Re: Cesariana eletiva
From: Bruno Derbli (derbli@ig.com.br)
Fri, 01 Jan 1999 00:46:03 -0200
Acho bastante interessante ver tantas defesas e tantas críticas ao parto
vaginal e ao parto cesáreo. Particularmente, não concordo com tantas
condenações feitas ao parto normal. Concordo sim que a grande maioria
das mulheres (principalmente as médicas) preferem a cesárea, mas são em
sua maioria NULÍPARAS. Eu nunca vi nenhuma mulher que tenha tido parto
vaginal e cesáreo preferir o cesáreo. TODAS que foram perguntadas até
hoje por mim preferiram o parto vaginal, principalmente devido ao
desagradável pós-operatório da cesariana. Além disso, todos aqui que já
operaram mulheres com várias cesáreas anteriores sabem o qto é ruim,
difícil por causa de tantas e inevitáveis aderências que se formam, além
do risco de ruptura uterina em cicatizes anteriores. É claro que deve
ser dada a mulher a chance de escolher sua via de parto, mas tendo antes
de ser esclarecida qto ao pré, per e pós operatório de todos os
procedimentos, assim como possíveis conseqüências negativas destes e
isso NUNCA deve ser feito durante o trabalho de parto, e sim no início
da gestação. Qto as alterações perineais, essas sim realmente são
bastante danosas à paciente, tanto do aspecto genital qto do urinário.
Mas se esse fosse o maior dos problemas, acredito que não seria enorme a
multiparidade de grande parte das mulheres brasileiras.
Bruno Derbli
perineo
varias anteriores
Jaime Nonato gravada:
>
>> ----- Original Message -----
> From: Jaime
> To: Multiple recipients of list OBSTET-L
> Sent: Wednesday, July 10, 2002 11:48 PM
> Subject: Re: TRH
> Caros Colegas da lista Cresce nos EUA e alguns
> paises da Europa um movimento que daria à mulher o direito
> de optar por cesariana eletiva em gravidez sem riscos. Na
> Inglaterra, 1/3 das médicas obstetras afirmaram que optariam
> por cesareana eletiva se engravidassem. A
> polêmica está formada e os defensores de ambas as vias de
> parto emitem seus argumentos. O artigo abaixo foi
> publicado em 16/09/2002 pelo Dr. Peter S. Bernstein, MD,
> MPH - New York Jaime Nonato
> Elective Cesarean Section: An Acceptable Alternative to
> Vaginal Delivery?
> from Medscape Women's Health
> Posted 09/16/2002
> Peter S. Bernstein, MD, MPH
>
> Recently, a movement has begun to gather momentum that
> argues in favor of a pregnant woman's right to choose to
> deliver by cesarean instead of undergoing a trial of labor.
> Supporters of this position argue that the safety of modern
> cesarean delivery has reached a point such that it is time
> to reevaluate its merits compared with the risks of a trial
> of labor -- both for the mother and fetus. Proponents cite
> in particular a survey of female obstetricians in England in
> which a third reported that if they had an uncomplicated
> singleton pregnancy at term, given the choice, they would
> opt for a cesarean delivery.[1] This position may be gaining
> additional support among physicians for medico-legal
> reasons, as doctors are more frequently being sued for
> failure to perform a cesarean rather than for performing
> one.
>
> One argument often cited in favor of elective cesarean
> delivery is 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 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, 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 reports of similar rates of
> urinary incontinence in nulliparous women 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 rare, 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 1 of
> these poor outcomes. Thus, resorting to cesarean delivery
> would not be appropriate standard procedure. Instead, it is
> clear that the tools we have to identify which pregnancies
> are at risk need to be improved, as reviews of cases of
> women whose pregnancies ended with these complications often
> reveal that many had factors that put them at risk for these
> outcomes, such as medical diseases or fetal growth
> restriction.
>
> 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. Women
> 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 as almost 3 times the
> risk of a vaginal delivery.[3] In addition, risks to the
> fetus associated with cesarean delivery range from
> lacerations 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. We can safely
> assume that most women who would opt for an elective primary
> cesarean delivery would not choose to undergo a trial of
> labor in a subsequent pregnancy. 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 accreta and previa
> increases with each subsequent cesarean delivery, reaching a
> risk of > 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 increasing rates of cesarean
> delivery.[5]
>
> A move toward routine elective cesarean delivery may also
> have significant costs in terms of lost opportunities for
> bonding between the mother and newborn. A woman who has had
> a cesarean delivery may be less able to care for her child
> and may have a more difficult time breastfeeding as a result
> of discomfort from her surgery. 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 delivery
> 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 United States 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 benefits 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 delivery is very
> different. The benefits of elective cesarean delivery
> relative to vaginal delivery are not established, and the
> risks are substantial, especially given the potential for
> future repeat cesareans. Other elective surgeries are
> usually meant to be 1-time events.
>
> That women are seeking elective cesarean deliveries is
> probably more significant in that it indicates failures 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 delivery
> becomes an acceptable alternative, we may never be able to
> undo the practice.
>
Peter S. Bernstein, MD, MPH, Associate Professor of Clinical Obstetrics
& Gynecology and Women's Health, Department of Obstetrics & Gynecology
and Women's Health, Albert Einstein College of Medicine/Montefiore
Medical Center, and Medical Director, Obstetrics and Gynecology,
Comprehensive Family Care Center/Montefiore Medical Group, Bronx, New
York.
Medscape Women's Health 7(2), 2002. © 2002 Medscape
>
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