Part 2 ~ False Association btw Cesarean surgery, preventing pelvic floor damage in moms & protecting OBs & hospitals from lawsuits ~ Part 2 (of 3)

by faithgibson on March 7, 2019

in Cesarean Politics, Electronic Fetal Monitoring, OB Interventions: Dubious or Detrimental

Part 2 (of 3) ~ 2019

word count 2800

Easy-to-copy-&-share link –>  http://tinyurl.com/yxz3h5oe

Is a policy ‘elective’ Cesareans an effective strategy for saving the pelvic floor of childbearing women?

~ “A Scar is Born Every 39 Seconds” ~

Headline for an April 15, 1998 ad in Ob.Gyn.News for a new product to rub on C-section incisions to diminish scarring.

This statistic — that a ‘scar’ is born 39 seconds — refers to the number of Cesareans performed in 1995 when the rate was merely 20%. The ad was promoting a skin product specially formulated to treat surgical incisions in post-Cesarean mothers.

Imagine what the ‘per second’ rate of new Cesarean scars is in 2019, with a 32.8 % rate?


  • The INABILITY of Cesarean surgery to prevent pelvic floor damage in childbearing women is well-documented

When what you see is not what you get!

There are many published studies that refute the notion that Cesarean surgery effectively reduces or eliminates what used to be called “females troubles” — pelvic floor problems that include incontinence, uterine prolapse, and related issues.

However, nothing I could say about the false strategy of using ‘elective’ Cesareans to prevent ‘female troubles’ could possibly be more informative or authoritative than the following two excerpts.

Documentation ~ Published studies and professional warnings by obstetricians to obstetricians

The first is from “Elective C-section Revisited” by Sacramento obstetrician Dr. Elaine Waetjen (Ob.Gyn.News; August 1, 2002, Vol 36, No 15):

The prophylactic use of elective cesarean section to prevent pelvic organ prolapse and urinary incontinence is gaining increased attention

Dr. Benson Harer, Jr, past president of the American College of Obstetricians and Gynecologists, stated publicly last year that women should have the right to choose a cesarean delivery. 

“….why shouldn’t we offer prophylactic C-section to prevent this problem later in life?”

The answer is that the evidence does not support this approachPreventive strategies should cause no more harm than the disease or problem that they are trying to prevent. Ideally, they should:

    • incorporate some kind of screening to identify people at risk
    • they should be cost effective
    • based on very good evidence of benefit 

Elective C-section to preserve pelvic floor function fails on all these measures. 

Cesarean surgery causes more maternal morbidity and mortality than vaginal birth. In the short term, C-Section doubles or triples the risk of maternal death, triples the risk for infection, hemorrhage, and hysterectomy, increase the risk of potentially-fatal blood clots 2 to 5 times and causes surgical injury {to the baby} in about 1% of operations.

In the long term, cesarean section increases the mother’s risk of a placenta previa, accreta or percreta, uterine rupture, surgical injury, spontaneous abortions, and ectopic pregnancies while decreasing fecundity {i.e. infertility}.

Babies delivered by cesarean have a higher risk of lung disorders and operative lacerations.” Cesarean babies also have triple the rate of asthma as adults. (*Cesarean Birth Associated with Adult Asthma — ObGynNews, 6/15/01, Vol  36, N0. 12)

…would have to do 23 C-sections to prevent one such surgery {for organ prolapse or incontinence} later in life.

So instead of offering elective cesarean in an attempt to prevent future prolapse or incontinence, we should be examining what we can do in our management of vaginal deliveries to protect pelvic floor function”.

The second excerpt is from Elective Cesarean Section: An Acceptable Alternative to Vaginal Delivery? published in Medscape Ob/Gyn & Women’s Health; 9/16/02

Dr Peter Bernstein, MD, MPH; Associate Professor of Clinical Obstetrics & Gynecology and Women’s Health, Dept of Obstetrics and Gynecology, Albert Einstein College of Medicine / Montefiore Medical Center, and Medical Director, Obstetrics & Gynecology, Comprehensive Family Care Center / Montefiore Medical Group, Bronx, New York

One argument often cited in favor of elective cesarean delivery is the prevention of pelvic floor damage, which can occur with vaginal delivery. Stress urinary incontinence, pelvic organ prolapse, and anal incontinence have been associated with vaginal delivery.

But these adverse side effects may be more of the result of how current obstetrics manages the second stage of labor

    • Use of episiotomy and forceps has been demonstrated to be associated with anal incontinence in numerous studies.

Perhaps also vaginal delivery in the dorsal lithotomy position with encouragement from birth attendants to shorten the second stage with the Valsalva maneuver [prolonged breath-holding], as is commonly practiced in developed countries, contributes significantly to the problem

Nonetheless, the prevention of pelvic floor injury by routine elective cesarean delivery is not an appropriate solution. Rather, more research into the management of the second stage of labor is clearly necessary. Moreover, cesarean delivery does not guarantee protection against pelvic floor dysfunction, given the reports of similar rates of urinary incontinence in nulliparous woman as in parous women [2]

A potentially more persuasive argument in favor of elective cesarean delivery is based on the potential for fetal risks before and during vaginal delivery, including intrapartum death, intrapartum acquired hypoxic-ischemic encephalopathy, and stillbirth at term before the onset of labor.

What is not clear, however, is how many cesareans would have to be performed to avert these disastrous events and what the cost would be in terms of maternal morbidity and mortality in order to prevent a single untoward fetal outcome.

To suggest that performing an elective cesarean delivery in a low-risk patient will avert intrapartum fetal injury is very misleading. These outcomes are rate, even in higher-risk women.

Indeed, they are so rare in women without any identifiable risk factors that an absurd number of cesarean deliveries would need to be performed to avert even one of these poor outcomes. Thus, resorting to cesarean delivery would not be an appropriate standard procedure.

Although cesarean delivery has clearly become safer over the past 50 years with advances in antibiotics, anesthesia, and thromboprophylaxis, it is still not without risks. Woman undergoing cesarean delivery have greater blood loss and risk of damage to internal organs. The mortality risk of undergoing an elective cesarean delivery with no emergency present has recently been reported almost 3 times the risk of vaginal delivery. [3]

In addition, risks to the fetus associated with a cesarean delivery range from lacerations [a cut in the baby’s face or head when the surgeon makes the incision into the uterus] to respiratory distress syndrome and transient tachypnea of the newborn. Although these are typically manageable, their cost will be multiplied many times over if more elective cesareans are performed.

One of the most significant risks of cesarean delivery is the need for a subsequent cesarean delivery.  …  A repeat cesarean delivery carries significantly more risk in terms of placenta previa, placenta accreta, uterine rupture, injury to internal organs during surgery excessive blood loss, need for hysterectomy and maternal death.

These risks rise with each subsequent repeat cesarean delivery. Risk of [placenta] accreta and previa increases with each subsequent cesarean delivery, increasing to 60% in women with 4 or more cesarean deliveries. [4] In addition, the incidence of emergency peripartum hysterectomy for abnormal placentation seems to be rising as a result of the increased rates of cesarean delivery.

A move toward routine elective cesarean delivery may also have significant costs in terms of lost opportunities for bonding between mother and newborn. A woman who has had a cesarean may be less able to care for her child and may have a more difficult time breastfeeding

…..  Although this impact may be small for the individual patient, again, its costs multiplied over a large population may be great, based on the accumulating evidence for the benefits of successful long-term breastfeeding.

Arguments made by proponents of elective cesarean that it should only be provided to women who intend to have only 1 or 2 children fall flat, given that the rates of unintended pregnancy in the US approach 50%. And what of the woman who changes her mind 10 years later and chooses to have another child after having had 2 prior cesareans?

There may be no legal liability to the physician who performed the patient’s first cesarean section when the patient winds up with a hysterectomy or worse, but that does not clear that physician of responsibility for performing a surgical procedure of unclear benefit upon a patient’s request.

Some argue that, from an ethical point of view, allowing a patient to choose to deliver by cesarean is not substantially different from allowing her to choose to undergo cosmetic surgery.

But cesarean is very different. The benefits of elective cesarean relative to vaginal delivery are not established and the risks are substantial, especially given the potential for future repeat cesareans.

That women are seeking elective cesarean deliveries is probably more significant in that it indicates the failure of modern medicine and society at large, in the sense that women may fear the experience of labor and birth attendants may fear the legal risks of allowing appropriate women to have a trial of labor.

Modern management of labor should be reassessed to address the concerns raised by proponents of elective cesarean delivery. If elective cesarean becomes an acceptable alternative, we may never be able to undo the practice.

Excerpts from “Elective Cesarean Section: An Acceptable Alternative to Vaginal Delivery?” by a clinical professor of obstetrics and gynecology, Dr. Peter Bernstein, MD, MPH;  9/16/02

Failed Medical Experiment:

How the policy of using C-EFM as the obstetrical Standard for all childbearing women is related to our sky-rocketing C-section rate and its many complications

The current EFM technology was invented in 1969, but not widely adopted until the mid-1970s. In 1970, the C-section rate was 3%-5%. By the 1980s, it had sky-rocketed to 25% and now is 33%

And yet, the consensus the professional studies and journal articles, starting in 1975, is simple and straightforward: The policy by the American obstetrical professional of continuously monitoring all laboring women and performing emergency cesareans based on “non-reassuring” EFM tracing is a failed medical experiment.

This undeclared medical experiment was based on a hypothesis that continuous electronic monitor of all labor patients would virtually eliminate cerebral palsy and perinatal morbidity and mortality, thus reducing the financial burdens on families and the taxpaying public by virtually eliminating the incredibly expensive care required for children with CP and permanent neurological damage.

As quoted in the previous post, an article written by an obstetrician for other obstetricians and published in 2011 (The Female Patient “Electronic Fetal Monitoring Update”:

“Despite the widespread use of EFM, there has been no decrease in cerebral palsy.

… a meta-analysis of randomized control trials has shown that EFM has no effect in perinatal mortality or pediatric neurologic morbidity.2

However, EFM is associated with an increase in the rate of operative vaginal and cesarean deliveries.1”

These have always been extremely worthy goals, and I personally hope we can figure out how to achieve them, the sooner the better. But when it comes to c-EFM, the scientific literature does not provide the “proof of theory” so desired by hospital chains and the obstetrical profession because universal use of c-EFM does not achieve its own goals when applied to the 70-85% of healthy childbearing women with normal pregnancies.

Instead of helping healthy childbearing parents and society, its routine use results in expensive iatrogenic complications that primarily affect the childbearing woman, in particular, an increased rate of morbidity and mortality that is extraordinarily expensive for society and painful if not tragic for families.

All this is a direct result of the higher Cesarean section rate and its propensity for spawning complications during the surgery itself, immediately post-op and/or serious delayed and downstream problems for both mothers and babies.

The ethical high road: To admit and correct mistakes

The history of western medicine includes dozens of policies and highly regarded medical treatments that were ultimately proven to be ineffective, harmful or both. For the most part, these researchers and developers were highly ethical people motivated by a genuine desire to advance medical science, reduce suffering, and prevent untimely deaths.

It’s normal for inventors of a new or improved medical treatment or medical device to be excited about them and more focused on their potential benefits than possible risks and negative side-effects. Nonetheless, its a fact of life that many of these new policies or protocols, new drugs or medical devices turn out to be ineffective or harmful.

When that happens, developers and manufacturers of these new medical treatments have to acknowledge the harm and stop promoting their product or process in its current form.

An example of admitting and correcting a mistake is the story of a new therapy introduced in 1947 for premature babies. This treatment consisted of piping high concentrations of oxygen into the baby’s incubators over long periods of time. By 1952 — just 5 years later — over 7,000 premature babies had been blinded as a result of this new oxygen therapy.  What seemed like a really good idea actually caused irreversible damage to the eyes of these babies that resulted in permanent blindness. [1]

This new iatrogenic condition was originally called retrolental fibroplasia but is now referred to as “retinopathy of prematurity” (ROP). A close friend of our family was one on those premies. His parents were assured that their baby was getting the most up-to-date treatment and they had nothing to worry about but the high levels of oxygen left him totally blind. A more well-known victim of RLF is the famous musician, Stevie Wonder.  

One study reported that in developed countries, the oxygen toxicity accounted for 10% of the case of childhood blindness.

But the medical profession realized what was happening and corrected the problem. As a result, high concentrations of oxygen are no longer the “standard of care” for all premature babies. 

But so far the American obstetrical profession has steadfastly refused to admit that their policy identifying c-EFM as the universal standard wrong: c-EFM for healthy low-risk mothers is ineffective, introduces unproductive expense, and results in a statistically-significant increases the C-section rate and exposes these new mothers to the serious risks of Cesarean surgery and all its delayed and downstream complications.     

Cesarean Surgery – the “gift” that keeps on giving!

Cesarean surgery is the gift that keeps on giving, not only at the time the operation is performed but in all future pregnancies. Unfortunately for 6% of post-Cesarean mothers, a downstream complication of their Cesarean surgery is infertility as a result of a post-operative infection.

Life-threatening complications of this surgery can result in the need for blood transfusions, unplanned emergency hysterectomy for uncontrollable hemorrhage and days or even weeks in the ICU.

The postpartum recovery period is longer, harder, more painful and in some cases of prolonged post-op pain, exposes new breastfeeding mothers to opioid addiction as a result of the needed narcotic medication. In other instances, the problem is post-operative infections that have to be treated with IV antibiotics and may require new mothers to be readmitted to the hospital.

Obviously, none of this is conducive to bonding with one’s new newborn or learning how to care for and meet its needs, something that may be a make-it-or-break-it issue for post-op mothers trying to breastfeed for the first time.

Then there is the long shadow that a previous C-section casts over all subsequent pregnancies. This begins with the risks of possible uterine rupture of the Cesarean scar either before or during labor. That is the primary source of controversy over vaginal birth after Cesarean (VBAC), as many doctors, hospitals and medical malpractice insurers do not want to risk being sued in these cases. As a result, they either decide not to  “do” VBACs, or hospital policies (often based on liability insurance contracts) won’t allow them to do so.

This sets up previous-Cesarean mothers for additional, often unwanted (and certainly not medically necessary) major surgeries by requiring that all future babies be delivered by repeat C-section. This exposes her to all the aforementioned risks, over and over again, and dramatically increases the likelihood of the placenta-related complications described below.

The most devastating and potentially deadly of the many delayed and downstream complications of Cesarean surgery is the propensity to develop abnormal placental implantation in future pregnancies, a risk that increases exponentially with each subsequent Cesarean delivery.

Even the very best of circumstances — the least invasive category of placenta accreta — can be life-threatening. Luckily. the majority of these new mothers come through without requiring blood transfusions, major surgery, or admission to the ICU.

But when the placenta grows into the uterine muscle (placenta increta), or worse yet, grows completely through the wall of the uterus (percreta) and attaches itself to other abdominal organs (usually bladder or bowel), it requires a highly risky preterm Cesarean-hysterectomy. This dire but mostly preventable emergency is fatal 7-10% of the time.

Unfortunately, the delayed and downstream complications associated with Cesarean surgery make any policies or practices that increased the C-section rate counterproductive in the extreme.

Vocabulary Review for types and levels of abnormal Placental attachments:

  • Placenta Previa is when the placenta implants at the bottom of the uterus. Depending on how close to the cervix, there are 4 levels of previa: (a) low-implantation (b) marginal (c) partial and (d) complete, which covers the cervix completely and makes vaginal birth impossible.
    In addition to the previa, the placenta may also grow abnormally deep into the uterus, which means the mother-to-be has both a previa and a perceta. 
  • The most serious levels of previa (c & d) or any level of accreta-percreta require Cesarean delivery.
  • Placenta accreta is when the placenta grows abnormally into the superficial lining of the uterus and is the least serious level of invasion
  • Placenta increta is when it grows into the uterine muscle
  • Placenta Percreta is when it grows through the uterine wall and attaches to other abdominal organs.

    These are life-threatening complications that frequently require an emergency hysterectomy to stop the bleeding and has a 7 to 10% maternal mortality rate.

What is the word for promising one thing & doing the exact opposite?

Now we come to the well-documented facts about the current national standard for obstetrical care in the US, which is organized around the universal use of c-EFM. There is no question that the frequent use of emergent C-section based on EFM tracings that are ‘non-reassuring’ increases our national Cesarean rate. In fact, “non-reassuring fetal heart tones” is the second most frequent diagnosis for Cesareans performed on first-time mothers.

Yet the raison d’etre for EFM — reducing the instance of cerebral palsy and other neurological disabilities — is NOT happening. What surely is happening is a decades-long medically-unnecessary increase in Cesarean surgery and its many intra-operative, post-op, delayed and downstream complications that remains an everyday reality for the four million laboring women (3.5 million of whom are healthy and have normal pregnancies).

These women will find themselves immobilized in their labor beds while they remain hooked up to continuous electronic monitoring equipment. This is almost always followed by a cascade of obstetrical interventions — IVs and epidurals for pain, automatic blood pressure cuff, pulse oximeter, foley catheter and far too often, the need for vacuum extraction or Cesarean delivery.

As if this is not problem enough, this “standard care ” predictably doubles or triples the cost of normal childbirth.

How could such a discordant practice have been perpetuated for the last 50-plus years? How come no one else had noticed?

Hospitals economics & the Nancy Reagan “Just Say No” policy

The professional journal publications quoted in this post and many other peer-reviewed articles clearly convey the obvious — the routine use of continuous EFM on low and moderate risk women is NOT a science-based practice AND has never been able to do what was advertised– eliminate or greatly reduce the rate of CP and other neurological pathologies of the newborn.

Nonetheless, the obstetrical profession and hospitals have masterfully ignored everything they don’t want to hear, decade after decade after decade, as they swept new studies under the rug to join all the earlier studies– something not to be talked about, and certainly not to be acted on!

The R2D2 of EFM!

In spite of the many complications associated with the universal EFM for healthy women with normal pregnancies, and well-established fact that c-EFM is not associated with better outcomes, the practice continues unabated in the 3,400 hospitals in the U.S. that provide obstetrical services.

EFM is now the single most frequently used medical procedure in the US, which is to say that the use a $15,000 electronic monitor system has outstripped every other medical device or procedure in America.

The official estimate is that 85 to 93 % of all childbearing women are hooked up to continuous EFM equipment during their entire labor. [citation L2M Survey 2002 & 2005; Martin et al 2003]

Many health insurance carriers reimburse hospitals $400 an hour for intrapartum continuous electronic monitoring. According to doctors and hospitals, this is the cheapest and best way to protect them from multi-million dollar malpractice suit for a damaged baby, and like one’s American Express card, you shouldn’t go anywhere without it!

The April 2011 article quoted in Part 1 acknowledges the lack of a scientific basis for c-EFM, but at the same time, they went on to say some version of:

“ya, but we have to keep using universal EFM because there are too few nurses to use IA”

This means that hospitals in the US have systematically chosen NOT to hire enough L&D nurses to use the ‘alternative’ to EFM — a simpler but equally-effective monitoring method of known as Intermittent auscultation (IA). {full explanation and description of how it works follows in Part 3}

As noted, many hospitals bill health insurance companies and the federal Medicaid program up to $400 an hour for each labor patient who is hooked up to c-EFM. Each hospital is reimbursed many thousands of dollars for average labor (8-10 hrs = $3200-$4,000), multiplied by 3 to 12 labor patients in the unit at any one time (i.e. generating from $10,000 to $40,000 per shift).

L&D nurses certainly are NOT getting paid $400 an hour (average RN pay in the US is btw $28 and $45 an hr).  Obviously, hospitals in the US find it a whole lot more profitable NOT to hire enough L&D nurses to monitor (i.e. the active verb, not the machine!) the unborn baby using a hand-held Doppler and Intermittent Auscultation (IA) protocols.

While “auscultation” is a strange and hard-to-pronounce word, IA itself is a simple and straightforward screening process that collects essentially the same 4-points of information on the fetal heart rate and rhythm as EFM to determine the health status of the fetus at each specific point in time as either ‘reassuring’ or ‘NOT reassuring’. The use of low-level technologies similar to IA that are regularly used during labor includes a blood pressure cuff and thermometer to repeatedly check on the well-being of the mother.

In the case of intermittent auscultation of an unborn baby, the birth attendants or nursing staff are listening for four data point listed below and will use them, just as they would information about the mother’s BP or temp, to determine if everything is normal or if there is a problem that needs to be medically evaluated. These four data points for fetal well-being are:

  • normal baseline  (y/n)
  • normal variability (y/n)
  • the presence of reassuring Accelerations (y/n)
  • the absence of pathological Decelerations (y/n)

This screening process is repeated many times during labor, usually every 30 minutes during the 1st stage and every 15 minutes or more often during the 2nd (pushing) stage.

Whether this data is gathered by EFM or IA,  the ‘screening’ process uses the same binary data (yes/no) of four specific markers that provide a clinical picture of normal vs not normal. This tells the primary birth attendant (OB or midwife) and/or L&D staff whether an additional evaluation is indicated or if emergent interventions is necessary.

These four points of information as provided by IA on fetal wellbeing allows the unborn baby to be monitored without the many complications, expense, increase C-section rate and maternal mortality associated with c-EFM.

The dilemma that c-EFM poses to obstetricians are humorously described in this brief tongue-in-cheek editorial by Dr. Drosman to his fellow obstetricians.

Why the C-section rate is rising by Dr. Steven Drosman, MD, obstetrician-gynecologist in San Diego, CA; Editorial ~ Medical Economics, Oct 2000 ~

“Probably the biggest C-section motivator, however, is fear of a lawsuit. The rationale is simple: At worst, you’ll be criticized for performing a C-section but you can be roasted for delaying one!

When a patient is hooked up to a fetal monitor, it initiates an unholy trinity — the anxious patient, the hovering nurse, and the paranoid physician. The tension escalates as monitoring devices are added: the fetal scalp electrode, the fetal pulse oximeter, and intrauterine pressure catheter.  Add some more Pitocin to the mix, and the action begins.

The labor and delivery nurse watches the monitor and observes decreased variability and persistent late decelerations. The obstetrician is notified, wipes the perspiration from his forehead and pops a handful of antacids.

The patient and her family are informed of the potential crisis, and the can of worms has been opened. More likely than not this “electronically compromised” fetus will be delivered by emergency C-section, with perfect Apgar scores.

Continue to Part 3 (of 3)

The False Association btw the routine use of EFM to prevent Cerebral Palsy in babies or to protect OBs & Hospitals from lawsuits


Reference

1. The Permanente Journal

. 2011 Winter; 15(1): e108–e113.
Published online Winter 2011.
PMCID: PMC3138176
PMID: 21892344

Maintaining Optimal Oxygen Saturation in Premature Infants

Yoke Yen Lau, RN, BHSN, Yih Yann Tay, RN, BHSN, Varsha Atul Shah, MD, MBBS, MRCP, Pisun Chang, RN, and Khuan Tai Loh, PEN
…. retinopathy of prematurity (ROP) …. a disease of the retina that occurs after birth among premature infants who are born weighing <1500 g, when blood vessels in the vascular bed of the retina begin to grow abnormally.
ROP is a potential cause of blindness in children and accounts for up to 10% of cases of childhood blindness in developed countries.
The goal for clinicians is to deliver adequate oxygen to the tissue without creating oxygen toxicity.

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