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Vaginal Delivery Recommended Over Maternal-Request Cesarean

March 21, 2013

Washington, DC -- The nation’s largest ob-gyn organization recommends that pregnant women plan for vaginal birth unless there is a medical reason for a cesarean. In new guidelines issued today, The American College of Obstetricians and Gynecologists (The College) says maternal-request cesareans are especially not recommended for women planning to have several children, nor should they be performed before 39 completed weeks of pregnancy.

In the Committee Opinion, The College addresses the controversial issue of “maternal-request cesareans.” Cesarean deliveries done at the request of the mother without a medical indication represent an estimated 2.5% of all US births. Some women request cesareans because they fear childbirth pain, while others believe a cesarean will prevent urinary incontinence or preserve sexual functioning.

Cesareans involve risks and require longer hospital stays than uncomplicated vaginal births. Women face the risk of bladder and bowel injuries during cesarean surgery, as well as serious complications in future pregnancies. Placental problems, uterine rupture, and emergency hysterectomy are all risks that increase with each subsequent cesarean. Compared with vaginal births, planned cesareans have a lower risk of excessive bleeding during birth and the need for blood transfusions.

Benefits of vaginal births for women include shorter hospital stays, lower infection rates, and quicker recovery. Babies born vaginally have a lower risk of respiratory problems.

The rates of postpartum pelvic pain, sexual dysfunction, pelvic organ prolapse, and depression in women are similar between vaginal and cesarean births. The College says additional research is needed on both the short-term and long-term outcomes of maternal-request cesareans on women and babies.

Committee Opinion #559, “Cesarean Delivery on Maternal Request,” is published in the April issue of Obstetrics & Gynecology.

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Other recommendations issued in this month’s Obstetrics & Gynecology:

Committee Opinion #556 “Postmenopausal Estrogen Therapy: Route of Administration and Risk of Venous Thromboembolism” (NEW!)
ABSTRACT: The development of menopausal symptoms and related disorders, which lead women to seek prescriptions for postmenopausal estrogen therapy and hormone therapy, is a common reason for a patient to visit her gynecologist, but these therapies are associated with an increased risk of venous thromboembolism. The relative risk seems to be even greater if the treated population has preexisting risk factors for venous thromboembolism, such as obesity, immobilization, and fracture. Recent studies suggest that orally administered estrogen may exert a prothrombotic effect, whereas transdermally administered estrogen has little or no effect in elevating prothrombotic substances and may have beneficial effects on proinflammatory markers. When prescribing estrogen therapy, the gynecologist should take into consideration the possible thrombosis-sparing properties of transdermal forms of estrogen therapy. As part of the shared decision-making process, the gynecologist should weigh the risks against the benefits when prescribing combination estrogen plus progestin hormone therapy or estrogen therapy and counsel the patient accordingly.

Committee Opinion #557 “Management of Acute Abnormal Uterine Bleeding in Nonpregnant Reproductive-Aged Women” (NEW!)
ABSTRACT: Initial evaluation of the patient with acute abnormal uterine bleeding should include a prompt assessment for signs of hypovolemia and potential hemodynamic instability. After initial assessment and stabilization, the etiologies of acute abnormal uterine bleeding should be classified using the PALM–COEIN system. Medical management should be the initial treatment for most patients, if clinically appropriate. Options include intravenous conjugated equine estrogen, multi-dose regimens of combined oral contraceptives or oral progestins, and tranexamic acid. Decisions should be based on the patient’s medical history and contraindications to therapies. Surgical management should be considered for patients who are not clinically stable, are not suitable for medical management, or have failed to respond appropriately to medical management. The choice of surgical management should be based on the patient’s underlying medical conditions, underlying pathology, and desire for future fertility. Once the acute bleeding episode has been controlled, transitioning the patient to long-term maintenance therapy is recommended.

Committee Opinion #558 “Integrating Immunizations Into Practice” (NEW!)
ABSTRACT: Given demonstrated vaccine efficacy, safety, and the large potential for prevention of many infectious diseases among adults, newborns, and pregnant women, obstetrician–gynecologists should embrace immunizations as an integral part of their women’s health care practice. To provide direct examples, evidence-based recommendations for three commonly administered immunizations by practicing obstetrician–gynecologists are discussed: 1) human papillomavirus vaccine, 2) influenza vaccine, and 3) tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine.

Committee Opinion #560 “Medically Indicated Late-Preterm and Early-Term Deliveries” (NEW!)
ABSTRACT: The neonatal risks of late preterm (34 0/7–36 6/7 weeks of gestation) and early-term (37 0/7–38 6/7 weeks of gestation) births are well established. However, there are a number of maternal, fetal, and placental complications in which either a late-preterm or early-term delivery is warranted. The timing of delivery in such cases must balance the maternal and newborn risks of late-preterm and early-term delivery with the risks of further continuation of pregnancy. Decisions regarding timing of delivery must be individualized. Amniocentesis for the determination of fetal lung maturity in well-dated pregnancies generally should not be used to guide the timing of delivery.

Committee Opinion #561 “Nonmedically Indicated Early-Term Deliveries” (NEW!)
ABSTRACT: For certain medical conditions, available data and expert opinion support optimal timing of delivery in the late-preterm or early-term period for improved neonatal and infant outcomes. However, for nonmedically indicated early-term deliveries such an improvement has not been demonstrated. Morbidity and mortality rates are greater among neonates and infants delivered during the early-term period compared with those delivered between 39 weeks and 40 weeks of gestation. Nevertheless, the rate of nonmedically indicated early-term deliveries continues to increase in the United States. Implementation of a policy to decrease the rate of nonmedically indicated deliveries before 39 weeks of gestation has been found to both decrease the number of these deliveries and improve neonatal outcomes; however, more research is necessary to further characterize pregnancies at risk for in utero morbidity or mortality. Also of concern is that at least one state Medicaid agency has stopped reimbursement for nonindicated deliveries before 39 weeks of gestation. Avoidance of nonindicated delivery before 39 weeks of gestation should not be accompanied by an increase in expectant management of patients with indications for delivery before 39 weeks of gestation. Management decisions, therefore, should balance the risks of pregnancy prolongation with the neonatal and infant risks associated with early-term delivery.

The American College of Obstetricians and Gynecologists (The College), a 501(c)(3) organization, is the nation’s leading group of physicians providing health care for women. As a private, voluntary, nonprofit membership organization of approximately 56,000 members, The College strongly advocates for quality health care for women, maintains the highest standards of clinical practice and continuing education of its members, promotes patient education, and increases awareness among its members and the public of the changing issues facing women’s health care. The American Congress of Obstetricians and Gynecologists (ACOG), a 501(c)(6) organization, is its companion organization. www.acog.org

 

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