Wednesday, June 27, 2012

Planned Vaginal vs. Planned Cesarean: Research Spotlight

One of the things that comes up again and again when discussing modes of birth, is the idea that planned vaginal delivery is better for both mother and child than planned caesarean delivery. I remember when I was preparing for the birth of my daughter and looking into the research to help me decide what I should plan to do, that there was scant little that looked at planned mode of delivery and outcomes. Much of what existed at the time was retrospective in nature and lumped in emergent cesareans with elective cesareans. Logically, I knew that the risks varied depending on the type of cesarean it was (pre-labour, post-labour but non-emergent, and emergent caesarean) and I also new that most emergent cesareans were the result of planned vaginal births.

In the nearly two years since her birth, that seems to have improved a bit. The research that is out there is much better than it was then - and includes a very comprehensive book Choosing Caesarean by Pauline McDonagh Hull and Dr. Magnus Murphy. As well as a variety of other pieces of research that have been published since July 2010.

One of those pieces of research is the work of Geller, J.; Wu, J.; Janellie, M; Nguyen, T.; and Visco A. (2010) “Maternal outcomes associated with planned vaginal versus planned primary caesarean delivery” American Journal of Perinatology, Vol. 27(9): pp. 675-83. This paper came out after my daughter was born, but its results are interesting because of the prospective approach that was use. The paper examines the outcomes of 3868 planned vaginal deliveries and 180 planned caesarean deliveries. The paper found that planned caesarean had less chorioamnionitis at 2.2 percent versus 17.2 percent (a bacterial infection of the fetal membranes), less postpartum hemorrhage at 1.1 percent versus 6.0 percent (massive blood loss), less prolonged rupture of the membranes (2.2 percent versus 17.5 percent) but a longer hospital stay (3.2 days versus 2.6 days). There was no difference in transfusion rates. It was noted that laboured caesarean delivery had increased risks to the mother compared with either vaginal delivery and pre-labor caesarean delivery.

I note that the sample size of planned caesarean delivery in this study is quite small - this would mean that the confidence intervals would be larger than ideal (ie. there could be a lot of variability between this group of women and another group of women – larger sample sizes lead to smaller confidence intervals and greater certainty about the values that are reported). However, at first blush, this research seems to fly in the face of the generally accepted wisdom that planned caesarean is somewhat riskier for the mother than planned vaginal delivery. Previous research has indicated that its somewhat more risky for the mother, but less risky for the baby. I also note that the increased hospital stay for planned caesarean delivery is not substantial at about a half a day of increased length of stay compared with planned vaginal delivery.

I will also note that this study does not look at longer run risks and benefits of caesarean delivery or vaginal delivery - and those should also be carefully considered among mothers who are planning their mode of delivery.

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