Monday, August 18, 2014

Even "Complicated" Pregnancies Should Labor Whenever Possible

There's an interesting new study out from Finland. 

I haven't read the full study yet, but from the abstract it looks like the gist is that even in "complicated" pregnancies, women should be given a chance to labor and have a vaginal birth, not just scheduled for a cesarean. 

Many times, in "complicated" pregnancies, there are care providers who believe that there is no point in "trying" for a vaginal birth. They just plan to do a cesarean before labor. They feel they will minimize maternal morbidity that way. 

Not all providers are like this, by any means, but there certainly are quite a few out there that just jump from "complicated" to "planned cesarean."

This very large study shows that the best outcomes were associated with planning a vaginal birth

Of course, each case has to be judged on an individual basis. This study doesn't mean that a planned cesarean is never appropriate; just that outcomes were better on a population-wide basis if the women were usually given the chance to have a vaginal birth.

The only exception was in pre-eclampsia, which in severe cases can sometimes have very poor outcomes. But outcomes in women with pre-eclampsia were equivalent between vaginal birth and planned you could certainly make a case for laboring there too, as long as the condition of the mother and the baby allow it. 

Bottom line, care providers should utilize planned cesareans only when truly necessary. 


Arch Gynecol Obstet. 2014 Aug 13. [Epub ahead of print] The impact of maternal obesity, age, pre-eclampsia and insulin dependent diabetes on severe maternal morbidity by mode of delivery-a register-based cohort study. Pallasmaa N1, Ekblad U, Gissler M, Alanen A. PMID: 25115277
PURPOSE: To determine the rate of severe maternal morbidity related to delivery by delivery mode and to assess if the impact of studied risk factors varies by delivery mode. 
METHODS: A register-based study including all women having singleton delivery in Finland in 2007-2011, n = 292,253, data derived from the Finnish Medical Birth Registry and Hospital Discharge Registry. Diagnoses and interventions indicating a severe maternal complication were searched and the mode of delivery was assessed by data linkage. The impact of obesity, maternal age 35 years or more, pre-eclampsia and insulin dependent diabetes on severe maternal morbidity (all severe complications, severe infections and severe) was studied in each mode of delivery and calculated as Odds ratios.  
RESULTS: The overall incidence of severe complications was 12.8/1,000 deliveries. The total complication rate was lowest in vaginal deliveries (VD) in all risk groups. Obesity increased the risk for all severe complications and severe infections in the total population, but not significantly in specific delivery modes. Age increased the risk of hemorrhage in VD. Pre-eclampsia increased the risk for hemorrhage in all deliveries except elective CS. In women with pre-eclampsia, overall morbidity was similar in VD, attempted VD and elective CS. The presence of any studied risk factor increased the risk for complications within the risk groups by the high proportion of emergency CS performed.  
CONCLUSIONS: An attempt of VD is the safest way to deliver even for high-risk women with the exception of women with pre-eclampsia, who had a similar risk in an attempt of VD and elective CS.

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