Elective Cesarean For A Normal Pregnancy

QUESTION:

Do you have any experience with or opinion on elective Cesarean for a normal pregnancy? Do you believe that there are maternal benefits in avoiding later problems with the pelvic floor function.

REPLY (WMR):

No. For over twenty years we have been active in the development of obstetrical curriculum for family physicians nationally and overseas. Medicos has grown into one of the largest fellowships in Family Medicine Obstetrics with each of two fellows performing over 200 sections last year. Plus we do all of the continuing care for the mothers and their families. Our primary rate is approx 15%, but we are harvesting a large number of repeat sections as a legacy of the current health care system 1975-present.
 
Our system is six separate independent family medicine offices in Memphis. All of them are collectively feeding 2-4 fellows a year. Our FP-OB experience in Memphis goes back  20 years. We are delivering some of the daughters we delivered. Our office identity remains family medicine, and we do not specialize in OB. Our OB committment has caused some of our critics to label us as  "not real FP", but we are in an excellent position to observe a wide variety and large volume of birth related issues.
 
We do not encounter the large percentage of pelvic floor problems reported in the literature. The ones we encounter, have not been attributed to child birth by the women we serve. We acknowledge that more rigorous interviewing might produce an association.
 
We have studied the literature and believe that the reports of "significant damage" suffer from selection bias, surrogate measures,and all of the weaknesses of survey research. University investigators have been circumspect in reporting the significance of their findings, but medical reporters are always looking for a sensational story. Unfortunately these data have a large and receptive audience only too eager to find a rationalization for their self-fulfilling prophecies regarding the risks of vaginal birth.
 
I remember everyone teaching that routine episiotomy was "better" for the mother and the baby.  Funny how the professors will slip in an anecdote justifying an unproven surgical intervention. How much community followup do these professors actually do? See Brazilian item below.
With best wishes for your professional success,
 
Wm. MacMillan Rodney MD, FAAFP, FACEP
Adjunct Professor of Family Medicine
American Board of Family Medicine Obstetrics
Chair, Academic Affairs
Medicos para la Familia
Nashville, Memphis, and International

lockecolorado writes:

I don't have an answer for you and you already heard this in your research of the issue, but I am constantly amazed at Brazil's elective c-section rates.

http://findarticles.com/p/articles/mi_m0CYD/is_23_37/ai_95514138/

The vast majority of private-practice patients routinely opt for cesarean section; in some obstetricians' practices, the rate is 90%. In public-sector patients, however, cesarean section is performed only when medically indicated; rates in this population are comparable with those in the United States as a whole.

"My subjective impression is that C-section does protect against incontinence pathology In Brazil we see very little prolapse and incontinence in patients who've had only C-sections," Dr. Netto observed at the conference, which was sponsored by the Society of Pelvic Reconstructive Surgeons.

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International Federation of Gynecology and Obstetrics. Published by Elsevier Science Ireland Ltd.

The opinion of Brazilian women regarding vaginal labor and cesarean section

References and further reading may be available for this article. To view references and further reading you must purchase this article.

M. J. D. Osis, , a, K. S. Páduaa, G. A. Duartea, T. R. Souzaa and A. Faúndesa, b

a Center for Research into Maternal-Infant Diseases of Campinas (CEMICAMP), Campinas, Brazil

b Department of Obstetrics and Gynecology, FCM, State University of Campinas (UNICAMP) Campinas, Brazil

Available online 7 December 2001.

Abstract
Objectives: The opinions of Brazilian women regarding vaginal delivery and cesarean sections was studied. Methods: Six hundred and fifty-six women who had given birth in seven hospitals in São Paulo and Pernambuco, using the Public Health Service, were interviewed. The opinions of women who had delivered only by cesarean section was compared with those of women who had had at least one vaginal delivery. Results: Significantly more women who had experienced at least one vaginal delivery considered this to be the best way of giving birth (90.4% vs. 75.9% among C-section-only women). Similar proportions in both groups (45.5% and 42.8%) stated that vaginal labor is better because it causes less pain and suffering for the woman. Significantly more women who had experienced a vaginal labor (47.1% vs. 30.3%) reported that it had no disadvantage. More women who had only had cesarean sections referred not having contractions/pain as an advantage of this method (56.7% vs. 41.7%). Conclusions: Apparently, pain and women's perception of pain were the characteristics which differentiated women with history of vaginal delivery from those with cesarean sections in the sample studied. However, the opinion that vaginal delivery is better than cesarean section was expressed independently of the recognition that pain could be its main disadvantage.

Kelly Locke, MD

eastonjackson wrote:

After 5 years in rural practice and doing OB, I had a different question posed to me today. My primigravida 30 year old patient at 37 weeks was in for an OB check. She said, "I've been researching quite a bit about vaginal and C/Section deliveries. I'm worried about the risks of incontinence, pelvic floor relaxation, and sexual difficulties from vaginal delivery. I would like to have an elective C/Section instead. My husband and I have discussed it and we both feel like this a better option for us."

She's a very fit, collegiate level athlete with no medical problems. We had a discussion for a while about the lack of data regarding primary C/Section vs. vaginal deliveries and pelvic floor issues later in life. We discussed surgical risks, prolonged hospitalization, increased expense, hazards of VBACs and repeated C/Sections, and many other things.

I told her I'd need to consider this and discuss it with my partners and we'd talk again later in the week.

I've read some of ACOG's position papers on elective primary C/Sections. Like most committees, ACOG is staunchly non-committal. Their position was something like:

"After the patient and physician have discussed the relative pros and cons, in a trusting environment, in an appropriate ethical framework, we can see where there may be situations where an elective C/Section could be ethically appropriate, possibly..., well, we think it could be okay, or not, maybe."

The data is certainly incomplete with regards to this issue.

Have any of the list-serve members had this question from their OBs, or discussed it with either OB consultants or their patients who are going to OBs? My older partner, who really enjoys surgery, said he'd have to think about his answer as well.

Any thoughts?

Index--Cesareans, elective

Comments

[julie]

I can understand why doctors are nervous but I so resent a doctor bringing a nurse in for a pap test that I haven't a test in years even though I have cancer. I truly hate an audience because I can't ask personal questions I need to ask that way.

A couple of times nurses have also done things to really embarrass me!

I have never been embarrassed by a doctor as I have always trusted the ones I have gone to. I don't trust the confidentiality of nurses that I hardly know. I was practically in shock one time when the nurse wasn't available and the doctor brought in another female office person! So many of these women GAWK too! Why are they so nosy? Are they comparing my body parts to theirs? I don't like these nosy curious snoops in the room. The only reason I go to a male doctor in the first place is that I always feel women do compare their parts to the parts of other women -- same as men kind of do in a urinal.

I think there should be a sign on the door stating that if women are uncomfortable or fearful about being touched, they should ask for a nurse to be present. If they don't ask, it should be understood that any charges they may bring up could be viewed with a bias toward the doctor.

I have never made a pass at any doctor or accused one of anything, and no doctor has ever made one at me so it upsets me terribly that doctors treat all women the same.

This forced lack of privacy is of extreme humiliation and a real sort point with me.

When doctors get a prostate test done by a female patient, does the female doctor bring in another male? I wonder how many men could stand such humiliation!

[julie]

Woops! That was an awful slip. I meant, "when doctors get prostate tests done by a female "DOCTOR" not by a PATIENT!

[julie]

Oh crumb. Why did I even post here. Can you delete these? This was supposed to be in response to some article I saw written about doctors not doing pap tests without a nurse in the room. But after I signed in I appeared to have posted it in the wrong spot. It's not my day. Guess the comment just upset me too much.

[writing term paper]

In this era of web 2.0, we easily get nice & updated information for research purposes... I'd definitely appreciate the work of the said blog owner... Thanks!