Trends in delivery: Get everybody ready on the sidelines

20. January 2012
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Pregnancy is not a disease. Yet there's one question which stirs the mind ever more: How should birth take place? At home in familiar surroundings? Or on the other hand by cesarean section? One aspect is often left behind: what's best for mother and child.

It’s no practical joke: Already weeks before the date 11.11., year in year out, there is a pile-up in maternity hospitals of requests for optional non-obligatory caesarean sections. For some parents – and certainly not just for those to whom this date means so much – a particular date itself would just make too nice a birthday for their offspring to miss. It’s definitely the minority, yet the number of caesarean sections keeps rising over years. Is it a good sign?

Trend product caesarean

A scalpel brought the first light of day of the world to every tenth child as little as thirty years ago, which it now does for every third child, the German Federal Statistical Office reports. Expectant mothers opt, out of fear of pain or protracted births, for surgery, often without medical recommendation. Furthermore, many expectant mothers fear that the muscles of the pelvic floor will be damaged during vaginal deliveries – which means incontinence. Extremely rarely, particularly in cases of generally preventable deep perineal tears, the sphincter of the rectum may also be affected. The fear of painful intercourse after natural childbirth is also widespread. Reasons for wishing to have a caesarean section, however, are not only held by those who are actually pregnant. Many patients desire, according to the GEK-caesarian-section study, a natural, uncomplicated birth, especially when they already have a successful recovery from a caesarean section in their past.

Cutting out the uncertainty

From the viewpoint of gynaecologists as well there is some evidence in favour of setting a predetermined date of birth using Caesarean section: the whole medical team is made available during normal working hours. In addition, the procedure is now considered a safe method for mother and child. This does not apply however to emergency caesarean sections done in cases of complication – the risk here is still twice as high as it is for those coming through the natural route. Another point to note: the concern about possible financial recourse, should something go wrong. Considerable financial claims are then at stake, the newborn indeed literally does have a whole life ahead of them. Contributions to professional liability have increased accordingly, up to 40,000 € per year. Better then to just have a c-section in a controlled clinical environment, even if there is only the slightest element of trouble. Not to be forgotten are the immediate cost issues – a caesarean section brings in approximately twice that of vaginal birth, and that’s employing a reduced involvement of medical staff and time in comparison to a time-consuming protracted delivery.

Quick procedure – enduring consequences

From a medical point of view there is nevertheless some evidence which speaks against medically-unnecessary caesarean section performed on a pre-set date: If children come into the world too soon, they have a significantly increased mortality in their first year – even for births after the thirty-second week of pregnancy. If for instance children are brought into the world during the 38th instead of the 40th week, their risk of death increases by 75 percent compared to the control group, and the babies more often require induced respiration. Italian physicians encountered pneumothorax about eight times as often as with the naturally born. Important maturation processes in the brain are also not yet complete. Paediatricians diagnosed more physical or mental developmental problems – and that’s years after the birth right up into school years.

Caesarian section does not remain without consequences for the patient either. No oxytocin is released, the important peptide hormone which influences the mother-child bond immediately after birth. And physicians report of complications with subsequent pregnancies, should patients not choose the natural way of giving birth. These complications include life-threatening tears in the womb and the closure of the birth canal (placenta previa).

Excessive monitoring

At the other extreme: Some mothers choose birth at home, where possible without technology, without doctors, without a scalpel or analgesia. Are the risks predictable? As adj.Professor Dr. Karl Oliver Kagan of the University of Düsseldorf reported in early December at the German Congress for Perinatal Care, the risks for both mother and child are usually established after three months. This applies not only to hereditary malformations, but also to possible premature birth. Health screening in late pregnancy could thus even be reduced. Gynaecologists working under Professor Kypros Nicolaides from King’s College London therefore recommend a conversion of current practice, which at the moment oversees an ever tightening level of control the further the pregnancy progresses. Nicolaides recommends thorough investigations in the 12th to 14th week of pregnancy in order to assess potential problems. When these as such are not found, follow-up examinations in the 22nd and 37th week would suffice. During the last appointment the method of birth can be chosen, one option also of it not being done in hospital.

Horror home birth

Home births are nevertheless not without their own demons, a prospective cohort study from Great Britain shows. The authors led by Professor Peter Brocklehurst, of the University of Oxford, have now analysed data from nearly 65 000 pregnant women. They had wanted to show that under today’s standards choosing to have a birth out of the clinic is not a critical issue. The outcome of the study was different: 45 percent of first pregnancies presented complications, so that transportion to the nearest hospital was needed. The figure for non first-time mothers was nonetheless also twelve percent. Midwives, the study found, in these cases weren’t in the position to be able to bring about the birth even using conventional methods of control. Statistically speaking, in 9.3 of 1,000 home births serious complications such as brain damage, breathing problems, broken bones or paralysis occurred – in hospitalised deliveries the figure was only 5.3 per 1,000. The publication confirms earlier data from the Netherlands, wherein the mortality rate for births was higher outside the hospital by a factor of 2.3.

The differences in figures for Germany are not quite so dramatic, although one in ten women there need in-patient treatment during childbirth. The reasons named include excessive bleeding, a stoppage of the birth process or a lack of oxygen to the child. This is also reflected in the mortality rate: For every 1,000 births after the 37th week, 2.1 died when not in hospital and 1.3 children within it.

The German Society for Gynaecology and Obstetrics responded to the indicated data with the note, that the maximum safety for both mother and child during birth could be ensured only in a maternity hospital. In a hospital environment vaginal delivery is and remains moreover the best way, if no complications are expected. Caesarean sections, however, would be reasonable only in cases with well-founded medical recommendations. If pregnant women have fears of pain or have a traumatic birth already in their past, the medical fraternity is asked, together with their patients, to find the best way. This also includes recommendations such as epidural anaesthetics.

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