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ORIGINAL RESEARCH |
From the Department of Obstetrics and Gynecology and Perinatal Epidemiology Research Unit, Dalhousie University, Halifax, Nova Scotia; and Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, British Columbia, Canada.
Address reprint requests to: V. M. Allen, MD, MSc, Department of Obstetrics and Gynecology, IWK Health Centre, Room G2141, 5980 University Avenue, Halifax, Nova Scotia, Canada B3H 4N1; E-mail: vmallen{at}dal.ca.
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ABSTRACT |
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METHODS: A 14-year, population-based, cohort study (1988–2001) using the Nova Scotia Atlee Perinatal Database compared maternal outcomes in nulliparous women at term undergoing spontaneous labor for planned vaginal delivery with singleton, cephalic presentation and nulliparous women delivering by cesarean without labor.
RESULTS: From a total of 18,435 pregnancies, which satisfied inclusion and exclusion criteria, 721 were cesarean deliveries without labor. There were no maternal deaths or transfers for intensive care. There was no difference in wound infection, blood transfusion, or intraoperative trauma. Women undergoing cesarean deliveries without labor were more likely to have puerperal febrile morbidity (relative risk [RR] 2.2; 95% confidence interval [CI] 1.1, 4.5; P = .03), but were less likely to have early postpartum hemorrhage (RR 0.6; 95% CI 0.4, 0.9; P = .01) compared with women entering spontaneous labor. Subgroup analyses of maternal outcomes in women delivering by spontaneous and assisted vaginal delivery and cesarean delivery in labor were also performed. The highest morbidity was found in the assisted vaginal delivery and cesarean delivery in labor groups.
CONCLUSION: The increased maternal morbidity in elective cesarean delivery compared with spontaneous onset of labor is limited to puerperal febrile morbidity. Maternal morbidity is increased after assisted vaginal delivery and cesarean delivery in labor compared with cesarean delivery without labor.
There is a growing body of literature addressing the issue of elective cesarean delivery in the absence of a medical indication.1,2 Although the Committee for the Ethical Aspects of Human Reproduction and Women’s Health of the International Federation of Gynecology and Obstetrics advises that "performing cesarean delivery for nonmedical reasons is not ethically justified,"3 others advocate choice for the pregnant woman for cesarean delivery without labor after informed consent.4,5 Safety for both the mother and infant with cesarean delivery without labor compared with spontaneous labor and planned vaginal delivery remains unresolved. We assessed the risks of maternal mortality and morbidity in these two groups using data on a low-risk obstetric population from a large provincial database.
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MATERIALS AND METHODS |
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ABSTRACTMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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Maternal data included in this study consisted of information from pregnancies to Nova Scotia residents between January 1, 1988, and December 31, 2001. The low-risk obstetric population was defined by inclusion and exclusion criteria. Pregnancies were included if there was a live born singleton at term (37–42 weeks) born to a nulliparous woman. Pregnancies were excluded if there was a major fetal anomaly, if labor was induced, if there was nonvertex presentation with spontaneous labor, or if there was preexisting maternal disease, fetal growth restriction (less than 10th percentile birth weight for gestational age), pregnancy complications such as gestational diabetes or pregnancy-induced hypertension, or premature rupture of membranes. Ethical approval was obtained from the Research Ethics Board at Dalhousie University in Halifax, Nova Scotia, the Reproductive Care Program of Nova Scotia, and the IWK Health Center in Halifax, Nova Scotia.
Maternal and infant summary characteristics included maternal age, smoking, maternal weight at delivery, gestational age at delivery, and birth weight. Maternal morbidity outcome variables included venous thromboembolism (pulmonary embolus or deep venous thrombosis), need for blood transfusion, wound infection (infected abdominal or episiotomy wound), peripartum hysterectomy, puerperal febrile morbidity (greater than 38C on two or more occasions in any 48-hour period, excluding the first 24 hours after delivery), evacuation of hematoma, early postpartum hemorrhage (physician-diagnosed postpartum hemorrhage, or an estimated blood loss greater than 500 mL within the first 24 hours postpartum), third- or fourth-degree laceration, intraoperative trauma (including laceration of the uterine artery; laceration of the bladder, bowel or ureter; or severe extension of the uterine incision), need for postpartum readmission to hospital, near-miss maternal mortality (transfer to general hospital for intensive care), and maternal mortality. Outcomes in the cesarean delivery without labor group were compared with women who presented in spontaneous labor and by their method of delivery, including spontaneous vaginal delivery, assisted vaginal delivery, and cesarean delivery in labor.
Continuous variables (maternal age, smoking, present weight, gestational age at delivery, and birth weight) between groups were compared using the Student’s t test. Categoric variables were analyzed with 
2 tests using SAS Windows 8.0 (SAS Institute Inc., Cary, NC).
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RESULTS |
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), the rate of cesarean delivery without labor increased from 2.9% to 7.6% (P < .001), whereas the rate of cesarean delivery in labor increased from 8.5% to 11.3% (P < .001).
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. Number of cigarettes smoked per day and birth weight were not significantly different. Although maternal age, maternal weight at delivery, and gestational age at delivery showed statistically significant differences, the difference in mean values was not found to be clinically relevant.
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. There were no maternal deaths, no maternal transfers for intensive care, and no maternal readmissions in either the study group or the comparison group. The rates of venous thromboembolism, blood transfusion, hysterectomy, evacuation of hematoma, and intraoperative trauma were low (less than 0.5%) in both groups. There were no cases of venous thromboembolism or hysterectomy in the cesarean delivery with no labor group. There were no differences in blood transfusions, wound infection, evacuation of hematoma, or intraoperative trauma. The laceration rate (third or fourth degree) was 5.4% in the spontaneous onset of labor group (3.2% with spontaneous delivery and 15.2% with assisted vaginal delivery). There was an increased risk of puerperal febrile morbidity (relative risk [RR] 2.2; 95% confidence interval [CI] 1.1, 4.5; P = .03) and a decreased risk of early postpartum hemorrhage (RR 0.6; 95% CI 0.4, 0.9; P = .01) in the cesarean delivery without labor group.
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. There were 14 women who underwent spontaneous labor where the method of delivery was unclassified. These cases were included in the comparison of cesarean delivery without labor with spontaneous onset of labor, but not in subgroup analyses by method of delivery. There was an increase in wound infection (RR 3.5; 95% CI 1.8, 6.7; P < .001) and puerperal febrile morbidity (RR 5.4; 95% CI 2.4, 11.8; P < .001) with cesarean delivery without labor compared with spontaneous vaginal delivery, and an increase in puerperal febrile morbidity (RR 3.0; 95% CI 1.2, 7.2; P = .02) with cesarean delivery without labor compared with assisted vaginal delivery. There was a decrease in early postpartum hemorrhage (RR 0.4; 95% CI 0.3, 0.6; P < .001) with cesarean delivery without labor compared with assisted vaginal delivery, and a decrease in puerperal febrile morbidity (RR 0.3; 95% CI 0.2, 0.7; P = .03), early postpartum hemorrhage (RR 0.5; 95% CI 0.4, 0.8; P = .001), and intraoperative trauma (RR 0.1; 95% CI 0.01, 0.4; P < .001) with cesarean delivery without labor compared with cesarean delivery with labor.
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DISCUSSION |
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No maternal deaths were noted in either group, although sample size was not adequate to detect a difference. The Confidential Enquiries Into Maternal Deaths in the United Kingdom, 1997–1999,8 recently reported that there was a 4.9-fold increase in maternal mortality associated with cesarean compared with vaginal delivery (95% CI 3.0, 8.0), although the highest increase in risk was associated with emergency and urgent cesarean delivery (RR 12.0; 95% CI 6.3, 22.7; and RR 6.0; 95% CI 3.2, 11.4, respectively). In addition, the UK Confidential Enquires noted no difference in risk for maternal death for scheduled or elective cesarean deliveries compared with vaginal deliveries, and there was a 3.1-fold increase in risk for maternal death associated with assisted vaginal delivery compared with spontaneous vaginal delivery (95% CI 1.3, 7.1).8 Another study9 reported no increase in risk of death among women delivered by cesarean compared with women delivered vaginally.
No transfers for intensive care or readmission postpartum were noted in this study population, and, therefore, no assessment of risk for these outcomes was possible. In an unselected population in this province, Baskett and Sternadel10 reported an incidence of 0.7 per 1000 transfers for critical care. The main reasons for transfer were hypertension (25%), hemorrhage (22%), and sepsis (15%), and greater than 50% were associated with cesarean delivery or cesarean hysterectomy. Lydon-Rochelle et al11 found that rehospitalization for infectious morbidities was more common for women with cesarean and assisted vaginal deliveries (RR 1.8 and 1.3, respectively).
The risk of morbidity in patients requiring operative delivery has been reported in numerous studies.12–15 Maternal age, weight, and infant size are known to be risk factors for increased morbidity after cesarean delivery.16–18 In this study, there was no clinically significant difference in maternal age, maternal weight at delivery, or infant birth weight. The low rate of venous thromboembolism (less than 0.5%) is consistent with other findings,19 which demonstrate that although venous thromboembolism continues to be the most common cause of maternal deaths, it is a rare event. Our study showed a low rate of blood transfusion, with two cases of transfusion in the cesarean delivery with no labor group. These findings are consistent with the need for blood transfusion in an obstetric population, which ranges from 0.16% to 2.6%,20 and 6.4% of women undergoing cesarean delivery.21 This study demonstrated a low rate of peripartum hysterectomy, with no cases in either group. These findings are consistent with the need for peripartum hysterectomy reported in the literature to range from 0.2 to 1.5 per 1000 deliveries.22
During the period of study, wound infection rates decreased for both the cesarean delivery without labor group (2.1% to 0%, P = .03) and the spontaneous onset of labor group (1.6% to 0.1%, P < .001), whereas the rates of puerperal febrile morbidity varied from year to year but were usually less than 1%. All cesarean deliveries in labor received prophylactic antibiotics. Antibiotic use increased for both the cesarean delivery without labor group (27.1% to 64.3%, P < .001) and the spontaneous onset of labor group (13.6% to 26.2%, P < .001), consistent with findings reported in a recent Cochrane Review.23 Our study showed a 1.7-fold increase in risk of wound infection and a 2.2-fold increase in risk of puerperal febrile morbidity in women undergoing cesarean delivery without labor compared with women having spontaneous labor. However, there was a three-fold increase in risk of puerperal febrile morbidity in women having a cesarean delivery in labor compared with women undergoing cesarean delivery without labor. Wound infection rates for cesarean delivery without labor (1.5%) and for cesarean delivery in labor (2.2%) were similar to those predicted by prospective cohort and descriptive cross-sectional studies,15,24 which report rates of wound infection ranging from 1% to 4% in cesarean delivery groups. In studies comparing maternal infectious morbidity between planned cesarean delivery and vaginal delivery, no difference in risk25 and an increase in risk26 have been observed.
Although the risk of puerperal febrile morbidity doubled when cesarean delivery without labor was compared with spontaneous onset of labor, the rate for puerperal febrile morbidity was already low in the spontaneous onset of labor group (0.5%). A more clinically relevant difference may be observed in the almost 50% reduction in rate of early postpartum hemorrhage when cesarean delivery without labor (3.9%) was compared with spontaneous onset of labor (6.2%). In addition, when cesarean delivery without labor was compared with assisted vaginal delivery and cesarean delivery in labor, the rate of total morbidity in the cesarean delivery without labor was reduced by 40% (P < .001) and by 60% (P < .001), respectively.
This study did not attempt to address fetal, neonatal, or infant morbidity and mortality, or long term maternal outcomes. Although retrospective studies in general are limited by the reliability of data, information in the Nova Scotia Atlee Perinatal Database is of high quality. Routine data checks and edits are made at the time of data collection by qualified health records personnel, and validation27 and reabstraction studies attest to the quality of the data in the database.
The option of cesarean delivery by maternal request in the absence of complications in pregnancy remains controversial. This population-based study of maternal morbidity and mortality in a low-risk, nulliparous, obstetric group demonstrates low rates of operative complications. Compared with spontaneous labor and planned vaginal delivery, some infectious morbidities are increased in cesarean delivery without labor. However, maternal morbidity is increased the most after cesarean delivery in labor. The rate of emergency/urgent cesarean delivery in any group planning spontaneous labor and planned vaginal delivery will dictate how valid elective cesarean delivery might be for other selected populations, such as mature primiparous women or women facing induction of labor.
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Footnotes |
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doi:10.1016/S0029-7844(03)00570-2
Received February 13, 2003. Received in revised form April 15, 2003. Accepted April 17, 2003.
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REFERENCES |
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2. Bewley S, Cockburn J. The unfacts of "request" cesarean section. BJOG 2002;109:597–605.[Medline]
3. FIGO Committee for the Ethical Aspects of Human Reproduction and Women’s Health. Ethical aspects regarding cesarean delivery for non-medical reasons. Int J Obstet Gynecol 1999;64:317–22.
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5. Paterson-Brown S. Controversies in management: Should doctors perform an elective cesarean section on request? Yes, as long as the woman is fully informed. BMJ 1998; 317:462–3.
6. 1996 Census Nation tables. Ottawa: Statistics Canada.
7. The Reproductive Care Program of Nova Scotia. Perinatal care in Nova Scotia, 1988–1995, a report from the Nova Scotia Atlee Perinatal Database, Halifax, Nova Scotia, Canada, 1996.
8. Department of Health. Why mothers die. Report on confidential enquiries into maternal deaths in the United Kingdom, 1997–1999. London: Department of Health, 2001.
9. Lydon-Rochelle M, Holt VL, Easterling TR, Martin DP. Cesarean delivery and postpartum mortality among primiparas in Washington State, 1987–1996. Obstet Gynecol 2001;97:169–74.
10. Baskett TF, Sternadel J. Maternal intensive care and near-miss mortality in obstetrics. Br J Obstet Gynaecol 1998; 105:981–4.[Medline]
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12. Bashore RA, Phillips WH, Brinkman CR. A comparison of the morbidity of midforceps and cesarean delivery. Am J Obstet Gynecol 1990;162:1428–34.[Medline]
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16. Gregory KD, Henry OA, Ramicone E, Chan LS, Platt LD. Maternal and infant complications in high and normal weight infants by method of delivery. Obstet Gynecol 1998;92:507–13.[Abstract]
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19. Simpson EL, Lawrenson RA, Nightingale AL, Farmer RDT. Venous thromboembolism in pregnancy and the puerperium: Incidence and additional risk factors from a London perinatal database. Br J Obstet Gynaecol 2001;108:56–60.
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21. Neuf RW, Washburne JF, Martin RW, Magann EF, Scanlon PH, Morrison JC. Hemorrhage associated with cesarean delivery: When is transfusion needed? J Perinatol 1995;15:32–5.[Medline]
22. Engelsen IB, Albrechtsen S, Iversen OE. Peripartum hysterectomy—incidence and maternal morbidity. Acta Obstet Gynecol Scand 2001;80:409–12.[Medline]
23. Smaill F, Hofmeyr GJ. Antibiotic prophylaxis for cesarean section. Cochrane Library 2000;2:CD000933.
24. Chaim W, Bashiri A, Bar-David J, Shoham-Vardi I, Mazor M. Prevalence and clinical significance of postpartum endometritis and wound infection. Inf Dis Obstet Gynecol 2000;8:77–82.
25. Hannah ME, Hannah WJ, Hewson SA, Hodnett ED, Saigal S, Willan AR. Planned cesarean section versus vaginal birth for breech presentation at term; a randomized multicentre trial. Lancet 2000;356:1375–83.[Medline]
26. Irion O, Hirsbrunner Almagbaly P, Morabia A. Planned vaginal delivery versus elective caesarean section: A study of 705 singleton term breech presentations. Br J Obstet Gynaecol 1988;105:710–7.
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