Richard Paul, MD

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       "My name is Richard Paul, and I am from the University of Southern       California in Los Angeles."
       
       

       "And I'm Arulkumaran, Arul for short, from the University of       Nottingham in the U.K."
       
       

       "This afternoon, we would like to discuss the topic of cesarean       section today, some of the trends that we see, and ask the question - have       we gone too far in our demands to reduce the cesarean section rate which       is seemingly a great demand put upon the obstetrician/gynecologist by       organizations?"
       
       

       "I think the problem was mainly put on the physicians because it was       perceived that in the private sector the cesarean sections were done for       monetary reasons. Currently, the issue is becoming a broader one because       the women themselves want a cesarean section on request. There is debate       about whether it's a woman's right to request a cesarean section.       Discussions surround what is a woman's right as opposed to a privilege,       and what is society's right. One of the concerns is the limited budget to       provide health care services. The C-section that is done on request might       consume more money and may even block up the theaters necessary to do       emergency procedures. Many organizations like to consider C-section on       request as a privilege and to monitor the situation to see how it       develops."
       
       

       "My view is that an informed woman certainly has the right to request       a cesarean section. I think there's current debate relating on whether or       not cost effectiveness may not be about equal for a cesarean birth, at       least in the United States. Clearly in my opinion, the baby has a less       traumatic exit from the mother by cesarean birth. It's generally accepted       that the cesarean is associated with more morbidity for the mother. But       isn't the question then - can the mother accept increased morbidity if she       believes this is best for her baby as it's being born, and perhaps as we       now understand, better for her later in life as it relates to late       complications - less pelvic floor disorders, stress incontinence, and that       type of issue. So we are going to see this debate occur, and I think we       will see the demand for cesarean increase, and that will occur quite       rapidly."
       
       

       "In one of the surveys which they conducted in the U.K., they looked       at whether the decision to do a cesarean section is made mainly by the       physician or in participation with the woman. Increasingly the       obstetrician is willing to discuss the issue and a joint decision is made.       I think that is a right direction in which things should move in terms of       clinical practice. The advantages and disadvantages of any procedure       should be explained to the woman. She should be allowed to have an       informed choice in the matter. I do not know how it works in the United       States."
       
       

:       "I think that the public is becoming more and more aware of the       safety of cesarean sections - it's a safe operation. Particularly more and       more women are requesting an elective cesarean as opposed to one trial of       labor after prior section; the whole arena is changing. With women       beginning to predominate as the providers, I think many of them, in fact,       also tend to feel that cesarean is the preferable method of giving birth.       This will no doubt have a major impact over the next few years, regarding       the availability of that service, and the willingness of the obstetrician       to go ahead and do a cesarean at the patient's request. I think one of the       things that we believe medically is that there's more risk with cesarean.       But when you look at the safety of the operation - it's an incredibly safe       operation today. In my opinion, much of what has happened to drive this       demand to decrease the cesarean rate is driven on an economic basis. It       has been promoted by lobbies from insurance companies and by the Federal       Government in order to limit the cost as opposed to really what's       medically correct."       

Part       2 - "Vaginal Delivery Following       Previous C-Sections"

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I think the problem was mainly put on the physicians because it was perceived that in the private sector the cesarean sections were done for monetary reasons. Currently, the issue is becoming a broader one because the women themselves want a cesarean section on request.

Pros and Cons of C-Section on Demand in Low Risk Patients

There are a group of women who've had a previous cesarean but would like to have a vaginal birth following that, and the question is whether we should allow women who've had two previous cesarean sections to have a vaginal birth.

Vaginal Delivery Following Previous C-Sections

       "There are a group of women who've had a previous cesarean but would       like to have a vaginal birth following that, and the question is whether       we should allow women who've had two previous cesarean sections to have a       vaginal birth. Since Professor Paul has a lot of experience from his       institution, perhaps he might be able to tell us more about it."
       
       

       "Our experience is quite significant, it's published data. When we       were doing a large volume of deliveries we necessarily had to undertake a       trial of labor in women with two prior cesareans. The safety of that       procedure is different than with one prior, and it is complicated by a       three-fold increase in uterine rupture with its consequences but it still       approximates only about 2%. This particular group will never significantly       lower the section rate because it only represents about 2% of the given       population. Roughly, half of those women may achieve a vaginal birth so       the net lowering might be 1%, and the risk is significant. In general, we       are less and less interested in trying to promote VBAC in women with two       prior sections. We are currently doing VBAC or trial of labor in about 7%       of our patients to 10% which is about as low as we have been in many       years. It's acceptable if the woman knows the risk and if the facility can       deliver the baby when an emergency arises, and my feeling is fifteen       minutes should be the intervention point. If you can't do that, you're       better off doing elective repeat cesarean section and not undertaking the       procedure, which has some risk. So we're pretty much downplaying the use       of trial of labor with two prior sections."
       
       

       "Yes, I think that's a very important point. The institutions where       we allow women to have a trial of labor and a possible vaginal delivery,       we should remember that when the scar gives way it may lead to acute       bradycardia. Based on the study by Professor Paul, if the bradycardia       lasts more than seventeen minutes before the baby is delivered, the baby       is harmed, and certainly if it has been more than thirty minutes - most of       the babies die at the time of delivery or soon afterwards. So the timing       is of the essence, in most of the hospitals, we encourage them to audit       the decision to delivery interval especially in acute problems like       abruption, cord prolapse, scar dehiscence, and prolonged bradycardia       longer than ten or twelve minutes. Because if they can get their act       together and deliver the baby by seventeen or eighteen minutes, then the       baby might do well but if it takes longer than that, then the baby might       suffer neurological damage subsequently. I would like to ask Professor       Paul for some more information on prolonged bradycardia, other than the       study on women who had trial of labor after a previous cesarean. Is there       any other literature to suggest that prolonged bradycardia could be       harmful?"
       
       

       "We certainly see babies born following a prolonged bradycardia that       are acidemic and depressed. There's not an absolute direct correlation       with the bradycardic event and that outcome. Some babies no doubt develop       the bradycardic event but still maintain some perfusion within their       system. So you have the paradox where you may observe a prolonged       bradycardia, intervene, and still have a baby that isn't terribly acidemic.       Theoretically, when a baby is extruded from the uterus, it will represent       total cessation of circulation between the placenta and the fetus. But       even then you have a window of time in the previously unstressed baby to       intervene. In our experience, in the normal baby when there's an       intervention within seventeen minutes there was no evidence of permanent       sequela at discharge. If those babies had had prior stress factors going       on in their labor, they ended up with sequela as early as ten minutes. But       in general, there's a relationship - prolonged bradycardia and the       occurrence of acidemia depression is time related but not in an absolute       one-on-one correlation."
       
       

       "Thank you. That information is very useful in those patients with       bradycardia without a previous cesarean section

. If they have bradycardia,       we tend to intervene if it is more than nine to ten minutes because we       think there will be some adverse outcome for the baby. What would be       advisable with regards to the intervention time in relation to the       duration of bradycardia?
       
       

       "I think if you have a bradycardic event and it's seventy beats per       minute for three, four, or five minutes and you find no resolution, at       that time you assume the worst case and move toward emergency delivery.       You don't wait nine minutes for your decision to get the baby delivered.       In most places it's going to probably take eight to ten minutes to effect       operative delivery. So after four or five minutes of bradycardia you have       to make your decision to move towards an operative delivery. I wouldn't       advise waiting nine or ten minutes. Take your steps, if you can't resolve       the problem in maybe four minutes with really a prolapsed cord, and you       assume there's been a bad circumstance - get the baby delivered as quickly       as you can."
       
       

       "That's very useful information for us to know, not only with a       previous cesarean section but even in other circumstances. Thank       you."
       
       

"Pros and Cons of C-Section on Demand in       Low Risk Patients"

Author | Richard Paul, MD

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