Ideal gap between caesareans – new research

A new study by Soroka University indicates that there may be reasons, other than risk of scar rupture, why a longer interval between caesarean births is ideal. Up to now recommendations have suggested that a gap of 15-18 months or more be planned to reduce the likelihood of scar rupture during subsequent pregnancies. However Kessous et al discovered during their review of 3176 births between 1988 and 2010 that in fact scar rupture was no more likely in any of their groupings (less than 12 months, 13-18 months and more than 18 months gaps).

However they did find an increased likelihood of premature birth in the group of women who had a second caesarean within 12 months of the first. This risk was 12%  whereas those who waited longer had only a 5% risk.

Premature birth has significant implications for baby in particular. Low birth weight and the immaturity of baby’s lungs are just two of the complications that can occur and the earlier the baby arrives the more likley they will need assistance in a SCU (Special Care Unit).

Repeat caesarean or VBAC?

There has been a lot of coverage in the media over the last few years quoting research looking at the comparative safety of a repeat caesarean versus a vaginal birth after caesarean (VBAC).

The findings are invariably such that the research can be used both by protagonists wanting to reduce the caesarean rate and those wanting to promote the validity of repeat caesarean birth (particularly maternal request CS). In other words it is still very much a matter of personal opinion.

What is clear is that for women trying to make decisions about their birth plans the risks typcially being discussed (e.g. scar rupture, fetal death and haemorage) are, with either delivery mode, incredibly small.

While findings can be manipulated to make controvercial headlines all current research can really emphasise is that rather than making snap decisions one way or the other women need to evaluate the broader risks of both modes of birth in their specific situation and make their decision based on their preference once fully informed.

So revisiting pre-conceptions and assessing the quality of the information you are given is of paramount importance. For example: Hemorrhage risks are incredibly small (2.3% in planned VBAC and 0.8% in planned caesarean). Despite this some women, who would prefer a vaginal birth, rule out an attempt accepting a potentially ‘unnecessary caesarean’ because they have not been given the full facts. Conversely those women, for whom the risks associated with a planned caesarean feel more acceptable than the risks associated with a failed vaginal attempt, may not consider a prophylactic caesarean because they feel unable to challenge the popular opinion being pushed by the media and natural birth advocates that VBAC is better.

It is important that women feel empowered to make decisions, that they are involved in the decision making process and that they challenge the advice they are given. Afterall they are the ones that have to come to terms with the outcome.

Caesareans, breastfeeding and gut bacteria

Once again the media have gone rather mad about a research paper without assessing the details of paper itself in an attempt to deliver sensational headlines about caesarean birth.

This paper actually describes gut bacteria in 24 infants at 4months of age but the media have rehashed old concerns about links with asthma.

It is entirely possible to make statements about the presence of the various bacteria from reliable tests conducted on the infants fecal matter and the paper should really have stopped there. However, it goes on to suggest links between caesarean birth and lower levels of breastfeeding and an increased likelihood of developing health problems in the long term (as a result of a lack of exposure to certain gut bacteria due to not having passed through the birth canal).

Aside from the media’s poor attempts at reporting on a very small, inconclusive study, I  take issue with the research paper itself:

  • No mention, or assessment of any environmental factors which can also easily influence gut bacteria level, other than use of antibiotics, (it looks purely at birthmode and breastfeeding patterns)
  • Only one assessment of gut bacteria levels are taken (at 4 months of age – no follow up to assess changes due to on-going development and exposure to new environmental factors – yet it is widely acknowledged that “gut profiles vary widely in the first year of life.”)
  • Sample size is laughable small (the total number of babies assessed – 24, of these only 6 were actually caesarean births) “A study of this size is too small to reliably detect any differences between natural and caesarean deliveries, and formula and breastfed babies, and even less so to detect any differences according to type of caesarean delivery (emergency vs. elective) or brand of infant formula, for example”

What is particularly disappointing is that the researchers feel comfortable making vague statements along the following lines “It could be that C-section physically prevents newborns from acquiring microbes they would during vaginal births” (which quite clearly shows even they cannot say their study provides conclusive evidence let alone how these bacteria levels relate to later health issues) and yet they are happy to produce a paper suggesting there is a link with caesarean birth specifically. Not only this but they take no account of the impact their statements may have on mothers who ‘need’ a caesarean to avoid serious outcomes. Nor dothey offer any information about how women can redress the bacteria imbalance. In otherwords they scare without offering any hint of a solution.

The NHS have been very quick to denounce the media’s scarmongering and suggest extreme caution when attempting to draw any conclusions from such a small study.

“The study does not provide any evidence that the mode of delivery or feeding pattern was the cause of the bacterial levels measured. Neither does the study provide any evidence that being born by caesarean delivery leads to developing asthma later on in life”

They go on…

“The researchers say that the development of bacteria in the gut in the early part of a person’s life is poorly understood. However, the design of this study means that it arguably adds little to that understanding. It only examined the gut bacteria of an extremely small sample of babies at one point in their life and can tell us little else about the causes of these bacterial levels, or how they related to longer-term health outcomes.”

And there is more…

“Neither does the study provide any evidence that being born by caesarean delivery leads to developing asthma later on in life.”

As for the media’s poor attempts at interpreting the paper, they have chosen to re-hash claims suggesting there are links with childhood asthma. This despite the majority of studies investigating such a link having been repeatedly shown to be inconclusive often omitting significant environmental factors, such as the presence of parental smoking.

Actually don’t get me started on the media…

Weight and blood sugar implications for mother and baby

Women have long been encouraged to eat sensibly rather than excessively when pregnant. While it has been known for sometime that obesity tends to be linked with a greater risk of complications a study published in the New England Journal of Medicine suggests that even women with ‘slightly elevated weight’ (not presenting with diabetes) but who have higher levels of glucose in the blood are at increased risk of carrying a large baby and thereby at increased risk of complications which may result in injury to the baby during vaginal delivery or in the need for a caesarean delivery.

Tests during pregnancy typically look for diabetic and obesity indicators but this research suggests that there is a group of women outside of these indicators who may also be at risk of complications.

Preparing for the possibility of medical intervention should, in my opinion, be a formal part of everyone’s antenatal education as we never truly know what is going to happen on the day. These result emphasise the fact that there is yet another group of women for whom this is essential – unfortunately at present most of them do not know that they fall into this category.

‘Failure to progress’ new tool to monitor labour may reduce caesarean rate

‘Failure to progress’ (dystocia) is one of the most common reasons women are given during labour for the need to resort to a caesarean despite the fact that “…no precise definition of dystocia exists.” Hospital policies or individual practise therefore tend to dictate what is acceptable in any given hospital setting. In actual fact if mum and baby are showing no signs of distress, this diagnosis should not be used as justification for a caesarean, though it often is.

This is where knowing just that little bit more about birth ‘complications’ (not that ‘failure to progress’ is a complication) and rights versus hospital policies can make all the difference to whether or not you have the birth you hope for, assuming of course you are simply progressing slower than expected.

Incredibly studies from the 1950s which suggested that cervix dilation was a linear process (dilation = 1.2cm per hour) are still being referred to as ‘normal’ progress today. New research from Ohio State University suggests not only that the progress if not linear but that they have found a way to more accurately access labour progress for first time mothers. The tool, a partographer, “is a printed graph on which a clinician can plot cervical dilation and the baby’s descent to determine whether labor is progressing normally or if intervention might be needed.”

The researchers predict that “if their partograph were adopted widely in the United States, dystocia diagnoses would be limited to only the slowest 10 percent of first-stage labors; oxytocin interventions would drop by more than 50 percent; and cesarean sections performed because of dystocia would decrease by more than 50 percent.”