Re: elective C/S (long)
From: Robert J. Carpenter, Jr. MD (zygote@icsi.net)
Thu Nov 25 16:01:16 2004
2 years ago because of the requests within two weeks of a physician and an atty,
both > 40 years with first pregnancy, both wanted primary elective c/S. 4 page
detailed informed consent document generated. If any one wants to see it or even
use it let me know and I will email to you. It's on the computer at work so can't be
sent with this reply.
On 25 Nov 2004 at 7:46, RModugno@aol.com wrote:
>
> David Priver MD writes:
>
> So far, no one in my practice has asked for an elective CS in the
> absence of what we used to call "indications". I doubt seriously
> that I would agree to do this any more than I would agree to do an
> elective appendectomy just because the patient asked for it. I think
> this issue will be revealed as the foolishness it is when and if we
> ever evolve a payment system wherein people are responsible for at
> least some portion of their own expenses. If such a patient were
> told we'd be glad to do an elective CS for her if she would agree to
> pay for the difference between this and a vag del, the whole issue
> would fade back into the woodwork where it belongs. Moreover, what do
> you suppose will happen when this patient has her fourth CS and needs
> a hysterectomy for a placenta accreta? What will you say on the
> witness stand when she says "but he never told me this could happen"?
> Hard as it may be to do, I suggest we try to uphold the standards we
> were all taught. David
>
> David, plastic surgeons do elective surgery all the time. As far as
> placenta accreta is concerned - that's what informed consent is all
> about. In reality, with the trend in decreasing numbers of children
> per family( in the U.S.) - I doubt that the fourth cesarean would
> come up very often. Please see the following two articles from
> Medcape.com
>
> Robert Modugno MD MBA FACOG
> Marietta, GA
> _www.novaobgyn.yourmd.com_ (http://www.novaobgyn.yourmd.com)
>
> (http://www.medscape.com/sendurl)
> (http://www.medscape.com/viewarticle/494349_print)
>
> Increased Cesareans in Women at No Medical Risk: A Newsmaker
> Interview With Eugene Declercq, PhD
>
> Laurie Barclay, MD
>
> Nov. 19, 2004 — Editor's Note: Cesarean deliveries have
> dramatically increased in women with no reported medical risk,
> according to the results of a large, cross-sectional analysis
> reported in the Nov. 19 Online First issue of the British Medical
> Journal. Undergoing a cesarean delivery when there is no medical
> indication raises serious questions and mandates more research on
> whether the risks associated with surgery outweigh the benefits in
> these circumstances. This study analyzed U.S. national birth
> certificate data on approximately four million births each year. The
> investigators defined a new category of mothers at "no indicated
> risk," defined as mothers with singleton, full-term (37 weeks or
> longer), vertex presentation births who were not reported to have any
> medical risk factors and for whom no complications of labor or
> delivery were listed on the birth certificate. They then examined the
> increase of primary cesarean deliveries in these women from 1991 to
> 2001. To learn more about the implications of this study for
> obstetrical practice, Medscape's Laurie Barclay interviewed lead
> author Eugene Declercq, PhD, a professor of obstetrics and gynecology
> at the Boston University School of Medicine and assistant dean for
> doctoral education at the Boston University School of Public Health
> in Massachusetts. Medscape: What are the main findings of your study?
> Dr. Declerq: My colleagues, Fay Menacker and Marian MacDorman from
> the National Center for Health Statistics, and I analyzed national
> birth certificate data, which allowed us to identify a group of
> mothers who appear to be at very low risk for poor outcomes since
> they are giving birth to singleton, full-term babies and have none of
> the 31 medical risk factors or labor and delivery complications
> listed on the birth certificate. The proportion of these mothers
> decreased slightly through the early 1990s to about 42% of all
> births. Among this low-risk group, the likelihood of having a
> primary, first-time cesarean rose substantially between 1996 and 2001
> from 3.7% to 5.5%, or 80,028 of these "no indicated risk" cesareans.
> In multivariate analysis controlling for the mother's age, race,
> ethnicity, education, parity, and infant birth weight, the likelihood
> of a mother having a no-indicated-risk cesarean was still almost 50%
> higher in 2001 compared to 1996. Medscape: What are the limitations
> of your study? Dr. Declerq: There are several limits. Most notably
> these births we have identified cannot be termed "patient choice"
> cesareans since there is no indication on the birth certificate
> concerning mother's choice or intention. Also there is the
> possibility that some of the cesareans were for medical reasons not
> covered by the birth certificate items or that those completing the
> forms simply failed to complete them correctly. Medscape: Why do you
> believe the number of cesarean deliveries in women at no medical risk
> has increased? Dr. Declerq: The trend in these cesareans since 1996
> has paralleled a general and rapid growth in cesareans in the U.S.
> Primary cesareans have not only been rising for no indication, they
> have also been rising for virtually every medical indication,
> suggesting a practice change in obstetrics to perform cesarean
> section more liberally. Some of these may also reflect physician or
> patient choice, but we can't determine that with any certainty.
> Medscape: What role does patient convenience, physician and hospital
> scheduling, and concerns regarding litigation play in the increased
> number of cesarean deliveries? Dr. Declerq: These data do not allow us
> to address those questions directly. Some of these cases may involve
> patient convenience. The strong relationship to age of mother may
> reflect a physician viewing age itself as a risk factor without any
> medical reason, although research generally doesn't support that
> view. It may also reflect a mother's decision to have her only (in
> the case of primiparous mothers) or "last" (multiparous mothers)
> birth by cesarean. Published research on timing of cesareans related
> to physician convenience is mixed. The birth certificate does not
> include time of birth, so we could not examine that question here.
> Access to operating rooms may play some minor role in smaller
> hospitals, but again, we cannot directly address that with our
> analysis. Litigation, however, probably plays little direct role in
> our findings since one would expect the bias, if any, in reporting
> would be towards listing an indication for the cesarean if the
> physician were concerned with litigation. Medscape: How do the risks
> of cesarean deliveries in women with no reported medical risk compare
> with the benefits? Dr. Declerq: These cesareans would presumably have
> the normal risks associated with any cesarean — greater chance for
> postpartum infection; greater likelihood for postpartum pain, longer
> hospital stay, less early contact with the baby, greater difficulty
> in breast-feeding, higher costs, etc. In normal circumstances when a
> cesarean is done for a medical indication, all of these concerns can
> be easily outweighed by the possible health benefits to the mother or
> baby associated with avoidance of the medical condition the cesarean
> prevented. It is not as clear what the countervailing health benefit
> is in these cases, beyond avoidance of labor pain, less painful
> perineum in postpartum, (although that is offset by much higher
> reported pain from the cesarean) and the much-debated potential
> longer-term benefits to the perineum, although the evidence on this
> last point is hardly conclusive. There is an interesting summary of
> the literature on this point available at
> http://www.maternitywise.org/mw/topics/cesarean/booklet.html.
> Medscape: Should there be guidelines regarding cesarean delivery in
> women with no reported medical risk? Dr. Declerq: The question is how
> far we should go beyond the FIGO statement, which says that
> "...because hard evidence of net benefit does not exist, performing
> Caesarean section for non-medical reasons is ethically not
> justified." Medscape: What additional research is planned? Dr.
> Declerq: With the national data we are examining subgroups of the
> no-indicated-risk primary cesarean group, while another group of
> colleagues and I are looking at the outcomes of these
> no-indicated-risk cesareans in Massachusetts. Disclosures: The study
> received no external funding, and the authors report no competing
> interests. BMJ Online First. Published online Nov. 19, 2004. Reviewed
> by Charlotte E. Grayson, MD
>
> No Added Risk Seen for Five or More Repeat C-Sections.
>
> NEW YORK (Reuters Health) Nov 15 - There is no added risk to the
> mother or fetus with five or more repeat cesarean sections compared
> with three or four c-sections, according to a report in the October
> issue of BJOG: an International Journal of Obstetrics and
> Gynaecology. Women are often counseled not to undergo more than three
> c-sections due to an increased risk of uterine scar rupture. However,
> in certain countries where large families are encouraged, such as
> Saudi Arabia, this advice often falls on deaf ears. Although the
> safety of this operation has improved over the years, little is known
> regarding the risks seen with five or more c-sections. To investigate,
> Dr. Mumtaz Rashid, from the Security Forces Hospital in Riyadh, Saudi
> Arabia, and Dr. Rabia S. Rashid, from the University College School
> of Medicine in London, compared the outcomes of 308 women who had
> undergone at least four previous c-sections with those of 306 women
> who had undergone two or three previous c-sections. In the study
> group of 308 women, most (n!9) had four previous c-sections, while
> 1 woman had 8, 2 women had 7, 17 had 6, and 79 had 5 previous
> c-sections. A number of intraoperative differences were noted between
> the groups. Compared with the control group, the higher-order
> c-section group had longer operating times, more severe adhesions,
> and experienced a greater drop in hemoglobin. However, the blood
> transfusion rates for the groups were comparable. Despite these
> differences, the maternal and fetal outcomes for the two groups were
> general similar. No significant difference between the groups was
> noted in Apgar score, neonatal admission rate, rate of cesarean
> hysterectomy, placenta previa, placenta accreta, uterine scar
> rupture, bladder injury, rate of post-partum pyrexia, wound
> infection, and urinary tract infection. No mothers in the higher-order
> c-section group died, whereas one died (massive bleeding from
> placenta accreta) in the control group, the investigators point out.
> "The results from this large-scale study demonstrate that, in
> general, the maternal and fetal outcome associated with higher-order
> multiple repeat cesarean section is comparable to the outcome with
> lower-order repeat cesarean section," the authors note. "Nevertheless,
> the general risks associated with operative delivery and frequently
> repeated pregnancies remain real and patients must be made aware of
> these." BJOG 2004;111:1090-1094.
>
--
Robert J. Carpenter, Jr. MD
6624 Fannin, #2720
St. Luke's Medical Tower
Houston,TX 77030-2339
713-795-4600
