the article by Carleton B. Chapman, M.D. "On the Definition and Teaching of the Medical Ethic," in The New England Journal of Medicine, Sept. 20, 1979, p. 630 ff. Dr. Chapman says, "...the profession should put its unwritten patient centered ethic into written form and officially affirm the profession's committment to it." He suggest a reading, "... the physician must put the pat- ient's interests, welfare and rights above all other considerations." (Ibid., p.632.) An example of an attempt to do this is found in the document currently being prepared by the American College of Obste- tricians and Gynecologists which begins with the words "By long-standing tradition a profession has been defined as being primarily concerned with those it serves rather than with personal profit." (A Code of Medical Ethics, Unpublished, American College of Obstetricians and Gynecologists). See "A Patient's Bill of Rights," prepared by the American Hospital Association, 1973, for a document that has been influential in the development of other similar documents throughout the world. (American Hospital Assn., 840 Northshore Drive, Chicago, Ill.) 474 The ethical code for Roman Catholic health facilities and practi- tioners (1971) states specifically, "man has the right and duty to protect the integrity of his body together with all of its bodily functions." (Quoted in Encyclopedia of Bioethics, p. 1755.) The above code also expressed a concept that is coming to be gener- ally accepted by the health professions in relation to patient rights, "The procedures listed in these directives as permissible require the consent at least implied or reasonably presumed, of the patient or his guardians. This condition is to be understood in all cases." (Ibid.) The concept of "informed consent" in therapeutics is of fairly recent origin and was largely stimulated by legal concerns arising out of human experimentation. "The doctrine of informed consent, introduced into U.S. case law in 1957, represents judges' groping efforts to delineate physicians' duties to inform patients of the benefits and risks of diagnostic and treatment alternatives, includ- ing the consequences of no treatment, as well as to obtain patients’ consent (Salgo v. Stanford University). The doctrine's avowed purpose was to protect patient's right to 'thorough-going self-de- termination' (Natanson v. Kline)." (Katz, Jay, "Informed Consent in Therapeutic Relationship: Law and Ethics," Encyclopedia of Bioethics, p. 770). Hippocrates admonished, to the contrary, "Perform (these duties) calmly and adroitly, concealing most things from the patient while you are attending him. Give necessary orders with cheerfulness and serenity, turning his attention away from what is being ‘done to him; sometimes reprove sharply and emphatically, and sometimes comfort with solicitude and attention, revealing nothing of the patient's future or present condition." (Quoted in Ibid.) Dr. Thomas Percival's book Medical Ethics (1803) so influential in shaping later medical ethical codes, warned only against "gloomy prognostications." He suggested that "friends of the patient" might be informed but the patient told only if absolutely necessary. Those who came after largely reiterated Percival and except for statements regarding surgery and experimentation. It was stated in Opinions of the Judicial Council of the AMA in 1957, "All facts relevant to the need and performance of the operation" should be disclosed. Also when using new drugs and procedures the physician 475 was to obtain "the voluntary consent of the person." (Quoted in Ibid.) According to Katz, "...in the context of therapy no authoritative statement has ever been promulgated by the medical profession." This is certainly true of the major codes - including the AMA code currently being reviewed. The document under study by the American College of Obstetricians and Gynecologists referred to earlier contains the statement of the patient's right "to make decisions regarding her own person, with access to relevant informa- tion on which to base such decisions." For the most part physicians are cognizant of the difficulty in achieving such a goal and are wary of the legal pitfalls involved and consequently do not view the notion of "informed consent" with enthusiasm. Other codes go further. The Patient's Bill of Rights of the American Hospital Assn. (1973) states specifically "The patient has the right to receive from his physician information necessary to give informed consent prior to the start of any procedure and/or treatment. Except in emergencies, such information for informed consent should include but not necessarily be limited to the specific procedure and/or treatment, the medically significant risks involved, and the probable duration of incapacitation. Where medically significant alternatives for care or treatment exist, or when the patient requests information concerning medical alternatives, the patient has the right to such information." He also "has the right to refuse treatment to the extent permitted by law, and to be informed of the medical consequences of his action." (Ibid., p. 1782) According to the Federal Register, Vol. 44, No. 80, Tuesday, April 24, 1979, p. 24107, "informed consent means the knowing consent of an individual or his legally authorized representatives, so situated as to be able to exercise free power of choice without undue inducement or any element of force, fraud, deceit, duress, or other form of constraint or coercion. The basic elements of information necessary to such consent include: (1) A fair explanation of the procedures to be followed, and their purposes, including identification of any procedures which are experimental; (2) A description of any attendant discomforts and risks reasonably to be expected; (3) A description of any benefits reasonably to be expected; (4) A disclosure of any appropriate alternative procedures that might be advantageous for the subject; 476 (5) An offer to answer any inquiries concerning the procedures; and (6) An instruction that the person is free to withdraw his consent and to discontinue participation in the project or activity at any time without prejudice to the subject." This definition was formulated for medical research and the last item applies, of course, primarily to experimental procedures. As to who should be informed (and thus consent), the above "individ- ual or his legally authorized representative" is further elucidated in the 1971 "U.S. Guidelines on Human Experimentation (Institutional Guide to DHEW Policy on Protection of Human Subjects) (revised in 1974). "Consent should be obtained, whenever practicable, from the subjects themselves. When the subject group will include individuals who are not legally or physically capable of giving informed consent, because of age, mental incapacity, or inability to communicate (fetuses, for example), the review committee should consider the validity of consent by next of kin, legal guardians, or by other qualified third parties representative of the subject's interests." (Quoted in Encyclopedia of Bioethics, p. 1780.) The "Statements of Policy Definitions and Rules" of the British Medical Association (1974) says something similar:"In the case of a person too ill to comprehend the situation, or incapable of giving valid consent to the disclosure of confidential informa- tion (fetuses?), consent should be sought where possible from the appropriate relative, guardian or legal adviser." (Quoted in Ibid., p. 1759.) The above mentioned code being developed by the American College of Obstetricians and Gynecologists simply refers to the patient's right "to have an appropriate representative to exercise these rights when the patient herself is unable to do so." This is on the principle of freedom of conscience and self-determin- ation. The developing code of the American College of Obstetricians and Gynecologists states under the physcian's rights, the right "to refuse to render treatment which is inconsistent with the Fellow's own moral code." The principle of the physician's maintaining control over his own actions is a long established fact of medical ethics. The ACOG Code also speaks of the right of the physician "to retain control of clinical management as long as the physician- patient relationship remains intact." The AMA "new principles" states the same principle when it says "Physicians may choose when they will serve except in emergencies" and "Physicians should resist restraints which interfere with medical judgment and skill or cause deterioration of the quality 10. 477 of medical care." (Proposed New Principles of Medical Ethics). The 1949 "Principles of Medical Ethics of the AMA" said "A Physician is free to chose whom he will serve." This principle is expressed by the American College of Obstetricians and Gynecologists in its 1977 statement of policy regarding induced abortion: "The College recognizes that situations of conflict may arise between a pregnant woman's health interests and the welfare of her fetus. Both legally and ethically this conflict can lead to a justification for inducing abortion. The College affirms that the resolution of such conflict by inducing abortion in no way implies that the physician has an adversary relationship towards the fetus and therefore, the physician does not view the destruction of the fetus as the primary purpose of abortion. The College consequently recognizes a continuing obligation on the part of the physician towards the survival of a possibly viable fetus where this can be discharged without additional hazard to the health of the mother." The widely publicized cases of Dr. Edelin in Boston and Dr. Waddill in Orange County, California, indicate the general legal concurrence with this principle. The United States Catholic Conference in its 1971 Ethical and Religious Directives for Catholic Health Facilities says, "Caesarean section for the removal of a viable fetus is permitted, even with risk to the life of the mother, when necessary for successful delivery. It is likewise permitted, even with risk to the child, when necessary for the safety of the mother." (Quoted in Ency- clopedia of Bioethics, p. 1756.) This principle is suggested by the traditional therapeutic indica- tions for abortion including those set forth in the Supreme Court's 1973 decision. . The American Hospital Association's "Patient Bill of Rights" states "The patient... has the right to know the name of the person responsible for the procedures and/or treatment." (Quoted in Encyclopedia of Bioethics, p. 1782.) The Catholic Conference's document declares, "Ghost surgery, which implies the calculated deception of the patient as to the identity of the operating surgeon, is morally objectionable." {1bid., p. 1757.) Chapter XXI - Medicolegal Concerns 481 INTRODUCTION TO THE ISSUES As noted in several places in this report, during the ten years between 1968 and 1977, the United States witnessed a threefold increase in cesarean births. While the national cesarean rate was 15.2% in 1978, some hospitals around the nation showed rates of 25%. 1 Indeed, the cesarean birth is the tenth most common surgical procedure performed in the United States, according to the National Center for Health Statistics.’ A recent study has claimed that the most significant factor in this rise in the incidence of cesarean birth is the threat of malpractice suits.’ Supposedly, physicians fear being sued if the outcome of a birth is a "less than perfect" baby and a cesarean section was not per- formed. Thus they undertake the cesarean operation as a means of prac- ticing defensive medicine. It should be noted that this development may be viewed in the larger context of a general expression of litigation in society. People in greater numbers are considering law suits as a means for attempting to redress many perceived wrongs. Society is becoming increasingly litigious, and as such, all of its members, including physicians, more often find themselves defendants in law suits. >? While it is true that available data from insurance claims do not clearly indicate that this concern is justified, it is, nevertheless, also true that 90% of all obstetrical malpractice cases fall into two cate- 482 gories: failure to perform a cesarean section, and improper use of forceps during delivery.” What, then, is the role of the legal system in the cesarean birth controversy? LIABILITY FOR NEGLIGENCE IN DIAGNOSIS In general, liability for negligence in regard to cesarean birth is premised on either misdiagnosis or incorrect or inadequate treatment. The standard of care applicable to diagnosis requires that the physician use the same degree of skill, care, and knowledge which would be used by the average reasonable physician with the same level of training.” For example, the mere fact that there has been a misdiagnosis is not alone sufficient to warrant the imposition of liability. A physician who meets the standard of a reasonably careful physician is not liable even if he or she makes an error in judgment or a mistake in diagnosis. The issue of liability usually involves whether the physician used the usual and customary inquiries, examinations, and tests in order to determine the nature of the patient's condition. In line with this, the physician has an obligation to keep up with advances in medical science. If one physician failed to use certain tests or other diagnostic aids which are in current use when the patient was first seen, because of a lack of knowledge concerning the tests, the physician may be liable for failure to use the tests. However, if the physician has performed the accepted tests which a reasonable oractibiones would consider appropriate, has taken into consideration relevant symptoms, and has made a careful evaluation of this information in light of the patient's past and present history, the physician is not negligent simply because he/she is wrong. For 483 example, if a number of different diagnoses would provide a reasonable explanation of a patient's condition, choosing among them is a matter of medical judgment, and if the physician chooses what turns out to be the wrong explanation, the physician is not liable. A physician is not negligent for misdiagnosis unless it can be clearly demonstrated that the chosen course was contrary to the course recognized as correct by the medical profession generally. Additionally, before a physician is liable for damages for misdiagnosis, it must be shown that the misdiagnosis in fact caused damage to the patient. The patient must establish that, not only did the misdiagnosis constitute negligence, but also that it result- ed in some damage to her. LIABILITY FOR NEGLIGENCE IN TREATMENT The definition of negligence in treatment is the same as that for diagnosis. After making a diagnosis, the physician is obligated to use that degree of skill and care in treating the patient that would be exercised by the average reasonable practitioner with the same level of education and teaining. The physician generally does not guarantee the outcome, but undertakes the use of diligence and ordinary skill in treating the patient.’ If the patient does not — or even gets worse, or if an unexpected and untoward result occurs in the course of treatment, no inference of negligence is drawn. Thus, the physician holds himself (herself) out as being qualified to make a careful diagnosis and plan for treatment, and to use good judgment in carrying out that treatment. The physician is not liable solely because that treatment had a poor result. 484 Most medical and surgical treatment which is found to be negligent involves either the physician who did not follow the standard practice in treating the condition, or the physician who undertook to administer proper treatment, but did so in an inadequate or incorrect manner. A physician who adopts the standards and accepted procedures will not be considered negligent, no matter what the outcome of the case. THE TERM "STANDARD PRACTICE" "Standard practice" may be difficult to define in some areas. Usually, medical opinion as to the appropriate treatment of an illness is divided. Yet if the treatment used is in accord with a recognized system, it is not negligence simply to give this treatment. If a physi- cian can demonstrate that he/she used a method which is approved by at least a "respectable minority" of the medical community, the patient would then have to prove that the method was applied in a negligent manner. This is so even if, in retrospect, another method would have produced better results. It should be noted that a physician is obligat- ed to keep up with advances in medical and surgical treatment. Obviously, the standard of practice changes as there are developments in medicine. VULNERABILITY TO MALPRACTICE IN OBSTETRICS AND GYNECOLOGY Obstetrics and gynecology as a specialty is an active one for malpractice suits. One reason would appear to be that the obstetrician is involved with two patients, the mother and the infant, instead of just one patient. The claim exposure rate for obstetricians-gynecologists, or, in other words, the likelihood of the obstetrician-gynecologist being named a defendant in a malpractice suit, is 2.4 times the average, or the fourth 485 highest among physician specialities. The probability of a claim eventually resulting in an award against an obstetrician-gynecologist is 42%, which is the third highest award rate among physician specialties.’ Many decisions involve injuries to the infant which occurred during or immediately after vaginal delivery. 10 Several cases involve brain and spinal damage caused by the negligent use of —L. In other cases the arms and legs of infants were fractured during difficult deliveries. In the absence of a life or death emergency which necessita- ted a forcible delivery, this type of injury has been held to be clearly actionable.’ For specific types of medical procedures, the highest claim and payment exposure rates are for obstetrical surgical procedures. These procedures also have high claim and payment probability rates. This is so, even though, in general, complications of pregnancy and/or childbirth have the third lowest risk of claim. Forty-nine percent of claims involving obstetrical-gynecological surgical procedures result in payment of $500 or mores 77% of claims which received awards of $500 or more in the area of complications of pregnancy and childbirth were surgical.” Interestingly, of those claims for diagnostic error receiving an award of $500 or more involving obstetrical surgical procedures, 25% involved o misinterpretation of tests or x-rays; 38% involved inadequate tests; 25% involved inadequate exams; and 13% involved inadequate history.1® NEGLIGENCE In discussing negligence actions concerning cesarean births, the relevant suits may be broken down into three main categories: (1) those 486 in which there was negligence in the performance of the cesarean; (2) those in which the physician failed to perform a necessary cesarean; and (3) those in which the physician performed an unnecessary cesarean. NEGLIGENCE IN PERFORMANCE OF CESAREAN The first category, negligence in the performance of a cesarean birth, is a common ground for bringing a malpractice suit, but is one in which we are less interested, since it really sheds less light on the problem at hand. These cases involve injuries to the patient during delivery, which are situations which occur in other types of surgery as well, such as sponges or other foreign objects being left in the patient's body. 17 Other situations, such as mother's death from anesthesia 0 or death from tetanus infection, also occur in other types of surgery. Another frequent suit claims physician liability for bladder lacer- ations. 20 Certain cases deal with incidents which are more related to the specific type of procedure being performed. For example, Comte v. 0'Nei1?! involved a situation in which the plaintiff's cecum "kinked" after performance of the cesarean, with subsequent remedial surgery being required, while in Graham v. Sisco? an infant's face was severely cut when the incision was made to perform a cesarean. NEGLIGENCE IN THE FAILURE TO PERFORM A CESAREAN The biggest concern among physicians in this area is the malpractice suit brought for failure to perform a cesarean delivery which the patient argues was necessary and, if performed, would have prevented the injury suffered. Misdiagnosis which leads to the conclusion that surgery is not 487 required certainly may result in liability. It cannot be denied that there are a fair number of cases alleging negligence in the failure to discover the necessity of performing a cesarean section?’ or, as a subcategory, in unduly delaying the decision to perform one, by which point the woman or the infant has sustained damages. 2 For example, in Mark v. Fong?’ a suit was brought against the physician (among others) who delivered a child who suffered birth injuries. Late in the patient's pregnancy, the fetus assumed a frank breech position, which persisted up to the time of delivery. At 5 a.m. on the day which was 35 days past the expected date of delivery, her membranes ruptured. She had not yet gone into labor when she entered the hospital at 9:30 p.m. The delivering physician ws notified, but did not arrive until 3 a.m. the following morning. He had not personally performed her pre- natal care, but had an agreement with two other physicians to perform the delivery. He did not know any of the patient's history or of the serious problems experienced during her last delivery. The physician ordered oxytocin and an enema, by telephone, before seeing the patient. The physician performed a difficult frank breech delivery at 4:55 a.m. The infant did not breathe spontaneously, and required resuscita- tion (Apgar 3) for more than a hour, and ultimately had convulsions. Subsequently the child was found to have spastic quadriplegia and cerebral palsy, which experts attributed to birth anoxia and asphyxia caused by umbilical compression during the delayed and difficult breech delivery. Experts testified at trial that it was wanton neglect not to perform a cesarean under the circumstances, and that it was malpractice to induce 488 the breech with oxytocin. It was generally agreed that the child would have been normal if a cesarean had been performed. The physician settled the claim for his policy limits of $200,000. Another cased involved an infant who, during the birth process, had his shoulder become impacted against his mother's pelvis. The physicians, instead of raising and rotating the infant to free his shoulder or fracturing his clavicle to relieve the pressure, forcefully drew the infant through the birth canal. During this process, the infant was deprived of oxygen resulting in slight brain damage, and sustained injury to his brachial plexus, which resulted in the "winging of his arm and shoulder", a condition known as Erb's palsy. Part of the claim was based on the physician's failure to perform a cesarean section if necessary to avoid the infant's oxygen deprivation. The case was tried before a medical malpractice panel which unanimously found for the plaintiff, which resulted in an $800,000 settlement. NEGLIGENCE IN DELAY BEFORE PERFORMING A CESAREAN Many of the cases in this area involve physicians who actually do perform the cesarean on the patient, but because of alleged negligence in their practice, do not do so in a timely fashion, and thereby cause injury. For example, the case of Chen v. Flaherty?’ concerned an action brought by the parents against an obstetrician. The plaintiffs alleged that, the day before the woman was to give birth, other physicians involved in her care indicated that they feared she would have an abnormal birth. However, when the defendant-physician was advised of-this the following day, he did not order x-rays or other monitoring devices to 489 determine the infant's condition. After the mother had been in labor for 5 hours, the plaintiffs alleged that the defendant ordered that she be given the labor inducing drug oxytocin, but that the amount was 3 times the normal dose and resulted in rupture of the mother's uterus. Beyond that, it was alleged that when the defendant saw that the baby would not be born in the normal head first position, but in a twisted position with one arm extending down, he ordered a cesarean birth but waited too long for the operation. Furthermore, when he did operate, it was alleged that he damaged the woman's uterus so that she became sterilized, and injured her urethra which caused the ultimate removal of her kidneys. The infant was stillborn. Supposedly because of the "emotional strain" on the woman, the plaintiffs settled the case during the trial for $431,000. Another case, Safadago v. Lash’S resulted in a $1,000,000 jury verdict for an infant who sustained mixed spastic athetoid cerebral palsy with quadriplegia as a result of anoxia during the birth process. The parents received $100,000. The plaintiffs sued the attending osteopath, the anesthesiologists, an intern, the surgeon, and the osteopathic hospital. The attending osteopath and the surgeon settled prior to trial, contributing $200,000 for the child and $200,000 for the parents. In that case the woman, who was having her second child, checked into the hospital in the evening and labored for 16 hours before she was taken to the delivery room. The hospital nurses failed to monitor the fetal heart tones or the woman's blood pressure. After the administra- tion of a spinal anesthetic, symptoms of fetal distress occurred. The 490 attending physician did not have the training or privileges to perform a cesarean birth. It was over an hour before a surgeon was located, and another fifty minutes before preparations for surgery were complete. During this time the woman's blood pressure dropped to 65 over 25. The anesthesiologist failed to treat this condition. It was also noted at trial that no x-ray pelvimetry had been performed. Immediately after birth, the infant was rushed to a neonatal center, where he suffered seizures. A linear skull fracture was diagnosed and attributed to the attending physician's attempt at performing a high forceps procedure. Thus, under some circumstances, failure to perform a cesarean may be found to violate normal standards of skill and care which a reasonable physician should employ in treating obstetrical patients. However, it should again be emphasized that the mere fact that a particular proce- dure ends in a bad result does not automatically mean that the physician was negligent. A review of the cases finding liability, such as those disussed above, indicates that, in most of them, there was evidence of gross deviation from the appropriate standard of care, and not merely a situation in which a physician made an honest error in judgment in not performing or in delaying a cesarean. Indeed, in the large majority of cases in which physicians were sued for not performing or for delaying a cesarean, the physician won the lawsuit, and was found not to be negligent or liable. Thus, in Henry v. Bronx Lebanon Medical Center,” a physician had determined late in his patient's pregnancy that her uterus may have been growing larger than normal. Tests indicated to him that she had an adequate pelvis for delivery of a child. Within two hours of labor the 491 head was engaged and within three hours the cervix was fully dilated, was completely effaced and the membranes ruptured. The physicians found no abnormality at this point, and found no reason that the infant could not be delivered by normal vaginal delivery. Fetal distress was noted at 2:23 a.m. (on delivery the umbilical cord was found wrapped around the infant's neck, a probable cause for the fetal distress). The fetus was low down in the pelvis, in a face up position (occiput posterior) rather than the more common face down position (occiput anterior). Several unsuccessful attempts were made to manually rotate the fetal head, and the physican decided that a mid forceps delivery was necessary. On delivery of the head it was discovered that the umbilical cord was wrapped around the neck and that the infant was cyanotic. After removal of the umbilical cord, it was observed that the shoulders were impacted. Because the infant was partly delivered, it was decided that cesarean birth was impossible at this point. The child was delivered vaginally, and sustained an occipital bone fracture, injury to the upper and lower brachial plexus, and a fractured clavicle. The court found that 3% Was against the weight of evidence to say that there was malpractice in allowing labor rather than performing a Cesare section. It stated that where alternative procedures are available to a physician, any one of which is medically acceptable and proper under the circumstances, a physician cannot be held liable for malpractice when he/she uses one of two acceptable techniques. The court also noted that there is a much higher risk of death to the mother when the delivery is by cesarean rather than by vaginal delivery. 492 A similar case is Schreiber v. Cegtaris The patient had been admitted to the hospital at 3:00 a.m. to deliver her first child. After at least 12 hours of true labor, involving more than three hours of second stage labor, the plaintiff gave birth at about 8:15 p.m. The baby's birth was aided by manual and forceps rotation. Because of the transverse position of the baby in the patient's womb, it was necessary to deliver the baby either by cesarean birth or forceps rotation. The injuries sustained by the patient consisted of a tear of the cervix and urinary bladder, a torn urethra, a torn vagina, and a resulting urethro- vaginal fistula. The evidence established that, following proper medical practice, the physician optionally might have undertaken to deliver the baby by cesarean birth or by vaginal birth with forceps rotation. The court said that, where alternative procedures are available to a physician, any one of which is medically acceptable and proper under the circumstances, a physician cannot be held liable for malpractice when he uses one of two acceptable techniques. In another eden,” a patient 40 years old, weighing 320 pounds, alleged that her physicians should have performed a cesarean birth a month earlier. She suffered a tear of the anal sphincter muscle, resulting in loss of bowel control. The baby had Erb's palsy, causing shoulder atrophy. The jury found for the physicians. Another suit?Z involved an allegation that the physician had improperly used downward traction on the infant's head in an attempt to complete the delivery. One of the infant's shoulders had become impacted 493 behind the mother's pubic arch. This use of traction caused injuries to the infant's left brachial plexus, resulting in Erb's paralysis. The court held that there was insufficient evidence to find the physician negligent for failing to perform a cesarean section. Note the contrast in this case and the case reported earlier. This was resolved in favor of the defendant because a suitable choice was employed. The earlier case was resolved in favor of the plaintiff because an incorrect tech- nique for delivery was utilized. In Cardona v. Hollywood Community Hospital,” it was alleged that at the time of delivery, the woman had prolonged labor with uterine inertia. Further allegations contended that, although the patient was ready for delivery at 4:30 p.m., the birth was not completed until 8:14 a.m., when forceps were applied. In the interval, the fetal heart beat indicated hypoxia. At 7:00 a.m., the mother was given a saddle block and pressure was used. At 8:05 a.m. the baby's legs and torso were out but not his head. The plaintiff alleged that the delivery was delayed and improper. The child suffered cerebral palsy as a result of birth injuries. At the time of trial, the child was 7 1/2 years old and was unable to speak, walk, or care for himself. A California jury denied recovery of damages. PERFORMANCE OF AN UNNECESSARY CESAREAN The third category is performance of an unnecessary cesarean birth. In general it may be said that a physician who concludes in good faith that a patient's condition will be best served by a "wait and see" approach is not negligent. As long as such a delay occurs under circum- stances where the reasonable practitioner would do the same thing, no 494 negligence is present even if damages result. It should be noted that rushing into surgery might expose the physician to a liability suit if the operation turned out to be unnecessary. Only where the reasonable practitioner would have performed immediate surgery is a physician negligent if he/she fails to do so. By analogy, there are cases which concern patients who have condi- tions for which any treatment would be ineffective. The patient may have a condition from which he will "recover" in due course without treatment. If a treatment or procedure with a potential for a serious harmful result is undertaken, where the treatment is essentially useless for a condition from which the patient would inevitably "recover" without treatment, and a harmful result occurs, the physician will be liable for not having "left well enough alone, "5% The physician should have allowed "nature to take its course." There seem to be almost as many cases in which physicians have concluded that patients suffered from serious disease which they did not have, as there are cases in which a serious disease was overlooked, and the same rules of potential legal liability apply in each. Damages have been very large where unnecessary surgery has been performed on patients. However, while a surgeon is theoretically liable for "unnec- essary surgery", there are very few successful actions in this area. If the diagnosis has not been negligent, surgery is not usually considered legally "unnecessary." Frequently the preoperative diagnosis is not confirmed when surgery is performed. The occurrence of this situation does not indicate negligence on the part of the surgeon unless he/she has not used standard procedures and tests in arriving at his/her preoperative 495 diagrosis.”’ Where the diagnosis of a condition is not based on proper tests, and the patient is further hospitalized, operated on, and/or subjected to mental anguish, and in fact does not have a condition which necessitated such action, the physician may very well be table o The physician is faced with a dilemma. If the physician advises surgery when others might regard it as unnecessary, he/she runs a risk of liabil- ity. On the other hand, if the physician fails to operate when others may have done so, an equal legal risk may be incurred. It nevertheless remains true that unnecessary surgery which results from a negligent diagnosis or mistake will render the physician liable. There have been several cases brought alleging that a cesarean birth which had been performed was unnecessary. In Beni v. Abrons,>’ an action was brought to recover damages for the death of a woman. In this case, the physician had cared for the patient during her prenatal period. When she went into labor, she entered the hospital. When the labor pains became more frequent, the physician first tried to produce delivery by manipulation. That failing, the physician resorted to the use of forceps, and when that proved unsuccessful, a cesarean was performed. After the child was delivered and the placenta removed, the physicians found a large fibroid tumor in the back wall of the uterus. The woman subsequently went into shock and died. The plaintiff did not claim that the cesarean was negligently or unskillfully performed, but that it should not have been performed at all. His expert witness testified that, in his opinion, the tumor would not have prevented the delivery of the child vaginally; that the cesarean 496 was unnecessary; and that it should not have been performed. The jury returned a verdict for the physician, which the court upheld. Hasemeier v. Spit? was a malpractice action against a physician for the death of a woman following administration of an anesthetic in connection with a cesarean performed to remove an infant which the defendant believed to be dead but which was actually alive and healthy. The court concluded that the only claim that the plaintiff was making was that an unnecessary operation was performed. While recognizing that a claim of this type would be a valid basis for physician liability if proven, it went on to decide that the plaintiff had not presented sufficient evidence to justify such a conclusion in this case. Another analogous case concerned a woman who entered the hospital suffering from severe hemorrhages. The physicians in charge, following an examination, performed a cesarean whereby a 4 1/2 or 5 month old fetus was removed, and the appendix and both fallopian tubes were removed. Following the operation peritonitis developed and, ultimately, the patient died. The plain ire alleged that a cesarean was not the proper method of treatment for the relief of the condition, alleged to have been a pending miscarriage. A jury returned a verdict for the plaintiff. On appeal, the court said that there was not the "slightest intima- tion" of negligence as to the technique of the operation or the following care of the patient. The only issue was whether the cesarean should have been performed at all. The court found that the situation was one in 497 which different segments of the medical community disagreed as to the appropriate course to take under the circumstances. In such a situation, the physician is bound only to exercise his/her best skill and judgment in determining the course to be followed and act accordingly. If this is done, no liability would be incurred. Accordingly, the judgment was reversed. As can be seen, in none of these cases was the physician ultimately found liable. Beyond that, the actions all involved cases in which there was a bad result following performance of the cesarean procedure. None of them involve the situation of a suit brought solely on the grounds of an unnecessary cesarean being performed, even though there was a "good result", i.e., good baby, healthy mother, etc. It is possible that this may change in the near future, and that, partly, has to do with the damages which are allowable as recovery in actions of this type. Compensable injury in a misdiagnosis case may consist only of an extension of the period of pain and suffering or other disability. The physician may be liable even though the patient eventually recovers completely, if negligent physician error prolonged the recuperation of the patient. The patient must show that she would have received petites results in a shorter length of time from proper treatment than she did from the treatment provided by the defendant 0 Where surgery is clearly unnecessary, the simple pain and suffering of unnecessary surgery might very well result in damages. Iatrogenic disorders are defined as complications caused solely by the intervention of the physician. Where it can be proved that incor- 498 rect information from the physician as to the patient's condition caused psychological symptoms and the patient was, in fact, made ill, damages may be awarded. However, if the physician's conclusion that the patient is, in fact, suffering from some serious complaint is reached on a reasonable probability which would have been arrived at by a reasonable practitioner, the physician is not liable if the patient does not, in fact, have the condition. One EL in this area provides an interesting discussion of damages possible simply for the performance of an unnecessary cesarean. It was an action brought by a patient whose child was stillborn, against a physician for failure to perform a cesarean as had been previously agreed upon. The jury found for the plaintiff, including damages for pain and suffering, and the court affirmed. In its decision, the court said that the law protects interests of personality, as well as the physical integrity of the person, and that emotional damage is just as real, and as compensable, as physical damage. Thus, even with a good outcome, possible damages available solely for the performance of an unnecessary cesarean include not only physical and financial damage due to the pain and complications associated with major surgery, prolonged postsurgical disability (including longer hospitalization), and other increased maternal and fetal risks, but also include those injuries associated with the natural childbirth movement, such as interruption of mother-infant attachment and maternal psycho- logical and emotional disturbances. It is a possible speculation that those claimed damages more closely aligned with the natural childbirth movement will more often be made part of lawsuits in the near future. Similarly, this movement, and the widespread interest in natural 499 childbirth which it has encouraged, may result in an increase in malprac- tice suits being brought solely on the grounds of an unnecessary cesarean being performed, even one that resulted in a "good" baby. Since these actions would have all the elements for a successful suit, combined with the law's growing recognition of the importance of people's reproductive rights, the fact that there have not been any such successful suits in the past should not necessarily provide solace for physicians who may per form unnecessary cesareans. INFORMED CONSENT What role, if any, can the legal principle of informed consent play? The principle of informed consent means that, before consenting to a procedure, a patient must be informed concerning the recommended proce- dure, its risks and benefits, alternatives, and major problems of recup- eration. If the patient is given this information and consents to the administration of treatment, she cannot recover damages if an unfortunate result occurs in the absence of negligence. The doctrine of informed consent obviously is applicable in the area of cesarean birth, and has been discussed by several courts. In Holt Vv. Nelson, the parents claimed that the physician was negligent in not telling them about the cesarean birth as an alternative to vaginal birth, and in not telling them about the comparative risks; that the cesarean would have been selected by the parents at an earlier time as the desired procedure had they been informed; and that the injury to the child proximately resulted because the medical technique was performed too late. The child was a spastic quadriplegic with brain damage and cerebral palsy. 500 In a lengthy discussion of informed consent, the court found it to be a valid cause of action. It held that a physician has a duty to obtain permission from his patient before treatment. If the physician breaches this duty, the patient has a claim for damages against the physician even if the treatment was performed properly and within the standards of care of the profession. If proven, the physician's failure to provide sufficient information and permit the patient to exercise her right of chioce in regard to a cesarean birth could be considered negli- gence. The case Shack v. Holland ® concerned the claim that, because of the lack of informed consent, the infant was born permanently maimed and deformed. The court applied the following definition of informed consent: Lack of informed consent means the failure of the person providing the professional treatment or diagnosis to disclose to the patient such alternatives thereto and the reasonably foreseeable risks and benefits involved as a reasonable medical practitioner under similar circumstances would have disclosed, in a manner permitting the patient to make a knowledgeable evaluation. While the obligation to disclose runs to the mother, the court found that the lack of informed consent creates a risk of harm not only to the woman, but to her fetus as well. Thus, the child had a good cause for action. THE RIGHT TO WITHHOLD CONSENT FOR TREATMENT The corollary to the right to consent for treatment is the right to withhold consent for treatment. Courts have recognized that, in general, 501 a competent person may refuse to undergo treatment, even a lifesaving treatment This principle would seem to have important implications for this area. As long as a physician non-negligently fulfilled his/her obligation under informed consent by providing sufficient information and permitting the patient to exercise her right of chioce, the physician could not be liable solely for the failure to perform a cesarean if the patient chooses to give birth vaginally. Information on maternal and fetal risks, maternal and fetal morbidity and mortality rates, postsurg- ical complication rates for cesareans, and the available information on the "once a cesarean, always a cesarean' controversy, among other issues, should be discussed. With adequate information, the patient could then decide to withhold consent to a cesarean, and the physician would not be liable for failure to perform one. This has already been recognized by the court system. In Parker v. Goldstein’ the patient had had a previous cesarean, and had been counseled during her pregnancy that she would need another. However, at the hospital following her arrival while in labor, she refused for‘over 4 hours to consent to a cesarean, in spite of the coaxing of her physician. When she finally gave consent the procedure was performed. While it resulted in a live birth, the woman died. The court emphasized that the patient had withheld her consent to the procedure, and that the physician could not properly order the operation per formed until she consented. Since the physician was unable to go ahead without the patient's permission, the court found that he was not liable for any injury which could have been the result of the delay. 502 FETAL RIGHTS IN CONSENT FOR TREATMENT It should be noted, however, that no court has said that the right to refuse treatment is absolute. Rather the courts have said that the individual's right to refuse treatment must be balanced against a variety of state interests. The one of interest here is the protection of innocent third parties. This is probably the strongest state interest that has been expressed. However, this is usually viewed as meaning that the state should be able to require treatment of a parent because the parent's death would have an adverse psychological and financial impact on his/her children. Yet may this have other meanings which could have implications for our problem? What are the rights, if any of the fetus? In Roe v. Wade ,>0 the United States Supreme Court determined that the state's interest in protecting the viable fetus was so important that it outweighed the woman's right of privacy, so that the state could constitutionally forbid abortion altogether after the second trimester, except in cases in which the woman's life or her health was at stake. Thus the right of privacy does not necessarily protect a woman's choice of the manner and circumstances in which her baby is to be porn.” Although Roe held that the fetus is not a person, it does not necessarily mean that the fetus is not entitled to any protection, or does not have any rights. Whether a fetus, as a potential human life, should be accorded protection depends on a balancing of the interests asserted in a particular context, and those interests may differ in situations other than abortion.”?2 In the childbirth area, the difference is that everyone is seeking the birth of a healthy child. In this context, the physician probably has a duty toward the fetus to provide it with adequate medical care both 503 before and during the delivery. This duty will probably not prevent a physician from following the decision of the patient in not performing a cesarean, but will require the physician to perform any standard screen- ing tests for high risk pregnancies, and to counsel such couples accord- ingly. Today, every jurisdiction permits recovery in tort for prenatal injuries.”’ Such actions may later be brought by the child. Some courts have implied that recovery of prenatal injuries is limited to cases in which the alleged injury occurred at a viable stage of gestation. However, the current trend is to eliminate the viability requirement in actions for prenatal injuries. A wrongful death action may be brought in cases where a child does not survive to assert a claim. While every state permits recovery for wrongful death, there is disagreement as to whether a live birth is required in order to maintain a wrongful death action. Several courts require it, maintaining that there has been no harm to a "person" until the fetus is born alive. Several cases involving cesarean births have dealt with the issue of prenatal injuries. In Shack v. Holland,” the informed consent case discussed earlier, the issue presented was whether liability to a Fetus is created when an unborn child's mother is not sufficiently informed of the risks, hazards, and alternatives of the delivery procedure adminis- tered, and whether such liability attaches upon the birth of the child and enures to the benefit of the child in a cause of action for lack of informed consent. The court, in a lengthy discussion, reviewed the trend in favor of granting a cause of action on behalf of the unborn child, and accordingly so found. In Bergstreser v. Mitehpll, >? the court recognized 504 an action for a preconception injury on behalf of an infant for alleged negligence by a physician in performing a prior cesarean on his mother, which allegedly caused a rupture of the uterus which forced the mother to undergo a premature emergency cesarean. Are there any parental responsibilities of relevance in this area? The parents' primary duty is to the child, but, so far, only after it is actually born. No state has yet attempted to require pregnant women to take any affirmative action to safeguard their fetuses. However, all states have passed statutes that forbid parents from abusing their children, and that require them to provide necessary medical attention for their children, so as not to be guilty of neglecting them. Parents may therefore usually make decisions regarding cesareans without fear of potential liability. However, if they have reason to know that complica- tions are likely to develop that will require a cesarean to prevent the child from suffering death or permanent injury, and the child dies or is permanently injured because they would not consent to a cesarean, it is theoretically possible that the parents could be criminally liable. In both instances the charge would be child abuse, and if the child dies, possibly manslaughter. This possibility is intended to encourage parents to consent to cesarean delivery where necessary. SUMMARY The following observations may be made about the effect of the legal system in this area: (1) A malpractice suit may be brought against a physician for negligent performance of a cesarean birth; for not performing a necessary cesarean; Or for per forming an unnecessary cesarean. 505 (2) While many malpractice suits in the area, to date, have claimed damages for negligent nonperformance of a necessary cesarean, the physician/defendant is successful in the large majority of them. Those cases in which liability has been found generally involve gross deviation from the standard of care on the part of the physician. (3) Proper application of the doctrine of informed consent, in which the patient is provided sufficient information to make a knowledgeable treatment choice, provides physician protection from liability for following the patient's decision regarding whether or not to have a cesarean. (4) The unborn child has rights which the law deems worthy of protection and which must be taken into account. 506 BIBLIOGRAPHY 1. 10. 11. 12. 13. 14. 15. 16. 17. Marieskind, H.I.: An Evaluation of Cesarean Section in the U.S.A.: A Report and Recommendations for the Office of the Secretary of Health, Education and Welfare. (HEW) 1980. Cesareans Join Most Frequent Surgical Procedure List. NAPSAC News 4:21, 1979. Marieskind, H.D., supra note 1. 48 U.S.L.W. 2833, 2837 (6-24-80). Jacobs, H. (Ed.): Obstetrical Malpractice. Medical Quality Founda- tion {1979)- E.g., Lab v Hall, 200 So. 2d 556 (Dist. Ct. App. Fla. 1967) (death of woman: failure to perform cesarean section). Dinner v. Thorp, 54 Wash. 2d 90, 338 P. 2d (1959) (failure to perform cesarean section on diabetic patient). Wilson v. Martin Mem. Hosp., 232 NC. 362, 61 S.E. 2d 102 (1950) (sufficient evidence for jury to decide whether physician failed to exercise due care in not performing cesarean). Burgdorf, K. Maffeo, C., and Thomas, K.: Injury prevention. In Medical Malpractice Closed Claims Study. (NCHS), 1978, pp. 4.1-4.8. Gardner, S.: Basic claims information. In Medical Malpractice Closed Claims Study. (NCHS), 1978, pp. 3.1-3.5. E.g., Dunn v Campbell, 166 So. 2d 217 (Fla. 1964). Scott v. McPheeters, 92 P. 2d 678 (Calif. 1939). Brooks v. Serrano, 209 S. 2d 279 (Fla. 1968); Korman v. Hagen, 206 N.W. 650 (Minn. 1925). Cooper, J. (Ed.): Medical Malpractice Claims: A Synopsis of the HEW/Industry Study of Medical Malpractice Insurance Claims. (HCFA), 1978, at pp. 11-2 - II-3. Id. at Table 4 - 27. Id. at Table 4 - 32. Id. at Table 4 - 37. Druilhet v. Comeau, 317 So. 2d 270 (La. 1975); Piper v. Epstein, 326 111. App. 400, 62 N.E. 2d 139 (1945); Key v Caldivell, 39 Cal. App. 2d 698, 104 P. 2d 87 (1940); Armstrong v. Wallace, 8 Cal. App. 2d 429, 47 P. 2d 740 (1935); Roark v. Peters, 162 La. 111, 110 So. 106 (1926). 18. 19. 20. 2%: 22. 23. 24. 25. 26. 27. 507 Aubert v. Charity Hosp., 360 So. 2d 1223 (La. Ct. App. 1978). Garafola v. Maimonides Hosp., 22 App. Div. 85, 253 N.Y.S. 2d 856. E.g., Estate of Ramos v. Chicago Osteopathic Hosp., Docket No. 75L-4439 (I11. Cir. Ct., Cook Co., June, 1976). 125 I11. App. 2d 450, 261 N.E. 2d 21 (1970); See Carpenter v. Campbell, 271 N.E. 2d 163 (App. Ct. Ind. 1971) (cesarean procedure resulted in bowel obstruction and subsequent abdominal infection: physician found not negligent in performance). 449 S.W. 2d 949 (Ark. 1970). E.g., Thomas v. Ellis, 106 N.E. 2d 687 (Mass. 1952) (placenta detach- ed before delivery; negligent to fail to perform cesarean); Koebel v. United States, settled administratively by Judge Advocate General's Office, Dept. of the Air Force, Sept. 14, 1977, 21 A.T.L.A. Rep. 276 (1978) (among other allegations, physicians ignored meconium staining and used forcepts for 40-45 minutes in attempt to rotate infant; infant born with severe brain damage, including cerebral palsy: settlement for $600,000). E.g., Cueva v. Simon, Docket No. 465173 (N.Y., Kings Co. Sup. Ct., Dec. 15, 1977 (physician ordered pelvimetry; before results, admin- istered Pitocin and started oxygen inducement for an hour; after reading pelvimetry, ordered cesarean; infant suffered anoxia leading to brain damage: physician settled for $500,000). Docket No. 217266 (Cal. Sup. Ct., Sacramento Co., Aug. 7, 1974). Lopez v. Beth Israel Hosp., Docket No. 16949/74 (Bronx Co. Sup. Ct., N.Y., June 14, 1979). See Stetson v. Easterling, 161 S.E. 2d 531 (N.C. 1968) (infant's oxygen supply was cut off and brain damage resulted; evidence indicated cesarean should have been performed). Docket No. 11,009-74 (D.C. Super. Ct., Oct. 1975). See Braziel v. Presbyterian Hosp., Index No. 6626/72, Calendar No. 51735 (Bronx Cty. Sup. Ct., NY. 1976). (failure to perform timely cesarean, causing rare bacterial infection and requiring removal of uterus, one tube and ovary: jury verdict for $125,000); Thomas v. Ellis 329 Mass. 93 (1952) (failure to perform timely cesarean on woman with diagnosed separated placenta). 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. 508 No. 796299 (King Cty. Sup. Ct., Wash., Nov. 21, 1978). See Coble v Kaiser Found.Hosp., 21 ATLA L. Rep. 472-73 (Calif. 1978); Duncan v. St. Joseph's Hosp., 21 ATLA L. Rep. 426-27 (Fla. 1978); Medel v. Valentine, 21 ATLA L. Rep. 328-29 (Fla. 1978); Medel v. Valentine, 21 ATLA L. Rep. 328-29 (Fla. 1978); Marquez V. Maimonides Hosp., 21 ATLA L. Rep. 186 (NY 1978); Graham v. Bayer, 21 ATLA L. Rep. 15 (NJ 1978). 53 A.D. 2d 476, 385 N.Y.S. 2d 772 (1976). See also Christian v. Galutia, 236 S.W.2d 177 (Ct. Civ. App. 1951) (evidence insufficient to sustain jury finding that physician negligent in delaying perfor- mance of cesarean). 40 A.D. 2d 1025, 338 N.Y. S. 2d 972 (1972). Farthing v. Lahr, Docket No. 387448 (Calif. Sup. Ct., Alameda Co., Aug. 23, 1973). See Morales v. Martin, Docket No. 67-L-14008 (Il1. Cir. Ct., Cook Co., April 26, 1972) (allegation of negligence in giving woman a labor inducing drug instead of performing a cesarean section: jury denied damages). Mulligan v. Shuter, 419 N.Y. S. 2d 13 (N.Y. Sup. Ct., App. Div., July 30, 1979). See Goheen v. Graber, 181 Kan. 107, 309 P. 2d 636 (1957) (wrongful death action for failure to do cesarean). See also Schoonover v. Martin, Docket No. C191853 (Calif. Sup. Ct., Orange Co., July 7, 1974) (child delivered by delayed cesarean suffered from cerebral palsy and became a "human vegetable."). Docket No. C17288 (Calif. Sup. Ct., Los Angeles Co., Feb. 6, 1976). Rotan v. Greenbaum, 273 F. 2d 830 (D.C. Cir. 1959). Martin v. Parks, 165 So. 2d 220 (Fla. 1964). Gruccio v. Baxter, 343 A. 2d 145 (N.J. 1975); Lasseigne v. Earl K. Long Hosp., 316 So. 2d 761 (La. 1975). 19 P. 2d 523 (Dist. Ct. App., 1st Div. Calif. 1933). 361 S.W. 2d 697 (Mo. 1962). Gleason v. McKeehan, 66 P. 2d 808 (Colo. 1937). Green v. Louisiana, 309 So. 2d 706 (La. 1975); Weatherman v. White, 179 S5.E. 2d (N.C. 1977). Francois v.Mokrohisky, 226 N.W. 2d 470 (Wisc. 1975). Steward v. Rudner, 349 Mich. 459, 84 N.W. 2d 816 (1957). 43. 44. 45. 46. 47. 48. 49. 50. 51. 52. 53. 54. 55. 56. 509 Cobbs v. Grant, 8 Cal. 3d 229, 502 P. 2d1(1972); Natanson v. Kline, 186 Kan. 393, 350 P. 2d 1093 (1960); Rehearing den. 187 Kan. 186, 354 P. 2d 670 (1960). Schwartz v. Boston Hosp. for Women, 442 F. Supp. 53 (D.C.N.Y. 1976); Roberts v. Young, 369 Mich. 133, 119 N.W. 2d 627 (1962); Young v. Group Health Cooperative, 85 Wash. 2d 332, 534 P. 2d 1349 (1975); Wale v. Barnes, 261 So. 2d 201 (Fla. App. 1972), appealed, 278 So. 2d 601 (Fla. 1973). 11 Wn. App. 230, 523 P. 2d 211 (1974). 89 Misc. 2d 78, 389 N.Y. 5. 2d 988 (1976). 389 N.Y. 5S. 2d at 993. (1976). E.g., Matter of Quinlan, 70 N.J. 10,335 A. 2d 647 (1976); Superinten- dent of Belchertown v. Saikewicz, 370 N.E. 2d 417 (Mass. 1977). 78 N. J. Super. 472, 189 A. 2d 441 (1963). 410 U.S. 113 (1973). See Bowland v. Municipal Ct. for Santa Cruz Cty., 134 Cal. 630 (1976); Fitzgerald v. Porter Mem. Hosp., 523 F2d 716 (7th Cir. 1975) « Commonwealth v. Edelin, 359 N.W. 2d 4 (Mass. 1976). E.g., Bonbrest v. Kotz, 65 F. Supp. 138 (D.D.C. 1946). E.g., Graf v. Taggert, 43 N.J. 303, 204 A. 2d (1964); Carroll v. Skloff, 415 Pa. 47, 202 A. 2d 9 (1964). 89 Misc. 2d 78, 389 N.Y. S. 2d 988 (1976). 577 F. 2d 22 (8th Cir. 1978). EE RTT Sa tn Chapter XXII - Economic Concerns 1 513 INTRODUCTION Part of the concern about the increase in the rate of cesarean birth stems from the higher medical costs associated with cesarean delivery. As major abdominal surgery, cesarean birth generally requires more intensive patient care and more prolonged hospitalization. In 1978, for example, the average length of stay in a national sample of 1,425 hospi- tals was 6.4 days for repeat cesarean cases and 3.3 days for uncomplicated vaginal deliveries. ] In addition, when compared with vaginal births, cesarean births also require more hospital ancillary services such as laboratory tests, medications, and special therapeutic procedures. THE MEASUREMENT OF COST How much does this extra care cost? As an economic concept, cost is a measure of value - the value of productive resources that must be withheld from other uses when a cesarean patient is treated. Such resources include those provided by the hospital (labor, capital equipment, supplies, etc.) and the physician's labor. These costs are "avoidable", in the sense that they would not be incurred if the cesarean operation were not performed. However, the definition of what costs are avoidable depends upon the time during which the results of the decision are studied and the number of births that are avoided. In general, the longer the time perspective, and the larger the number of patients considered, the more medical care costs are avoidable. In the very short time perspective, the only truly avoidable costs of a single cesarean delivery may be the extra materials, supplies, food and utilities expended on the patient. In the longer time perspective, for 514 example when, as one result of change, cesarean birth rates might be permanently reduced, avoidance of cesarean births should lead to adjust- ment in hospital capacity. The costs associated wich excess capacity would no longer be incurred. Thus, in a long run analysis of the cost of cesarean births, elements such as the extra labor, beds and capital equipment used would have to be included. A common but inadequate approach to estimating cost is to use the prices charged for services, in this case the average hospital bill and physician's fee for cesarean birth versus vaginal delivery. Using this approach, Banta and Thacker? estimated the net additional medical costs of a cesarean delivery in 1977 at $2,300. Maisels et al.’ used a single hospital's total charge per case to estimate the median cost of hospital care associated with infant hyaline membrane disease, an occasional complication of cesarean section, at $2,678. In other sectors of the economy, the use of prices to measure cost is appropriate. However, hospital rates are often set in a way that has no relation to the value of productive resources needed to render health care services; hence estimates set in this manner are inadequate. For example, some hospital services or procedures are priced high rela- tive to costs. These services may actually subsidize the provision of other hospital services whose prices are set below their actual costs. The large variation among hospitals in prices of particular procedures attests to this phenomenon. COST FOR HOSPITAL STAY BY DIAGNOSIS IN NEW JERSEY AND MARYLAND These considerations led to a search for improved estimates of the 515 actual hospital cost of cesarean and vaginal birth. Data on hospital costs associated with vaginal and cesarean deliveries are available from New Jersey and Maryland. In these states, hospital rate setting has been in place from 1975 to 1980. The total cost of hospital stays in about 360 diagnostically related groups (DRG)” has been estimated by the state agencies in charge of rate setting. The methodologies used to estimate costs are superior to the usual reliance on hospital charges and more closely approximate the true long-run resource costs associated with vaginal and cesarean deliveries. It is noted that these estimates are for maternal costs and do not include any net positive or negative costs of treating an infant born by cesarean. In New Jersey, annual hospital costs by department are allocated to patients in each DRG according to predefined cost allocation rules. For example, total inpatient nursing costs are allocated among groups according to the percent of total hospital days accounted for by the patients in that group. Ancillary department costs (radiology, laboratory, etc.) are allocated according to the proportion of total billed charges in the department accounted for by the patients in each group. Indirect costs (administration, etc.) are allocated in proportion to direct costs in each DRG. In Maryland, data are available on total hospital charges by DRG. Unlike hospitals in other states, however, hospitals in Maryland are required by the state's rate setting commission to set average prices by department approximately equal to departmental costs. Thus, although the correspondence is by no means exact, charges in Maryland hospitals more closely approximate actual cost than in other states. 516 The average total costs or charges for hospital care in 1978 assoc- iated with vaginal and cesarean birth in 26 New Jersey hospitals and in all hospitals in Maryland with maternity services are seen in Table I. Comparing DRG 282 (cesarean delivery with complications) with DRG 281 (vaginal delivery with complications), it appears that cesarean birth involves an increase in hospital costs or charges of 47 and 85 percent in these two states. The reviewer is cautioned, however, that it is dangerous to general- ize from these estimates. The data are based on a small sample of hospitals, and the costs may be biased in that both are in eastern states with rate setting programs. In addition, these estimates do not include neonatal infant care costs. Nevertheless, they represent the information currently available on long-run hospital costs associated with cesarean birth. PHYSICIAN COST FOR CESAREAN COMPARED WITH VAGINAL BIRTH The physician component of medical cost is also generally higher for cesarean deliveries than for vaginal births. Physicians usually charge higher fees for cesarean than for vaginal deliveries. The differential between these fees varies widely among individual physicians, areas of the country, and types of payors. For example, payments to physicians allowed by Medicaid in various states or areas are shown in Table II. (These allowed payments probably do not reflect the fees charged by physicians to non-Medicaid patients in these areas). Fee differentials must be interpreted with care, for just as hospital prices are inadequate measures of cost, so, too, are physician fees unlikely to reflect the 517 true value of the physician's productive resources that must be devoted to cesarean and vaginal births.’ But, short of a detailed analysis of physician time inputs associated with cesarean and vaginal deliveries and their follow-up, there is no alternative to the use of the fee as a surrogate for physician costs. OTHER FACTORS AFFECTING THE PROBLEM OF COSTS That cesarean birth is a more costly obstetrical method than vaginal delivery is no surprise. Two comments will help put this fact into better perspective. First, since the most complicated cases are likely to become cesarean deliveries, there is a selection bias at work in these estimates. The same cases, if delivered vaginally, might also cost more than would the average vaginal delivery. This is reflected in the Maryland data but apparently not reflected in the New Jersey data (Table I). Thus, it cannot be assumed that the avoidance of a cesarean birth would reduce medical care cost by the difference in average cost between vaginal and cesarean deliveries. Actual savings would probably be less. Second, one must assess the additional burden of medical cost associated with cesarean birth in relation to its benefits to both ipfant and nother. Presumably, cesarean birth is chosen because the risk to mother and/or fetus from a vaginal delivery outweighs the cost and risk of surgical intervention. The medical benefits include reduction in untoward outcomes such as neonatal death or infant developmental disabil- ity. They also include "negative benefits" such as maternal morbidity and surgically-related maternal mortality. 518 COST-BENEFIT RATIOS If it were possible at this time to identify and quantify the most important medical benefits of cesarean delivery in different obstetrical situations, a ratio of cost to medical benefit could be computed. Moreover, if dollar values could be attached to these benefits, then the net value to society of cesarean birth could be calculated for specific indications. Such information would enlighten the question of whether and when cesarean delivery is worth its costs. As other sections of this report demonstrate, however, at present there are important restrictions on our ability to isolate the effect of cesarean birth on mortality, and we do not have adequate tools or data to measure effects on childhood development. Consequently, it would be unproductive to apply the techniques of economic evaluation to analysis of cesarean birth at this time. FINANCIAL INCENTIVES FOR PHYSICIAN AND FOR PATIENT A further economic issue involves the question of incentives to perform the cesarean birth. Are there financial advantages to the patient or physician to be gained from a cesarean birth, and if so, do these advantages affect physician and patient choices? With regard to the extent of economic incentives, the evidence is conflicting. Possible incentives are rooted in two aspects of our system of health insurance. First, group and private health insurance plans have typically discriminated between vaginal and cesarean delivery in their benefits. These plans often covered cesarean births as they did any illness while limiting the financial benefits following a vaginal delivery. In the past, many women .have been largely uninsured for both hospital and 519 physician charges for a vaginal delivery but may have been fully covered for a cesarean birth. Recent changes in the Civil Rights oy have mitigated this problem by requiring employers to treat pregnancy as they do an illness. Since April 1979, employers have been required to provide health insurance benefits for vaginal deliveries in the same way that they do for cesarean births, thus eliminating the economic incentive to the patient. Although employer compliance with the law has been gradual, ® the inverted incentives facing these patients seem for the most part to be disappearing. The second set of incentives concerns the physician who, as medical gatekeeper and the patient's agent, exercises the major control over decisions on cesarean birth. In fee-for-service medicine which predom- inates in the United States health care system, the physician charges a different fee for each procedure. Typically, the fee for cesarean birth is higher than that for vaginal delivery, as the maximum allowed fees under Medicaid shown in Table II illustrate. Such disparity in fees does not represent an incentive if cesarean birth is inherently more time consuming or difficult than a normal delivery. Whether or not this is the case has been debated. For example, in some instances cesarean birth may be the least demanding approach to obstetrical management during labor. However, cesarean patients may require more intensive followup during and after the hospital stay. The physician's physical and emotional efforts with ressent to surgical complications in the operating room or following surgery may be extreme, but is difficult to measure. Although we have found no studies that compare the relative physician costs of cesarean and vaginal deliveries, studies of other 520 surgical procedures have found wide disparities in the relative fees per unit of time input.”? The fact that the fee differential between cesarean and vaginal deliveries varies widely implies that an incentive may exist for some physicians. Thus, we return to one question posed at the beginning of this subsection. Do patients and providers respond to financial incentives by resorting to cesarean birth more frequently? The evidence, limited though it is, is also conflicting. In Chapter VIII of this report differences in cesarean birth rates among classes of patients and providers are examined. In one study, insurance coverage was not significantly related to rates of cesarean delivery. 10 Moreover, comparison of the rate of cesarean birth shows no significant difference between fee-for-service and mili- tary settings. However, data from a large health maintenance organiza- tion which operates on a prepaid basis shows a lower cesarean rate than in the fee-for-service sector. Whether such difference, or lack of difference, can be attributed to economic incentives is problematical. Other factors, for example the influence of the group practice, may be at work. It would appear, then, that the problem of economic incentives to the patient is gradually disappearing, while the existence and effect of incentives to the physician is unclear at best. 521 SUMMARY 1. The medical cost of delivery by cesarean birth is generally higher than that for vaginal delivery. The available evidence does not permit an accurate assessment of the value of health care resources that would be saved by avoiding a cesarean birth. It appears that in the short run such savings are likely to be much less than the difference in average hospital and medical bills for cesarean and vaginal deliveries. Additional medical costs can only be assessed in relation to their benefits to both infant and mother. At present, information on benefits is inadequate to determine direct medical cost effects of cesarean birth in relation to either maternal mortality and morbidity, or to perinatal and infant mortality and morbidity as represented by child development. Historically, financial incentives to patients for cesarean delvery have existed. These are declining in frequency due to a change in civil rights legislation. Sufficient evidence on the effect of these incentives on cesarean birth rates does not exist. Financial incentives to physicians to perform cesarean births may exist in some instances. Evidence on the effect of incentives on cesarean birth rates is limited and conflicting at present. 522 Table I Estimated Average Cost/Charge Per Hospital Stay for Vaginal and Cesarean Deliveries in New Jersey and Maryland--1978 New Jersey - Cost Maryland - Charges Diagnostically Related (26 Hospitals) (All Hospitals) Group Teaching ° Non-Teaching 278-- Vaginal Delivery ° $ 567 ° $472 ° $ 788 w/o Complications ° ° ° o o o 0 0 0 280--Cesarean Delivery ° $1,045 ° $688 S $1,902 w/o Complications * ° ° ° 0 o o 281--Vaginal Delivery ° $ 561 ° $514 2 $ 903 with Complications ° : . 282--Cesarean Delivery ° $ 907 ° $758 3 $1,673 with Complications ° ° ° Source: New Jersey Department of Health; Maryland Health Services Cost Review Commission. * Cases included in DRG 280 probably represent anomalies of medical record documentation and medical record abstract coding. Cesarean deliveries generally should not occur in the absence of obstetrical complications (prior cesarean birth is a recognized complication). Cases may be classified in this group because of inadequate documen- tation of complication or naive diagnosis coding on medical records abstracts. 523 Table II MEDICAID PAYMENT RATES FOR PHYSICIAN SERVICES VAGINAL AND CESAREAN DELIVERY* JANUARY, 1980 CLASSIC LOW CERVICAL® ’ STATE i VAGINAL DELIVERY . i CESAREAN DELIVERY : Maryland : As billed, maximum : $250.00 ’ $350.00 : Virginia : Without prenatal care : $150.00 : $300.00 : : With prenatal care : $250.00 : $350.00 : New Hampshire : Without prenatal care : $150.00 : $275.00 : ’ With prenatal care ° $214.00 ° $325.00 ° North Carolina ; ° ° : (region 05; rural)’ Without prenatal care : $320.00 ’ $420.00 ’ California ’ Without prenatal care : $150.00 ° $375.00 ° | ° With prenantal care ° $300.00 ° $487.00 *Source: State Medicaid Agencies o o o © o 0 oo o co o o o © o o o o o 524 BIBLIOGRAPHY 10. Commission on Professional Hospital Activities, PAS Data for 1978. Banta, H.D., Thacker, S.B.: Costs and Benefits of Electronic Fetal Monitoring: A Review of the Literature. NCHSR publication U.S. Department of Health, Education and Welfare, 1978. Maisels, M.J., et al.: Elective Delivery of the Term Fetus: An Obstetrical Hazard. Journal of the American Medical Association, Volume. 238, No. 19:2036-2039, November 7, 1977. Silvers, J.D.and Prahalad, C.K.: Financial Management of Health Institutions, Halsted, N.Y., 1974, pp. 24-25. Fetter, Robert: AUTOGRP Patient Classisfication Scheme and Diagnosis Related Groups (DRGs) Health Care Financing Grants & Contracts Report, Publication # HCFA 03011 1979. Blumberg, Mark S.: Rational Provider Prices: An Incentive For Improved Health Delivery. George K. Chacko, Ed. Health Handbook Amsterdam: North Holland Publ. Co 1978, p. 33. Amendments to Title VII of the Civil Rights Act of 1964, P.L. 95-555, 1978. Personal communication with staff of a major commercial health insurance company. Hughes, Edward: Surgical Workloads in a Community Practice.. Surgery, 7 (1972) pp. 315-72. Cynamon, M.L. and Placek, P.J.: Insurance coverage for prenatal care, hospital stay and physician care: United States, 1964-1969 and 1972. National Natality Surveys. Paper presented at the American Public Health Association Poster Session, New York, 1979. 525 SECTION VI - SUMMARY AND TENTATIVE CONSENSUS CONCLUSIONS AND RECOMMENDATIONS Chapter XXIII - Summary and Tentative Consensus Conclusions and Recommendations If IL . 2 ow Chapter XXIII - Summary and Tentative Consensus Conclusions and Recommendations 529 INTRODUCTION TO THE TENTATIVE CONSENSUS CONCLUSIONS AND RECOMMENDATIONS In a Task Force such as this the backgrounds of the participants are varied. The health care provider and the patient represent different kinds of life experiences and educational experiences. Similarly the lawyer, ethicist, epidemiologist, and economist as group members bring different ideas and data sets to bear on the questions. These tentative consensus recommendations have been reached after working through large volumes of data and many hours of active discussion. During the group's tenure, as a virtue of working together and listening and learning, many personal positions and attitudes present at the first meeting were quite different by the last meeting. These tentative consensus conclusions and recommendations represent the result of that learning process to this point, and are subject to further modification based on additional discussion and information that may be presented at the Consensus Development Conference on September 22-23, 1980. The members feel that the rising cesarean birth rates are a matter of concern. The tentative consensus statements reflect the Task Force's judgment that this trend of rising cesarean birth rates may be stopped and perhaps reversed, while continuing to make improvements in the maternal and fetal outcomes which are the twin goals of clinical obstetrics today. The constructive steps which may be taken are recorded in the tentative consensus recommendations. In the remainder of this chapter each set of tentative consensus conclusions and recommendations is preceded by a very brief synthesis of the more complete summaries presented at the end of each chapter. 530 THE EPIDEMIOLOGIC DATA During the 1970's, the cesarean birth rate in the United States increased about threefold, from 5.5% in 1970 to 15.2% in 1978, and appears to be continuing to increase. This trend is evidenced throughout the United States, irrespective of hospital, sabient, or medical practice characteristics. The diagnostic categories having the largest effect on the increase in the cesarean birth rate are dystocia and previous cesarean birth. Other conditions that contributed importantly, but at a lower level, are breech presentation and fetal distress. The cesarean birth experience in New York City, a specific area for which birth and death data are available for the assessment of changes in methods of delivery over the decade, 1968-1977, is consistent with the national situation. In addition, along with the rise in cesarean births, there appears to be a trend away from forceps delivery. All observations for birth weight and mortality in this report are based on the New York City data. Low birth weight is associated with relatively high primary cesarean birth rates. However, because more than 90% of all births are in the over 2500 gram category, this normal birth weight group makes the largest contribution to the number of cesarean births. The rate of increase in primary cesarean births over the decade was similar at almost all birth weights. In New York City the incidence of low birth weight has decreased both overall and among cesarean births. These changes in low birth weight incidence run counter to the upward trend in cesarean birth rates in general. 531 Since the New York City perinatal data includes antepartum deaths, which are more likely to be delivered vaginally, the more useful outcome measure is neonatal mortality. Neonatal mortality has fallen between 1967-68 and 1976-77 for all infant birth weights. The largest decreases have occurred in the 1000-2500 gram infant group. The largest relative decrease in neonatal mortality during this period was among cesarean births. Shifts into the cesarean birth group may have occurred in patient populations from the forceps group (a lower risk group for mortality) or from the medical illness group (a higher risk group). Neonatal mortality may also be influenced by concomitant improvement in factors such as neonatal intensive care. In births above 2500 grams in New York City there has been an overall small decrease in neonatal mortality. When allowing for possible selectivity from the forceps delivery group, no decrease is demonstrable in primary cesarean birth neonatal mortality. Breech presentation is associated with higher neonatal and perinatal mortality rates than vertex presentation. Vaginal breech birth is associated with a higher neonatal mortality than primary cesarean breech birth. At the end of the ten year period studied, neonatal mortality among low birth weight infants showed no consistent difference between the primary cesarean and vaginal breech births. Among births over 2500 grams, primary cesarean birth is associated with a far lower neonatal mortality rate than birth by vaginal breech. However, neonatal mortality in the total group of breech presentations did not decrease over the decade. 532 The recorded diagnosis of dystocia increased in frequency at the end of the decade. It is reported most frequently in the mature birth weight groups. Neonatal mortality rates show insignificant differences between primary cesarean births and vaginal births in the presence of dystocia. In the New York City data, fetal distress ranks third along with breech presentation in importance in the rise of cesarean birth rates. Fetal distress ranks far less than dystocia and repeat cesarean birth as an important factor in the rising cesarean birth rate. In the national data, fetal distress ranks fourth behind breech presentaton as a factor in rising cesarean birth rates. The large majority (90% in New York City) of the diagnosis of fetal distress occurs in the mature birth weight group. Because of the small numbers in this category, fetal distress cannot be reliably explored for risk of mortality in relation to method of delivery. As noted in the body of this report, morbidity for the newborn cannot be measured from the data presented in Chapters VIII and IX. Thus, information needed to investigate neonatal and childhood morbidity (the later appearance of, for example, brain damage with respect to decreasing use of forceps or increasing use of cesarean birth) is not available from the national or the New York City data. This is an important restriction on the determination of outcome or patient benefits as they may relate to changes in methods of delivery. CONSENSUS CONCLUSIONS AND RECOMMENDATIONS BASED ON THE EPIDEMIOLOGIC DATA 1. Any attempt to address the increased cesarean birth rate must be broad based rather than concentrate on a particular demographically defined subgroup of pregnant women or subgroup of hospitals. 533 The increase in the primary cesarean birth rate has been heavily influenced by increased proportions of births with dystocia as a diagnosis. Therefore, dystocia is a prime candidate for close scrutiny. Dystocia represents a wide range of obstetrical problems. The diagnosis is concentrated in low risk, mature infants and in this group there is no survival advantage for cesarean births over vaginal births. Based on neonatal mortality rates, the practice of routine repeat cesarean birth is open to question. At birth weights less than 2500 grams, there is a consistent mortality disadvantage for cesarean as compared with vaginal births; at birth weights of more than 2500 grams, they have the same mortality experiences as vaginal births. Breech presentations as a group represent a mixed situation at low birth weights, but at birth weights over 2500 grams there have been no gains in overall neonatal survival rates over the decade resulting from increased primary cesarean birth. The need for examining this situation more closely may have been obscured by the usual observation of higher survival in cesarean compared with vaginal births in term infants. This observation is limited by the lack of morbidity studies in this particularly vulnerable group. Among infants weighing less than 2500 grams, the increased primary cesarean birth rate has been associated with large reductions in neonatal mortality rates. The contribution of neonatal intensive care may, however, be an important factor in explaining this improve- ment. 534 6. In summary, the mortality experience among births in New York City provides strong evidence that well designed studies are needed on (a) conditions diagnosed as dystocia that result in primary cesarean birth for mature infants, (b) present practices that lead to routine repeat cesarean for nearly all pregnant women with prior cesarean births, and (c) preferable mode of delivery of breech presentations of mature infants. For selected subgroups, randomized trials may be required and this methodology should be included among the approaches to resolve equivocal issues. Zs Measures of infant outcome need to be extended beyond the available mortality data. These studies should include the condition of the neonate, later infant morbidity in growth and development, and particularly neurologic outcome with respect to brain damage. CANADA AND WESTERN EUROPE The increased use of specialists is a cross national trend. Increases in cesarean birth rates are influenced by availability of physicians, which in some national systems is controlled by government policy and incentives. In some countries, such as Canada and France, the cesarean birth rate appears to have risen in association with investments in services and facilities. The Netherlands is an example of control of access to such facilities by insurance reimbursement and by early identifi- cation of high risk mothers. Public preferences for specialist services and, by inference, the reduction of risk provided by these resources, appears in all the studied countries. 535 CONSENSUS CONCLUSIONS AND RECOMMENDATIONS ON CANADA AND WESTERN EUROPE DATA Given the basic similarities in medical issues facing industrial- ized countries, international coordination of future inquiries into cesarean birth rates would provide a much better comparative data base. The kinds of questions this Task Force is asking about practice and outcome should be communicated to other nations. Developing nations should be included in this international communi- cation. To place our own data in a better comparative framework, information on morbidity and mortality associated with cesarean delivery should be sought from other nations and such information should be based on standardized definitions. The impact of increased medical resources, such as professional services and fully equipped hospital facilities, on cesarean delivery rates warrants study. A major question raised by the Canadian and European data is one of optimal management of high risk mothers in different medical settings. Planning for a safe labor and delivery demands serious consideration by medical professionals, hospital administrators and the public. MATERNAL MORTALITY AND MORBIDITY Although maternal mortality is extremely uncommon (9.9 deaths/100,000 births in 1978), cesarean birth carries four times the risk for mortality when compared with vaginal delivery. Some components of maternal mortality following cesarean birth are related to maternal illness rather than the 536 surgery. The repeat cesarean birth carries two times the risk of vaginal delivery and the rate has not fallen since 1970. Maternal mortality rates are still underreported. Cesarean birth is a major surgical procedure with morbidity greater than vaginal delivery. The most common infections include endometritis, urinary tract infections, and wound infections. The morbidity may also reflect the demographic features of the population cared for, as well as the events of labor and birth. CONSENSUS CONCLUSIONS AND RECOMMENDATIONS ON MATERNAL MORTALITY AND MORBIDITY DATA 1. Despite the overall rarity of maternal death, the relatively greater risk of mortality in cesarean compared with vaginal delivery makes it an important consideration. 2. Adequate data collection is needed in order to identify the reasons for maternal operative and non-operative related deaths. The identification of this medical risk data should lead to more appropriate plans for lowering maternal death rates in general. 3 The National Center for Health Statistics should consider revising (a) the standard certificates of birth and fetal death to include items that distinguish between cesarean and vaginal delivery, and (b) the standard certificates of death to include or modify items that improve the identification of maternal deaths. 4. State Health Departments should adopt similar revisions in certif- icates of birth and death. 5. For statistical analysis, maternal death certificates should be matched with the corresponding birth and fetal death certificates. 537 6. There is need for improved delivery of medical care to cesarean birth patients. Operations on these patients often occur under emergency or non-elective circumstances where hospital support systems do not deliver care similar to that available to general surgical patients. 7. There is a need for measures of maternal morbidity with respect to changes in obstetrical practices. Comprehensive morbidity studies with respect to cesarean births, vaginal births and forceps births are lacking. REPEAT CESAREAN DELIVERY Prior cesarean delivery is numerically the largest indication for cesarean birth at this time, and is likely to become larger if present trends continue. This diagnostic category accounted for 27% of the increase in cesarean rate from 1970 to 1978. Following a cesarean delivery, nearly all women in the United States undergo a repeat cesarean for any subsequent pregnancy. This practice began in the early 1900's, when classical cesarean incision predominated and the cesarean birth rates were extremely low, to avoid the risk of uterine rupture at the scar site during labor. The low segment transverse uterine incision now generally used is associated with lower maternal and fetal morbidity and mortality initially and in subsequent pregnancy and labor than the classical incision. With any uterine scar, however, rupture is unpredictable. The incidence of rupture is higher in classical, low vertical and inverted T incisions, as compared with the low segment transverse incision. The studies reported in the literature on this subject are generally old, incomplete, and rarely prospective or randomized. 538 CONSENSUS CONCLUSIONS AND RECOMMENDATIONS ON REPEAT CESAREAN DELIVERY The available data indicates that in hospitals with appropriate facilities, services and staff for immediate termination of labor by prompt emergency cesarean birth, a proper selection of cases would permit a safe trial of labor and vaginal delivery for women who have had a previous low segment transverse cesarean birth. Informed consent should be obtained before a trial of labor is attempted. In some hospital environments, the risk of a trial of labor in women who have had a previous cesarean may exceed the risk for both mother and infant of a properly timed elective repeat cesarean birth. There is a need for the collection of more adequate information with respect to risks in trials of labor in patients with previous low segment transverse uterine incisions. Of necessity, these studies must be large, multi-institutional, and include morbidity and mortality information for both mother and infant. Patients who have had a previous classical or inverted T type incision or a low vertical incision, as well as patients for whom there is no documentation of the site and type of the previous cesarean incision, are more safely delivered by elective repeat cesarean birth. Institutions in which trials of labor following a previous cesarean birth may take place should develop guidelines for the management of those labors. 539 6. Patient education relating to cesarean birth and repeat cesarean birth should continue throughout pregnancy and is an important part of patient participation in decisions concerning anesthesia and elective repeat cesarean birth vs. trial of labor following previous cesarean birth. DYSTOCIA Dystocia encompasses functional classifications of labor as well as terms such as fetopelvic disproportion or failure to progress during labor. The largest contribution (29%) to the overall rise in the cesarean delivery rate from 1970 to 1978 came from dystocia, warranting careful study of this diagnostic category. In the New York City data, the diagnosis of dystocia is concentrated in the over 2500 gram infant birth weight category, and cesarean delivery is not associated with survival advantage in this group when compared with vaginal births. Adequate data relating to infant morbidity, and specifically abnormal neurologic development, in association with studies of dystocia is unavailable. CONSENSUS CONCLUSIONS AND RECOMMENDATIONS ON DYSTOCIA 1. The term dystocia, as a reason for cesarean birth, encumbers two systems of classification. The first classification system relates to problems of fetal position or size. The obstetrician generally recognizes these problems, appropriate guidelines for obstetrical conduct in these situations are available, and fetal and maternal outcome effects are reasonably well known. These position problems, excluding the breech birth which is discussed as a separate category, are not a major reason for the increase in cesarean birth rates in the dystocia category. 540 The second classification system relates to the functional classifica- tion of labor as dystocia with a fetus in vertex presentation, and is more complex. The fetus weighing less than 1000 grams has not been well evaluated as to its ability to tolerate vaginal or cesarean birth. Similarly the fetus weighing more than 4000 grams, when recognized, requires particularly cautious obstetrical management of labor. The remaining more than ninety percent of vertex births are of normal size fetuses. Assessing the quality of labor, here defined as contractions with progress in labor, and the presence or impact of dystocia, may be facilitated by visual graphic labor monitoring, and by intrapartum electronic fetal monitoring techniques. Particularly in the absence of fetal distress, there is room for clinical decision making, as has been described in this report. For example, patient rest, patient ambulation, patient sedation and patient stimulation (oxytocin) may be effective in managing dysfunc- tional labor prior to considering cesarean delivery. The Task Force is not suggesting a return to difficult or manipulative forms of vaginal delivery or to methods of delivery that have slowly been removed from the obstetrician's routine of procedures. It is suggesting that the poorly defined category, dystocia, represents the most prominent reason for the increases in primary cesarean birth rates, and that the use of already available parameters for defining labor functionally, along with the use of appropriate interventions at appropriate times, may decrease the need for a cesarean birth. A compelling reason for close scrutiny of the dystocia category, in addition to its prominent position as a contributor to the increase 541 in the primary cesarean birth rate, is the absence of a survival advantage for the cesarean births over 2500 grams when compared with vaginal deliveries. 5. For the reasons noted above, there is a need for studies of labor management and outcomes in low birth weight infants and in the normal (2500-4000 gram) birth weights with respect to both cesarean birth and subsequent infant developmental morbidity. BREECH PRESENTATION Breech presentation is associated with an increase in both morbidity and mortality when compared with vertex presentations, irrespective of whether delivery is performed vaginally or by cesarean. There is a continuing trend toward delivery of breech presentations by cesarean. Nationally the proportion of breech presentations delivered by cesarean rose from 11.6% in 1970 to 60.1% in 1978, accounting for about 15% of the rise in cesarean rate during those years. Evaluation of breech presentation outcome is complicated by problems related to the increased frequency of prematurity in breech presentations, the different types of breech presentation, congenital anomalies associated with breech presentation, and influence of maternal pelvic size on ease of vaginal breech delivery. Maternal morbidity following surgery or difficult breech delivery is a consideration in choosing delivery method. Most clinical reviews suggest that abdominal breech delivery may be associated with less risk to the premature fetus. As in other areas, data on infant morbidity following vaginal or cesarean breech delivery are generally inadequate. 542 CONSENSUS CONCLUSIONS AND RECOMMENDATIONS ON BREECH PRESENTATION The large fetus presenting as breech, the fetus presenting as a complete or footling breech, and the fetus with marked hyperexten- sion of the head presenting as breech, have a better outcome if delivered by cesarean birth. Vaginal delivery of the term breech should remain an acceptable obstetrical choice for delivery when all of the following conditions are favorable: (a) anticipated fetal weight of less than 8 pounds; (b) normal pelvic dimensions and architecture; (c) frank breech presentation without a hyperextended head; and (d) delivery to be conducted by a physician experienced in vaginal breech delivery. More data are needed in order to evaluate the best mode of delivery for premature fetuses in the breech presentation. Analysis of outcome of these deliveries is most difficult because of the frequent medical complications in the lowest birth weight categories (i.e. < 1500 grams), increased fragility of the fetal skull, disparity between shoulder and head size, and the increased incidence of single and double footling breech presentation. Since all breech births have inherent risks, and since these risks are often uncertain and unpredictable, whenever possible it is important to share this information with the family as part of the decision making process. 543 FETAL DISTRESS Intrapartum fetal distress, leading to asphyxia and brain damage, remains an important concern evident in clinical patient care. The use of monitoring techniques is associated with an increased diagnosis of fetal distress, but not necessarily with an increase in cesarean delivery. The diagnosis of fetal distress, while more frequently made during the past 10 years, is responsible for approximately 1 percentage point in the 9 percentage point rise in cesarean birth rates, and 10% of all cesarean births. There is still a great deal of difficulty in differentiating the distressed from the non-distressed fetus during the intrapartum period. CONSENSUS CONCLUSIONS AND RECOMMENDATIONS ON FETAL DISTRESS 1. The diagnosis of fetal distress represents an area of concern. There are many limitations in evaluating both the meaning of the term fetal distress and the accuracy of the diagnosis. Further studies are needed to overcome these limitations. 2. The development of more specific techniques to improve the diagnosis of fetal distress may be expected to improve fetal outcome and to lower cesarean birth rates. 3. Fetal distress is another category in which not only study of mortality but of later infant morbidity is most important in improv- ing choice of obstetrical care techniques. OTHER MATERNAL AND FETAL CONSIDERATIONS Because of a need for early delivery, many maternal and fetal medical problems lead to cesarean birth. Examples include maternal diabetes, vaginal herpes infection, and erythroblastosis fetalis. In some of these 544 patients vaginal birth would be a safe alternative if an effective method for stimulation of labor were available. This entire group contributes only a small part of the cesarean birth rate increase, lagging well behind repeat cesarean, dystocia, breech presentation, and fetal distress in importance. CONSENSUS CONCLUSIONS AND RECOMMENDATIONS ON OTHER MATERNAL AND FETAL CONSIDERATIONS There are a number of maternal and fetal medical indications for early termination of pregnancy. An effective method for safe preterm stimulation of labor in this group is needed if vaginal delivery is to be used. NEONATAL RESPIRATORY DISTRESS SYNDROME Cesarean birth appears to be associated with a small increase in neonatal respiratory distress at all gestational ages. Iatrogenic neonatal respiratory distress should be avoidable with the appropriate use of clinical, biophysical and biochemical estimators of gestational age. The different effects on neonatal respiratory function of labor, when compared with cesarean birth, are not fully understood. In infants with previously demonstrated mature lungs, respiratory distress is unlikely to be a problem whatever the route of delivery. CONSENSUS CONCLUSIONS AND RECOMMENDATIONS ON NEONATAL RESPIRATORY DISTRESS SYNDROME 1. Emphasis must be placed on improved and intensive professional and patient education regarding the safe and effective assessment of fetal gestational age and fetal maturity before birth. 545 2 For both vaginal and cesarean births, further research is needed into the influence on neonatal pulmonary function of events sur- rounding labor and delivery. 2 Neonatal pulmonary physiologic studies may become even more neces- sary as the proportion of cesarean-delivered infants weighing less than 1500 grams increases. ANESTHESIA Obstetric anesthesia is unique in that it requires attention to the health of two patients. Substantial increases in knowledge of both maternal and fetal physiologic systems have lead to improved anesthetic care. Where medical circumstances permit, choice for the kind of anes- thesia should be available and discussed among obstetrician, anesthesio- logist and patient. Appropriate anesthetic selection and technique can minimize the inherent medical risks, including the risk of maternal death. CONSENSUS CONCLUSIONS AND RECOMMENDATIONS ON ANESTHESIA 1. Anesthesia-related maternal deaths, although at a very low incidence, continue to occur. Most anesthesia-related deaths are potentially avoidable. There is considerable variation and room for improvement in the number, quality, and availability of obstetric anesthesia services throughout the United States. The obstetric patient should receive the same quality, competence and availability of medical care extended to the surgical patient. In particular, and where not medically contraindicated, the patient should have the option of receiving regional anesthesia for cesarean delivery. 546 2s The use of obstetric anesthesia demands further study in order to minimize maternal and neonatal mortality and morbidity. Te More current, comprehensive and continuing data collection is needed to determine the training, availability and quality of anesthesia support systems and personnel for the obstetric patient. 4. The short and long term effects of anesthetic drugs and techniques on the neurobehavioral development of the newborn are poorly de- scribed in the existing literature. The understanding of these effects is critical to an evaluation of benefits and risks to infant development and warrants further study. MOTHER AND FAMILY There is limited research concerning the psychological impact on parents following a cesarean birth. Nevertheless, surgery is clearly an increased psychological and physical burden when compared with a normal vaginal delivery. In addition, negative responses from mother and father have been reported in the available retrospective studies. In some hospitals, family centered maternity care has been extended to the cesarean birth family, and in these cases there is no evidence of harm to mother, neonate or father. The presence of fathers in the operating room and closer contact between mother and neonate would appear to improve the post-cesarean behavioral responses of the families. One consistent finding from small scale studies of post-cesarean birth families (although the father was not always present at delivery) appears to be the greater involvement of fathers with their infants. Improvement in educational programs for all families so that they may understand the cesarean birth, 547 as well as specific educational programs for previous cesarean birth families is seen as a method of improving the birth experience. — CONSENSUS CONCLUSIONS AND RECOMMENDATIONS ON MOTHER AND FAMILY Parent education during pregnancy by primary care providers and in childbirth education classes should include information relating to the possibility of a cesarean birth, an explanation of the technical procedures surrounding the cesarean birth, and available parental options for choices. During labor and at the time a decision to perform a cesarean is made, as time and circumstances permit, a discussion of the indications, procedures and parental options should take place between the physician or his/her staff and the parents. Information exchange about the entire cesarean birth experience should continue in the postoperative period and at later postpartum visits. In the absence of scientific evidence regarding benefit or risk, the presence at a cesarean of the father or surrogate should be a joint decision among parents, physician and hospital representatives. Hospitals are encouraged to liberalize their policies concerning (a) the option of having the father or surrogate attend the cesarean birth, and (b) the routine separation of the healthy neonate delivered by cesarean to a special care nursery for monitoring. Further research is needed on the effect of a cesarean birth on families in various social, economic, cultural and ethnic settings. Additional research is also needed on the benefits and/or problems of the father's presence at a cesarean birth. 548 INFANT DEVELOPMENT Often lacking in comparative studies of the influence of cesarean birth on infant development is information relating to the obstetrical reasons for the cesarean birth and the presence of the father in the delivery room. Several studies noted that although the cesarean birth infant was in the higher medication group, assessments of neonatal behavior did not reveal depressive effects. Virtually no differences associated with delivery mode have been found in the few available reports of infant development beyond the neonatal period. The literature in this field is characterized as often inadequate in study design and incomplete in infant follow up. CONSENSUS CONCLUSIONS AND RECOMMENDATIONS ON INFANT DEVELOPMENT 1. There is a need for longitudinal follow up studies of cesarean delivered infants and their parents. These studies should include adequate size study populations, more suitable control groups and more standardized methods of assessment. MEDICOLEGAL CONCERNS Malpractice suits may be brought against a physician for negligent performance of a cesarean, for not performing a necessary cesarean, or for performing an unnecessary cesarean. Many malpractice suits have been in the area of negligent non performance of an assumed necessary cesarean. The physician defendant is successful in the large majority of these nn cases. Liability, when found, generally involves gross deviation from the 549 recognized standards of patient care. Appropriate application of informed consent by providing a patient sufficient information to make a knowledge- able treatment choice is protective for the physician. The law also deems the rights of the unborn child worthy of protection. CONSENSUS CONCLUSIONS AND RECOMMENDATIONS ON MEDICOLEGAL CONCERNS The legal system should recognize that the mere fact that a vaginal delivery resulted in a "less than perfect" baby does not necessarily mean that the physician was negligent for not performing a cesarean birth. Physicians should make a determination as to the need for a cesarean delivery based solely on sound medical judgment. Physicians should recognize the patient's right to participate in the decision making process concerning whether to have a cesarean by proper application of the doctrine of informed consent. Since information exchange and obtaining informed consent during emergency or crisis situations is more difficult, all patients should have available to them appropriate educational courses and opportunities to discuss medical problems during pregnancy, including cesarean birth. Physicians and hospitals should make the opportunities and programs available to patients in an active manner. Other than anecdotal information, there is no evidence from the materials reviewed both in the legal and the medical portions of this report that fear of malpractice litigation is a major cause for the rise in the cesarean birth rate. 550 ECONOMIC CONCERNS The medical cost of delivery by cesarean birth is generally higher than that for vaginal delivery. The available evidence does not permit an accurate assessment of the value of health care resources that would be saved by avoiding a cesarean birth. It appears that in the short run, such savings are likely to be much less than the difference in average hospital and physician bills for SEarens and vaginal deliveries. Additional medical costs can only be assessed in relation to their benefits to both infant and mother. At present, information on benefits is inadequate to determine direct medical cost effects of cesarean birth in relation to either maternal mortality and morbidity, or to perinatal and infant mortality or infant morbidity as represented by child development. Historically, financial incentives to patients for cesarean delivery have existed. Sufficient evidence on the effect of these incentives on cesarean birth rates does not exist. Financial incentives to physicians to perform cesarean births may exist in some instances. Evidence on the effect of such incentives on cesarean birth rates is limited and conflicting at present. CONSENSUS CONCLUSIONS AND RECOMMENDATIONS ON ECONOMIC CONCERNS Although it would be useful to know how the benefits of cesarean birth compare with its costs in various situations, until benefits can be better defined and measured, no recommendation can be made to conduct cost benefit studies to address this issue. 551 ETHICAL CONCERNS The ethical issues associated with cesarean birth are not specific to this procedure, but are shared with other specialized treatments. The ethical principles involved, even when confronting competing maternal and fetal interests, are similar to the generally established principles governing all relationships between physician and patient. These principles involve the commitment to placing the patient's interest above that of the physician, and the rights for decision making to include consideration for the mother as well as for the fetus. No separate consensus recommen- dation was made, since the Task Force felt these are the accepted principles for obstetrical practice today. *U,S. GOVERNMENT PRINTINGOFFICE : 1980 0-620-378/1 EE = BT) a C(028b9931Lu4