Risk of respiratory morbidity in term infants delivered by elective caesarean section: cohort study

BMJ 2008; 336 doi: http://dx.doi.org/10.1136/bmj.39405.539282.BE (Published 10 January 2008)
Cite this as: BMJ 2008;336:85

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There must be concern of missing information. This would be how quickly the umbilical cord was clamped off. Generally, hasty umbilical cord clamping is imposed, as an element of surprise, within 30-seconds of the child being removed from the womb. Or, the cord is clamped within 120 seconds, or under two minutes. The lungs then do not get sufficient infusion of the placenta blood. The brain cells are cut off the steady flow of oxygenated blood.

When is the proper time to clamp and/or cut the cord? After the placenta is birthed and all pulsation has ceased. The time period is between 10 minutes, more or less. This is due to the infant in order not to cause internal damages, particularly, to the lungs, the brain and the central nervous system.

What is also missing is where the placenta blood remaining in the placenta and the umbilical cord is taken? Is it to be burned, poured down the drain, or practically used? In the 1940 Anemia report the blood was taken to be put in blood banks, from 50 ccs, to over 200 ccs.

How much of the infant's blood was deprived the child? This can be measured from the contents taken from both the placenta and the umbilical cord. Was the placenta blood and the cord blood sent for separation and for stem cells to be sold on the open market? Did the mothers consent to this placenta blood collection? Were the medical persons paid for the collection of the human cells? If so, who paid them and how much?

There is motive to hold the baby above the placenta to allow blood in the baby and in the umbilical cord to drain back into the placenta if the largest collection of blood is to be obtained and sold.

If 80 ccs to over 250 ccs of placenta blood and cord blood were sent to a public blood bank or a private cord blood bank the child will be tested and found anemic. There will not be sufficient blood infused into the expanding lungs. This will explain the increased lung disorders.

The weakened children have been known in many past human baby experiments on the time of the early clamping off the umbilical cord. The logic is all revival is on the untied cord - and not to allow any finger or hand cord compression demonstration to students or other doubting medical persons - that the baby is being deprived of continous flow of essential properties owed to it - blood. Then the infant is revived by releasing the cord compression if the care giver is using fingers to compress the cord, for 10 or 20 seconds. And, while the child lives the heart may have been damaged. It may not go back to fetal size, particularly, if the child was chilled.

The blood in the placenta has purpose. It has immunities for the benefit of the child, enzymes, and hormones to the sex of the child, and the proper volume of blood and proper pressure to the altitude the child is born. When deprived of the proper placenta blood infusion, the child is caused to be weaker. This is a time bomb of latent internal injuries - that may take years to be noted. By that time the early cord clamping imposed at birth is long forgotten and who lit the fuse.

The issue of hasty cord clamping, very unnatural, should be taken to a Public Commissioned Inquiry for the proper after birth care for all infants born anywhere on Planet Earth. This is all revival on the untied cord. This is, if we want to prevent internal injuries, then, we must observe the stronger creatures who are not cord tied when born without the assistance of the human hands.

All babies who are not early clamped, more or less, the accidental birth - no one to tie off the cords, do thrive. This is an observation back to 1801 to Dr. Erasmus Darwin; also the observation and by tests, are in the report on one of the causes of anemia to infants of Dr. William F. Windle, 1940 report; and to the research of Dr. Mavis Gunther, 1957; and to the concern of an educator, Pearce, author of Magical Child. There are many more reviews of past research to note, healthier and stronger infants are those left on the untied umbilical cord, the longest, or never clamped or cut from the cord. That is a return to Primal and Natural Birth, that some today, call it the Lotus Birth.

The duty of care has always been one standard - do no harm.

Donna Young Birth Researcher since 1998

Round Table Discussion on Anemias of Infancy, Nov 18-20, 1940, American Academy of Pediatrics, William F. Windle, et al.

Petition: Protect Babies and Mothers, Too (on line)

www.medicalveritas.com (see complimentary downloads on birth articles).

Magical Child, 1977, J. C. Pearce

Competing interests: None declared

Competing interests: None declared

Donna Young, Natural Birth Education

P. O. Box 504 Dawson Creek, BC V1G 4H4 Canada

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Offering vaginal birth after caesarean section (VBAC) is an established recommendation to prevent further escalation in caesarean sections (CS) rates worldwide and to combat the fivefold increased risk of serious respiratory morbidity associated with early elective caesarean sections. (1) Success rates of VBAC are extremely variable ranging from 10% with an unengaged head at term to 74% for low-risk women without co- morbidities. (2) A planned VBAC carries a risk of uterine rupture of 22- 74/10,000 and a 2-3/10,000 additional risk of birth-related perinatal death when compared with an elective repeat CS; the latter is comparable to the absolute risk for nulliparous women.(3) In the UK, the overall vaginal delivery rate is only 33% following a previous CS suggesting poor uptake and supported by the fact that up to 60% women having a repeat CS may be unaware of other delivery options.(4)

The National Institute for Health and Clinical Excellence (NICE) developed a clinical guideline entitled ‘Caesarean Section’, published in April 2004, to provide information on risks for women contemplating birth after a previous CS.(5) The information for the public advises that “[women] be aware that some rare but serious complications are increased with vaginal birth after a caesarean section. These possible complications include your scar tearing apart or the baby dying”.(6) This statement is unqualified and clearly frightening. It is our experience that women are unable to make a balanced judgement once they have read the guideline. The actual risk of a perinatal loss following a VBAC is small – 1 in 2500 in units with appropriate facilities including obstetrician availability.(7) This equates to a comparable risk of perinatal death in a nulliparous woman. There is no mention of the benefits of a successful planned VBAC (7), or the serious morbidity that may be associated with elective surgery(1) or multiple repeat caesareans. These issues are equally emotive and it is inappropriate that they are not mentioned or quantified for the lay person.

In an audit of 70 women referred to a VBAC clinic over a 3-month period, conducted at two time points in 2006 and 2007, the proportion of women receiving the leaflets increased from 41% to 71% with a concomitant rise in the number of elective repeat CS performed from 19% to 27%. A majority of women requesting elective CS directly cited the NICE guidelines as providing the basis for this decision.

Guidelines should not only be accurate but balanced and either quantify risks or put them in perspective for lay people. We believe the current guideline is resulting in perverse and inappropriate practice.

References

1. Hansen AK, Wisborg K, Uldbjerg N, Henriksen TB. Risk of respiratory morbidity in term infants delivered by elective caesarean section: cohort study. BMJ 2008; 336: 85-87.

2. Gregory KD, Korst LM, Fridman M, Shihady I, Broussard P, Fink A, et al. Vaginal birth after caesarean: clinical risk factors associated with adverse outcome. Am J Obstet Gynecol 2008; 198: 452.e1- 10.

3. Varma R, Gupta JK, Smith GCS. Birth after previous caesarean birth. Green-top Guideline No. 45. London: RCOG Press, 2007.

4. Moffat MA, Bell JS, Porter MA, Lawton S, Hundley V, Danielian P, et al. Decision making about mode of delivery among pregnant women who have previously had a caesarean section: a qualitative study. BJOG 2007; 114: 86-93.

5. National Collaborating Centre for Women’s and Children’s Health. Caesarean Section. London: RCOG Press, 2004.

6. National Collaborating Centre for Women’s and Children’s Health. Caesarean Section – Understanding NICE guidance – information for pregnant women, their partners and the public. London: RCOG Press, 2004.

7. Landon MB, Hauth JC, Leveno KJ, Spong CY, Leindecker S, Varner MW, et al. Maternal and perinatal outcomes associated with a trial of labor after prior caesarean delivery. N Engl J Med 2004; 351: 2581-2589.

Competing interests: None declared

Competing interests: None declared

Manju Chandiramani, Clinical research fellow in Obstetrics & Gynaecology

Nina Khazaezadeh, Anna Kenyon, Lucy Chappell, Andrew H. Shennan

St Thomas' Hospital, London

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4 March 2008

Sir,

Sutchfield and Whittaker charge me with guesswork on the meaning of their published data but they needed to check their original data to show that my conclusion was incorrect. I would not accept that guesswork is the correct term and, without the full dataset available, it was impossible for me to reach another conclusion. This example confirms the potential value of my proposal to provide raw data with all publications (1) and demonstrated on the website(2). Providing raw data can easily be done with epublications.

It should be noted that the ASTECS trial was not blinded as Blinding participants and professionals was therefore neither desirable nor possible. Similarly the use of placebos was not practical. Furthermore the primary outcome, respiratory distress requiring admission to special care baby unit, is hardly susceptible to maternal influence. While respiratory distress requiring admission to the special care baby unit may not be susceptable to maternal influence, professionals making the decision to admit could well have been influenced by knowledge of whether or not the mother had steroids.

I fully agree that clinical management can be influenced by many factors including unsubstantiated statements, powerful and biased teaching and intransigent opinion. It could be argued that these factors have been responsible for the risk of immediate cord clamping being unrecognised for the past 50 years! Landau et al (3) working in the USA recognised that respiratory problems after caesarean delivery could be largely prevented by avoiding immediate cord clamping. They used a technique to allow the placental circulation to remain intact till long after delivery. I quote from their paper “Since instituting this technique our results with our cesarean babies have been much better than formerly. For this reason we have not felt justified in running a control series.” Similar conclusions of Professor Peter Dunn working in Bristol have also been virtually ignored for the last 20 years.(4) I am at a loss to understand why a pharmacological approach is promoted and the physiological approach has never been investigated further. Both have a logical basis and indeed could well be complimentary approaches particularly in the preterm baby.(5)

I fully agree that elective delivery by caesarean section should always be delayed until at least 39 weeks if possible. When earlier delivery is necessary there is an increasing risk of respiratory distress. Giving antenatal steroids reduces the risk that a professional will make a diagnosis of RDS which requires admission to a special care unit. In advising parents about the safety of antenatal steroids, professionals should advise that although the 30 year follow-up did not show any adverse effects neither did it show any benefit.(6)

If Stuchfield and Whittaker had been able to include raw data in their original paper (7) it would remain available in the foreseeable future for other workers to analyse further. The data could be copied into other applications and statistical analysis checked by peer reviewers and readers. In addition the raw data may make any future metanalysis more accurate.

Finally they state above that Our study was not powered to make conclusions about admissions other than for respiratory distress. In a previous response they stated that they stated If a larger study was designed and adequately powered to show an overall difference in all admissions , we are confident that a reduction would be seen as a direct result of fewer admitted with respiratory distress.(8) However according to Hewett et al such a statement will always be true given a large enough study.(9) Although total numbers of days admitted to special care (with its implications of cost, morbidity, and separation) for the babies was reduced by 50%, they do not tell us if this is a statistically significant difference. Using simply the number of days, I calculate a statistically significant odds ratio of 0.4 (95% confidence 0.3 - 0.6) in favour of steroids preventing admission.

References
1. Hutchon DJR BMJ Information in practice Infopoints Publishing raw data and real time statistical analysis on e-journals 2001;322:530
2. Demonstration real time statistical analysis.
3. Landau D B, Goodrich H B, Franka WF, Burns FR. Journal of Pediatrics (1950) 36:421-426
4. Dunn P M. Reservations about the methods of assessing at birth the predictive value of intrapartum fetal monitoring including premature interruption of the feto-placental circulation. (1986) In Fetal Physiology Measurements. Report of the 2nd International Conference, Oxford, 2-4 April 1984. Ed. P Rolfe. Publ Butterworths, London pp 130-137
5. Reynolds GJ. Beyond sweetness and warmth: transition of the preterm infant Arch. Dis. Child. Fetal Neonatal Ed. 2008; 93: F2-F3.
6. Dalziel SR, Walker NK, Parag V, Mantell C Rea HH, Rodgers A, Harding JE. Cardiovascular risk factors after antenatal exposure to betamethasone: 30- year follow-up of a randomised controlled trial. Lancet, 2005; 365:1856 – 62
7. Stutchfield P, Whitaker R, Russell I. Antenatal betamethasone and incidence of neonatal respiratory distress after elective caesarean section: pragmatic randomised trial. BMJ,doi:10.1136/bmj.38547.416493.06 (2005).
8. Stutchfield and Whittaker Rapid response Admissions to Special Care Baby Unit in the Antenatal Steroids for Term Elective Caesarean Section Trial 14 December 2005
9. Luis C Silva rapid response About p-values and confidence intervals: habitual misconceptions. 12 January 2008
David J R Hutchon FRCOG
Consultant Obstetrician

Competing interests: None declared

Competing interests: None declared

David JR Hutchon, Consultant Obstetrician and Gynaecologist

Darlington Memorial Hospital, DL3 6HX

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Sir,

As a journalist and writer with a special interest in caesarean delivery and a woman whose own birth choice was cesarean delivery on maternal request (CDMR) with no medical indication (up until the eighth month of my pregnancy when breech presentation was discovered), I would like to make five observations on this very useful study by Hansen et al with the aim of informing future research and analysis in this area.

1) Hansen et al extract: “For our final analyses we categorised deliveries into two groups: elective caesarean section and intended vaginal delivery - that is, all vaginal deliveries and emergency caesarean sections.”
Comment: It is very refreshing to see research that includes emergency cesarean outcomes in its analysis of an ‘intended vaginal delivery’ group.
To date, most research analysis either ignores this link or compares all cesarean outcomes (emergency and elective combined) with successful planned vaginal delivery (PVD) outcomes alone. Going forward, the inclusion of emergency caesarean outcomes in PVD risk analysis (in at least one component of the research) - when comparing PVD and planned elective cesarean delivery mortality and morbidity (for mothers and infants) - will aid the emergence of a much clearer picture of the risks and benefits of each. Hansen et al caution: “Exclusion of emergency caesarean sections from the comparison group could have resulted in an overestimation of the effect of elective caesarean section…,” and this is precisely what future studies need to acknowledge in order to ensure the most accurate and relevant conclusions.

2) Extract: “Our results also suggest that a significant reduction in neonatal respiratory morbidity may be obtained if elective caesarean section is postponed to 39 weeks’ gestation. This information should be taken into consideration by women contemplating an elective caesarean section and by the obstetricians counselling them.”
Comment: Hansen et al reiterate the widely established advice for elective caesarean deliveries, which is to wait until 39 weeks estimated gestational age (EGA). (1-7)

3) Extract [on the increased risk of respiratory morbidity]: “the risk was doubled in infants delivered at 39 weeks’ gestation (1.9, 1.2 to 3.0; table 2).”
Comment: Assuming that women and their obstetricians heed the advice given above (waiting until 39 weeks EGA), women choosing elective caesarean delivery need to look at the corresponding data presented by Hansen et al. Of 1074 babies, 23 (2.1%) had respiratory morbidity following elective caesarean delivery compared with 89 of 7755 (1.1%) following PVD. This doubled risk should undoubtedly be taken into consideration by pregnant women - but in the context of other risks for the infant with PVD that have been recognized in other studies. All of the following outcomes for infants have been found to have a greater risk with PVD (and in particular, with forceps and ventouse assisted PVD): significant fetal injury and demise, (8) neonatal complications, (9) neonatal intracranial hemorrhage, (10) cephalhematoma and intracranial hemorrhage, (11) caput, jaundice and cephalohematoma, (12) cranial traumatic injury (13) shoulder dystocia, (14-16) shoulder dystocia and cephalohematoma, (16) and sequential PVD assistance results in even higher morbidity. (18,19) Both ACOG (20) and the NIH (3) have acknowledged a substantial number of increased benefits for the infant with elective caesarean delivery at 39 weeks EGA.

4) Extract [on the increased risk of serious respiratory morbidity]: “…the relative risk at 39 weeks was no longer statistically significant.”
Comment: Again, assuming that women and their obstetricians heed the advice given above (waiting until 39 weeks EGA), women choosing elective caesarean delivery need to look at the corresponding data presented by Hansen et al. The percentage risk of serious respiratory morbidity was 0.1% for PVD and 0.2% for elective caesarean.

5) Extract: “…788 women had a caesarean section by patient choice. Repeated analyses of these showed risk estimates similar to those calculated for our low risk population.”
Comment: Related to the point made in comment 1 above (the need for analysis of birth outcome in direct relation to the birth plan intended), Hansen et al demonstrate a low risk for CDMR in their study. Given the current controversy surrounding CDMR in some countries, this is an area of research that requires further attention, especially since it is established that many risks associated with CDMR are lower than other types of caesarean delivery. (3)

In conclusion: Contrary to some media interpretation and commentary following the publication of Hansen et al’s study, the actual risks relevant to CDMR at 39 weeks EGA (above) should conceivably dilute concerns that women are endangering the health of their child by choosing caesarean delivery or that caesarean delivery is an unreasonable request with regard to the infant’s wellbeing.

References

(1) Maternity - Timing of Elective or Pre-Labour Caesarean Section, PD2007_024. 03-Apr-2007. Primary Health and Community Partnerships, New South Wales. File No. 04/3435-5 http://www.health.nsw.gov.au/policies/pd/2007/pdf/PD2007_024.pdf

(2) Planned cesarean versus planned vaginal delivery at term: comparison of newborn infant outcomes. Kolas T, Saugstad OD, Daltveit AK, Nilsen ST, Oian P. Am J Obstet Gynecol. 2006 Dec;195(6):1538-43. Epub 2006 Jul 17. PMID: 16846577. Department of Obstetrics and Gynecology, Innlandet Hospital Trust, Lillehammer, Norway. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&lis...

(3) National Institutes of Health State-of-the-Science Conference Statement Cesarean Delivery on Maternal Request, March 27-29, 2006 (Published 15 Jun 06) http://consensus.nih.gov/2006/CesareanStatement_Final053106.pdf

(4) An audit of neonatal respiratory morbidity following elective caesarean section at term. Nicoll AE, Black C, Powls A, Mackenzie F. Scott Med J. 2004 Feb;49(1):22-5. PMID: 15012048. Princess Royal Maternity Hospital, 16 Alexandra Parade, Glasgow. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?itool=abstractplus&db=pubm...

(5) The influence of timing of elective cesarean section on neonatal resuscitation risk. Zanardo V, Simbi KA, Vedovato S, Trevisanuto D. Pediatr Crit Care Med. 2004 Nov;5(6):566-70. PMID: 15530194. Department of Pediatrics, Padua University School of Medicine, Via Giustiniani 3, 35128 Padua, Italy. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&lis...

(6) Neonatal respiratory morbidity risk and mode of delivery at term: influence of timing of elective caesarean delivery. Zanardo V, Simbi AK, Franzoi M, Solda G, Salvadori A, Trevisanuto D. Acta Paediatr. 2004 May;93(5):643-7. PMID: 15174788. Department of Paediatrics, Padua University School of Medicine, Padua, Italy. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?itool=abstractplus&db=pubm...

(7) Neonatal respiratory morbidity and mode of delivery at term: influence of timing of elective caesarean section. Morrison JJ, Rennie JM, Milton PJ. Br J Obstet Gynaecol. 1995 Feb;102(2):101-6. PMID: 7756199. Department of Obstetrics and Gynaecology, University College London Medical School, UK. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&lis...

(8) Cesarean section on request at 39 weeks: impact on shoulder dystocia, fetal trauma, neonatal encephalopathy, and intrauterine fetal demise. Hankins GD, Clark SM, Munn MB. Semin Perinatol. 2006 Oct;30(5):276 -87. PMID: 17011400. The University of Texas Medical Branch, Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Galveston, TX 77555-0587, USA. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?itool=abstractplus&db=pubm...

(9) Short-term maternal and neonatal outcomes by mode of delivery A case-controlled study. Chiara Benedettoa, Luca Marozioa, Giovanna Prandib, Ajit Rocciaa, Silvia Blefaria and Claudio Fabrisb aDepartment of Obstetrics and Gynecology, University of Torino, Italy. bNeonatal Care Unit, Department of Paediatrics, University of Torino, Italy. Received 9 February 2006; revised 10 October 2006; accepted 20 October 2006. Available online 28 November 2006. European Journal of Obstetrics & Gynecology and Reproductive Biology Volume 135, Issue 1, November 2007, Pages 35-40 doi:10.1016/j.ejogrb.2006.10.024 http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6T69-4MFJJGG- 1&_user=10&_coverDate=11%2F30%2F2007&_rdoc=8&_fmt=summary&_orig=browse&_srch=doc - info(%23toc%235025%232007%23998649998%23673016%23FLA%23display%23Volume)&_cdi=5025&_sort=d&_docanchor=&_ct=31&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=02a7fe5fbca83882cde0163bd95874d9

(10) Intracranial Hemorrhage in Asymptomatic Neonates: Prevalence on MR Images and Relationship to Obstetric and Neonatal Risk Factors. Christopher B. Looney, BS, J. Keith Smith, MD, PhD, Lisa H. Merck, MD, MPH, Honor M. Wolfe, MD, Nancy C. Chescheir, MD, Robert M. Hamer, PhD and John H. Gilmore, MD Radiology 2007;242:535-541 http://radiology.rsnajnls.org/cgi/content/abstract/242/2/535

(11) Comparison of maternal and infant outcomes between vacuum extraction and forceps deliveries. Wen SW, Liu S, Kramer MS, Marcoux S, Ohlsson A, Sauve R, Liston R. Am J Epidemiol. 2001 Jan 15;153(2):103-7. PMID: 11159152. Bureau of Reproductive and Child Health, Centre For Healthy Human Development, Health Canada, Ottawa, Ontario. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?itool=abstractplus&db=pubm...

(12) Forceps or vacuum extraction: a comparison of maternal and neonatal morbidity. Shihadeh A, Al-Najdawi W. East Mediterr Health J. 2001 Jan-Mar;7(1-2):106- 14. PMID: 12596959. Department of Obstetrics and Gynaecology, Royal Medical Services, Amman, Jordan. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?itool=abstractplus&db=pubm...

(13) Review of singleton fetal and neonatal deaths associated with cranial trauma and cephalic delivery during a national intrapartum-related confidential enquiry. O'Mahony F, Settatree R, Platt C, Johanson R. BJOG. 2005 May;112(5):619-26. PMID: 15842287. Clinical Governance Office, Ward 59, North Staffordshire Maternity Unit, Stoke on Trent ST4 6QG, UK. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?itool=abstractplus&db=pubm...

(14) Shoulder dystocia and brachial plexus injury: a case-control study. Christoffersson M, Kannisto P, Rydhstroem H, Stale H, Walles B. Acta Obstet Gynecol Scand. 2003 Feb;82(2):147-51. PMID: 12648177. Department of Obstetrics and Gynecology at Central Hospital, Kalmar, Sweden. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?itool=abstractplus&db=pubm...

(15) Shoulder dystocia and brachial plexus injury: a case-control study. Christoffersson M, Kannisto P, Rydhstroem H, Stale H, Walles B. Acta Obstet Gynecol Scand. 2003 Feb;82(2):147-51. PMID: 12648177. Department of Obstetrics and Gynecology at Central Hospital, Kalmar, Sweden. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?itool=abstractplus&db=pubm...

(16) Management of Shoulder Dystocia Trends in Incidence and Maternal and Neonatal Morbidity I. Z. MacKenzie, FRCOG1, Mutayyab Shah, MRCOG1, Katie Lean, RM1, Susan Dutton, MSc1, Helen Newdick, BEd1 and Danny E. Tucker, MRCOG1 From the Nuffield Department of Obstetrics and Gynaecology, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom.1 Obstetrics & Gynecology 2007;110:1059-1068 © 2007 by The American College of Obstetricians and Gynecologists http://www.greenjournal.org/cgi/content/abstract/110/5/1059

(17) Forceps compared with vacuum: rates of neonatal and maternal morbidity. Caughey AB, Sandberg PL, Zlatnik MG, Thiet MP, Parer JT, Laros RK Jr. Obstet Gynecol. 2005 Nov;106(5 Pt 1):908-12. PMID: 16260505. Department of Obstetrics, Gynecology and Reproductive Sciences, University of California-San Francisco, 505 Parnassus Avenue, Box 132, San Francisco, CA 94143, USA. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?itool=abstractplus&db=pubm...

(18) What to do after a failed attempt of vacuum delivery? Sadan O, Ginath S, Gomel A, Abramov D, Rotmensch S, Boaz M, Glezerman M. Eur J Obstet Gynecol Reprod Biol. 2003 Apr 25;107(2):151-5. PMID: 12648860. Department of Obstetrics and Gynecology, Sackler Faculty of Medicine, Edith Wolfson Medical Center, Tel-Aviv University, Tel-Aviv, Israel. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?itool=abstractplus&db=pubm...

(19) Failed individual and sequential instrumental vaginal delivery: contributing risk factors and maternal-neonatal complications. Al-Kadri H, Sabr Y, Al-Saif S, Abulaimoun B, Ba'Aqeel H, Saleh A. Acta Obstet Gynecol Scand. 2003 Jul;82(7):642-8. PMID: 12790846. Department of Obstetrics and Gynecology, King Fahad National Guard Hospital, Riyadh, Saudi Arabia. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?itool=abstractplus&db=pubm...

(20) ACOG Committee Opinion No. 394: Cesarean Delivery on Maternal Request. Obstet. Gynecol., December 1, 2007; 110(6): 1501. PMID: 18055756 http://highwire.stanford.edu/cgi/medline/pmid;18055756

Competing interests: Pauline McDonagh Hull is editor of a website providing information on elective caesarean delivery, and it is her personal belief that CDMR (or EPCD (elective prophylactic caesarean delivery) as it is also referred to) is a legitimate birth choice for healthy women.

Competing interests: None declared

Pauline M Hull, Writer and journalist

Hellertown, PA 18055 USA

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In 2001, Levine et al published an extensive review [1] on the incidence of persistent pulmonary hypertension (PPH,) and respiratory diseases in elective cesarean sections (ECS). In response to that article, [2] I, like Mr. D. Hutchon above, referenced Landau’s 1950 full placental transfusion [3] that completely prevented respiratory disorders in C-sections. Immediate cord clamping (ICC) is routine treatment of the ECS child, and deprives it of physiological placental transfusion (PPT.)

PPH is also termed “persistent fetal circulation” (PFC.) In the fetus, virtually no blood flows through the pulmonary vessels. At a normal birth, using no cord clamp, PPT provides the blood volume needed to establish the pulmonary circulation and convert fetal circulation to adult circulation. ICC impedes this conversion, botches PPT, and leads to blood volume being diverted from all other organs to fill the pulmonary circuit. In some cases, especially ECS, this blood volume may not be sufficient, and the fetal circulation persists – often fatally. Peltonen [4] described clamping before the first breath as potentially fatal – and to be avoided.

In 1982, in an exhaustive review on placental transfusion [5], Linderkamp wrote:

“Immediate cord clamping can result in hypotension, hypovolemia and anemia. … Why does Nature intend maximal placental transfusion to the neonate? Obviously it is not to prevent the respiratory distress syndrome in immature neonates. It may be speculated that the prevention of severe iron deficiency in infants living under primitive conditions is more important than the risk of circulatory overload shortly after birth. In civilized countries, a medium placental transfusion appears to be more appropriate in order to escape the risk of hyper-viscosity, whereas Iron Deficiency in later infancy is probably less dangerous.”

Conclusions: PPT prevents infant iron deficiency and respiratory distress syndrome; infant iron deficiency is DANGEROUS.

Nature apparently intends maximal placental transfusion, PPT, to convert the fetal circulation to the adult circulation, and also to prevent DANGEROUS infant anemia.

What, then, is so DANGEROUS about infant iron deficiency anemia?

In 2007, Lozoff published a review of 99 articles [6] (from 1974 to 2006) that linked Infant Iron Deficiency Anemia to Long Lasting Neural and Behavioral Effects – mental retardation (MR) – in civilized and uncivilized countries. Ultee published a study [7] linking ICC with infant anemia and cognitive defects (MR) in a civilized country.

Last week (February 8, 2008) I had the good fortune of putting Landau’s [3] experience into practice. My daughter was scheduled for an elective term C-section for a breech presentation. I gave the operating obstetrician a summary of the risks of elective cesarean section (PPH, IRDS, autism [8]) and the risks of ICC (Infant anemia,[5] mental retardation, autism, neural and behavioural disorders. [6, 7])

The obstetrician readily agreed to my suggestions that:
• IV oxytocin would be started one hour ahead of the operation to develop the lower uterine segment and ensure uterine contractility after delivery for effecting placental transfusion. [9]
• The newborn would be lowered below the level of the placenta immediately after delivery.
• The cord would not be clamped until the child was crying and until all pulsation in the cord ceased.

All these requests were complied with, the child was crying within a minute; the placenta separated and was spontaneously delivered prior to the cord being clamped. My granddaughter received a full PPT and reflexively clamped her own cord. [9] The child was red, vigorous and plethoric, and at no risk for anemia, or respiratory, neural, mental or developmental disorders.

Other responses have mentioned the “value” of ante-natal steroids. Steroids produce vaso-constriction of the placental vessels – a de-facto prenatal placental transfusion that ameliorates the effect of ICC, and improves neonatal blood volume by shifting some blood from placenta to child. Long term steroids produce growth retardation. Physiology – not clamping the cord – works much better than steroids in preventing respiratory disorders.

Any procedure that tends to produce neonatal hypovolemia and infant iron deficiency anemia is VERY DANGEROUS and should be avoided. [4, 7] Clamping the umbilical cord before the child has closed the cord vessels physiologically is contraindicated. Every neonate requires a physiological, maximal placental transfusion to ensure the integrity of its brain and optimal function of all vital organs.

The danger of ICC is readily demonstrable to any doubting midwife or physician: Deliver several babies with a scalp FHR lead attached to record the heart rate while the cord is immediately clamped between finger and thumb. If the child does not breathe, the heart rate will plummet to 60 bpm due to hypoxia and loss of venous return to the heart; there may be brief cardiac arrest. [4] Severe bradycardia and neonatal distress releases the finger and thumb within 10-20 seconds and PPT rapidly restores normality to the monitor, the newborn and apprehensive observers.

A dozen or so documented, (videotaped) instances of this ICC-induced near calamity, and its recovery with PPT, should convince enlightened authorities (RCOG, ACOG, NICE) that, after birth, “There is good reason … to keep the umbilical circulation intact … in civilized countries.” [4, 5]

References:

1. Levine E. Vivek G. Barton J. Strom C. Mode of Delivery and Risk of Respiratory Diseases in Newborns. Obstetrics & Gynecology Vol. 97, No. 3, Mar 2001 439-441

2. Morley G. Letters. Obstetrics & Gynecology Vol. 97, No. 6, June 2001 1025-1026.

3. Landau D. Death of Cesarean Infants. A Theory as to Its Cause and a Method of Prevention. The Journal of Pediatrics (1950) 36. 421-426

4. Peltonen T. Placental Transfusion, Advantage - Disadvantage. Eur J Pediatr. 1981;137:141-146

5. Linderkamp O. Placental transfusion: determinants and effects. Clinics in Perinatology 1982;9:559-592

6. Lozoff B et al. Long-Lasting Neural and Behavioral effects of Iron Deficiency in Infancy. Nutrition Reviews Vol. 64 No. 5 s34–s43

7. Ultee c. et al. Delayed cord clamping in Preterm Infants Delivered at 34-36 weeks. Heart 2008. Arch Dis. Childh. Feb 2007 Online.

8. Glasson EJ. Et al. Perinatal factors and the development of autism: a population study. Ach. Gen. Psychiatry 2004 Jun;61 (6):618-27

9. Gunther M. The transfer of blood between the baby and the placenta in the minutes after birth. Lancet 1957;I:1277-1280.

Competing interests: None declared

Competing interests: None declared

George M Morley MD, Retired Obstetrician Gynecologist

none

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In a large study Hansen et al concluded that there is a four-fold increase in risk of respiratory distress in the newborn for those delivered by elective caesarean section at 37 weeks gestation compared to vaginal delivery, with a five-fold increase of serious respiratory morbidity.(1) This is defined as a need for continuous oxygen supplementation for 3 or more days, nasal CPAP or any period of mechanical ventilation. This risk decreases with increasing gestational age but with still a two-fold increase at 39 weeks gestation. There can be no doubt from the extensive publications over the past 30 years that delivery by elective caesarean section increases the risk of respiratory morbidity in the neonate. In the absence of the stress of labour, there is no catecholamine and cortisol release to stimulate lung fluid absorption and surfactant production, resulting in a delay in adaptation to birth particularly with the more immature lungs of those less than 40 weeks gestation, leading to respiratory distress.

Whenever an elective caesarean section is planned it is important that these risks are discussed with the mother. These can be reduced by planning the section for 39 weeks gestation, aware that an emergency section may be necessary if labour commences before this time. From 39 weeks gestation onwards the absolute risk of unexplained stillbirth with women who had a previous caesarean delivery are increased and calculated at 1.06/1000.(2)

In a large randomised controlled trial we demonstrated that the recognised benefits of the widely used antenatal betamethasone for preterm deliveries, extended to term babies delivered by elective caesarean section, halving the incidence of respiratory distress at 37-39 weeks gestation.(3) Hansen et al make reference to this but raise the sceptre of safety with reference to the editorial accompanying our Paper.(4) This editorial did not present the published data in a balanced way, totally contrary to the meta-analysis undertaken for the Cochrane review and the Royal College of Obstetricians and Gynaecologists guidelines on the safety of a single course of antenatal betamethasone.(5-8) With many publications up to 31 years follow-up, it is safe to conclude there is no evidence of long-term effect of a single course. (6-9)

Clinical management can be influenced by unsubstantiated statements which are published unless the original data is checked. With reference to our study , the assertion by Hutchon (rapid response above) that morbidity, cost and separation of mother and baby were not significantly reduced is incorrect and based on guesswork.. In the betamethasone group we report 11 babies admitted with respiratory distress, 15 for other reasons, a total of 26 and in the control group, 24 with respiratory distress, 8 other reasons, a total of 32 admissions. Our study was not powered to make conclusions about admissions other than for respiratory distress. However revisiting the data, considering admissions for all causes, babies in the betamethasone group were admitted for a total of 84 days which includes 35 days for respiratory causes 5 of which were intensive care. Babies in the control group were admitted for a total of 167 days, 129 of these with respiratory distress including 65 days intensive care . The total number of admission days to the neonatal unit were reduced by 50% confirming reduced morbidity , cost and separation of mother and baby for those in the betamethasone group.

Despite the volume of publications demonstrating the benefits of antenatal betamethasone in reducing respiratory distress, Hutchon proposes that there is an opportunity to prevent respiratory problems after caesarean section with delayed clamping of the cord. This again is speculation and not supported by evidence, with a misleading reference to the Cochrane Review and a “number of studies”.(10) The Cochrane Review concluded that there was evidence of reduced need in the preterm infant for blood transfusions with less intraventricular haemorrhage with delayed cord clamping, and insufficient evidence for a reliable conclusion about any respiratory effect.

There is sufficient evidence from follow-up studies of no adverse outcome from a single course of antenatal betamethasone to recommend that if an elective caesarean section has to be undertaken before 39 weeks gestation, that the benefits of a single course of antenatal betamethasone 48 hours before delivery should be discussed with mother when planning the delivery. The opportunity of reducing the adverse consequences of serious respiratory disease in those delivered by elective caesarean section before 39 weeks gestation should not be delayed a further 10 years through unsubstantiated assertions and a misleading editorial that gets repeatedly quoted(5).

References

1.Hansen AK, Wisberg K, Uldebjog N, Henriksen TB. Risk of respiratory morbidity in term infants delivered by elective caesarean section; cohort study. BMJ 2008; 336; 85-87.

2.Smith GS, Pell JP, Dobbie R . Caesarean section and risk of unexplained stillbirths in subsequent pregnancy. Lancet 2003; 362: 1779- 84

3.Stutchfield PR, Whittaker R, Russell I. Antenatal betamethasone and incidence of neonatal respiratory distress after elective caesarean section; pragmatic randomised trial. BMJ 2005; 331: 662-4

4.Steer PJ. Giving steroids before elective caesarean section. BMJ 2005; 331: 645-6

5.Hey E. The fallibility of experts. www.bmj.com/cgi/eletters/331/7518/645

6.Crowley P,Roberts D, Dalziel S,Shaw BNJ. Antenatal corticosteroids to accelerate fetal lung maturation for women at risk of preterm birth. Cochrane Database of Systematic Reviews 2003;4; CD004454

7.Antenatal corticosteroids to prevent respiratory distress syndrome.

RCOG 2004, Guideline no. 7

8.Roberts D,Dalziel S . Antenatal corticosteroids for accelerating fetal lung maturation

for women at risk of preterm birth . Cochrane Database of Systematic Reviews 2006, issue 3 reprinted 2008 Art no:CD004454.DOI:10.1002/14651858.CD004454.pub2

9.Dalziel SR, Lim VK, Lambert A, McCarthy D, Paraq V. Antenatal exposure to betamethasone: psychological functioning and health related quality of life 31 years after inclusion in randomised controlled trials. BMJ 2005; 331: 665-668

10.Rabe H, Reynolds G, Diaz-Rossello J. Early versus delayed umbilical cord clamping in preterm infants. Cochrane Database of Systemic Reviews 2004, issue 4, Art No: CD 003248. DOI: 10.1002/14651858. CD 003248. pub 2 republished 2008 issue 1

Competing interests: None declared

Competing interests: None declared

Peter Roy Stutchfield, Consultant Paediatrician

Rhiannon Whitaker

Conwy and Denbighshire NHS Trust , Glan Clwyd Hospital,Rhyl,Denbighshire LL18 5UJ

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Sir,

Hansen et al (1) provide further evidence that caesarean section is not without risk to the baby, especially when it is carried out electively before 39 weeks. There are probably a number of reasons why a baby at 37 weeks is more susceptible to respiratory problems after caesarean section than after vaginal delivery. Caesarean delivery will never be physiological and immediate cord clamping is common practice with this form of delivery. Immediate clamping of the cord prevents the normal redistribution of blood in the feto-placental vascular space after delivery. Hypovolaemia of the newborn baby is common. As long ago as 1950, long before antenatal steroids, surfactant or even neonatal ventilation were available, Landau et al (2) working in the USA recognised that respiratory problems after caesarean delivery could be largely prevented by avoiding immediate cord clamping. They used a technique to allow the placental circulation to remain intact till long after delivery. I quote from their paper “Since instituting this technique our results with our cesarean babies have been much better than formerly. For this reason we have not felt justified in running a control series.” How unfortunate that they did not realise the scepticism of their fellow obstetricians and pediatricians would be without a control series, and how many babies’ lives might have been saved if this report had been properly followed up. They go on to say “ in eighty-seven sections done since instituting this technique of placental suspension and drainage, there have been no instances of the previously described syndrome.” ("cyanosis, respiratory distress with dyspnea, air hunger, and costal retraction with weak pulse".)


Although the use of antenatal steroids for elective caesarean section before 39 weeks reduced the risk of admission with RDS in the study by Stutchfield et al (3), overall admissions to special care were not actually significantly reduced, (4) with the result that morbidity, cost, and separation of mother and baby were not affected.


I have called for a trial of physiological management of the cord at elective cesarean section. (5) Based on the evidence of Landau, and more recently Dunn (6), there appears to be the opportunity to prevent respiratory problems after cesarean section without the risks of antenatal steroids. The Cochrane review of delayed cord clamping and a number of studies since have shown the benefit of delayed cord clamping in preterm babies. Indeed there may be an adjunctive effect of antenatal steroids and delayed cord clamping when delivery is necessary well before 39 weeks. Judging by Landau’s results it would not take a very large trial to show benefit.



David J R Hutchon
References
1. A K Hansen, Wisbourg K, Uldbjerg, T B HenriksenRisk of respiratory morbidity in term infants delivered by elective caesarean section: cohort study BMJ 2007:335
2. Landau D B, Goodrich H B, Franka WF, Burns FR. Journal of Pediatrics (1950) 36:421-426
3. Stutchfield P, Whitaker R, Russell I. Antenatal Betamethasone and incidence of neonatal respiratory distress after elective caesarean section: Pragmatic randomized trial.BMJ 2005:331
4. Stutchfield P R Admissions to Special Care Baby Unit in the Antenatal Steroids for Term Elective Caesarean Section Trial (2005) http://bmj.com/cgi/eletters/331/7518/662#123781
5. Hutchon D J R. A trial of physiological delivery at Caesarean (2005) http://bmj.com/cgi/eletters/331/7518/662#124145
6. Dunn P M. Reservations about the methods of assessing at birth the predictive value of intrapartum fetal monitoring including premature interruption of the feto-placental circulation. (1986) In Fetal Physiology Measurements. Report of the 2nd International Conference, Oxford, 2-4 April 1984. Ed. P Rolfe. Publ Butterworths, London pp 130-137

Competing interests: None declared

Competing interests: None declared

David J R Hutchon, Consultant Obstetrician

Memorial Hospital, Darlington. DL3 6HX

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Sir

The recent study by AKH et al (1) has helped to provide further evidence that the risk of respiratory morbidity in term infants delivered by Elective Caesarean section is increased. Over the years many studies have been carried out and all have shown a similar result. (2) (3)

Following this results most NHS hospital have adopted policies that ensure that Elective Caesarean sections are not performed before 39 weeks gestation in uncomplicated/low risk pregnancy, except were clinically indicated. In clinical practice, one often encounters patients requesting Elective Caesarean sections for ‘social reasons’. Having shown that after 39weeks gestation the relative risk is no longer statistically significant (1), obstetricians should make sure that when advising women on options for delivery they should be given the adequate information, the overall risks and benefits of caesarean section for both mother and baby as compared to vaginal delivery should be explained especially the increased risk of respiratory problems to the baby.

With an increasing number of patients opting for Elective Caesarean section (patients choice), definitions of “Term” and Clinical indications for Elective Caesarean section need to be debated (2).This will ensure that the Gestational age of the fetus is accurate and will reduce the number of clinical indicated Elective Caesarean sections that after delivery are found to be of a lower gestational age and hence predisposed to a higher incidence of respiratory morbidity. It would also help to reduce the cost to NHS for level 1 and 2 care that may need to be offered to this neonates if they are admitted to neonatal intensive unit(2) and reduce the anxiety and stress that the parents face during this period of admission.

In Clinical practice many factors influence the timing of elective caesarean sections such as uncertainty on gestational age, medically indicated early delivery and concerns about possible spontaneous onset of labour and need for an emergency caesarean section with its antecedent risks to mother and baby. Peter Stutchfield et al looked at whether steroids would reduce respiratory distress in babies born by elective caesarean section at term. They concluded that antenatal bethamethsone and delaying delivery till 39weeks both reduce admissions to special care baby units with respiratory distress after elective caesarean section at term or give steroids prophylactic ally to those who are known to have increased risk of pre-term labour (3).It has also been shown that one dose of steroids has no long term adverse effects on infants either neurological or cognitive.

More studies need to be carried out on this option of antenatal steroids as this could be used in clinical practice where medical factors require that a caesarean section needs to be performed before 39 weeks.The timing of when the steroids would be given and the category of patients that would benefit from the treatment should be looked at and possibly guidelines could be made to incorporate this into our clinical practice.

The long term effects of steroids on the infants would also need to be studied.

Mojisola Oniah, MBBS, FTSTA
Obstetrics & Gynaecology, Colchester General Hospital, The UK

Sadia Farrakh, MBBS, FTSTA
Obstetrics & Gynaecology, Colchester General Hospital, The Uk

Corresponding Author: Mojisola Oniah.
Email: mojisaolamartinsdr@yahoo.com

References:

A K Hansen, Wisbourg K, Uldbjerg, T B HenriksenRisk of respiratory morbidity in term infants delivered by elective caesarean section: cohort study BMJ 2007:335

Alderdice F, McCall E, Bailie C, Craig S, Dornan J, McMillen R, Jenkins J. Admission to neonatal intensive care with respiratory morbidity following ‘term’ elective caesarean. Ir Med J. 2005 Jun;98(6):170-2

Stutchfield P, Whitaker R, Russell I. Antenatal Betamethasone and incidence of neonatal respiratory distress after elective caesarean section: Pragmatic randomized trial.BMJ 2005:331

Competing interests: None declared

Competing interests: None declared

Mojisola. A. Oniah, FTSTA 1 Obstetrics & Gynaecology

Sadia farrakh

Colchester General Hospital, Turner road, CO4 5JL

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We read with much interest the paper by Hansen et al.1 who investigated the association between elective caesarean sections and neonatal respiratory morbidity (transitory tachypnoea of the newborn, respiratory distress syndrome, persistent pulmonary hypertension of the newborn) and serious respiratory morbidity (oxygen therapy for more than two days, nasal continuous airway pressure, or need for mechanical ventilation) and the importance of timing of elective caesarean sections.

They found that compared with newborns delivered vaginally or by emergency caesarean sections, those delivered by elective caesarean section around term have an increased risk of overall and serious respiratory morbidity.

The relative risk increased with decreasing gestational age. However, among the neonatal respiratory morbidity evaluated in these patients, they did not evaluated the pneumothorax risk. This is relevant, considering that persistent pulmonary hypertension, pneumothorax or both conditions have been noted in 71.4% iatrogenic RDS infants delivered by elective caesarean section.2

Respiratory morbidity in infants born after elective caesarean section may be remarkably severe. Recently, we found that neonates delivered by elective caesarean section showed an increased incidence of pneumothorax (2.90/1000 births), in comparison with neonates delivered by an indicated cesarean (1.41/1000 births; OR 3.87; 95% CI 1.86-8.05) or vaginally delivered (0.39/1000 births; OR 7.95; 95% CI 4.41-14.32). In addition, in elective caesarean sections there was a significant progressive reduction in the incidence of pneumothorax from week 37 0/7-37 6/7 onwards (ƒÓ2 for trend = 1.62, P <_0.01.3 p="p"/>Persistent pulmonary hypertension and pneumothorax represent life- threatening conditions, that need a prompt recognition and therapy, and require specialized care offered only at tertiary referral centers. Their frequent occurrence indicates the need to extend the investigation in iatrogenic RDS, in an area where the timing of elective caesarean section have shown to possess a clinical significance.

Vincenzo Zanardo, MD, Stefania Vedovato, MD, and Daniele Trevisanuto, MD
Department of Pediatrics, Padua University School of Medicine, 35128 Padua, Italy

1. AK, Wisborg K, Uldbjerg N, Henriksen TB. Risk of respiratory morbidity in term infants delivered by elective caesarean section: cohort study. BMJ. 2007:335

2.Wax JR, Herson V, Carignan E, Mather J, Ingardia CJ. Contribution of elective delivery to severe respiratory distress at term. Am J Perinatol 2002;19:81-6.

3. Zanardo V, Padovani E, Pittini C, Doglioni N, Ferrante A, Trevisanuto D.The influence of timing of elective cesarean section on risk of neonatal pneumothorax. J Pediatr 2007 ;150:252-5.

Competing interests: None declared

Competing interests: None declared

Vincenzo Zanardo, Aggregated Professor of Pediatrics

Stefania Vedovato, Daniele Trevisanuto

35128 Padua, Italy

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