Elective cesarean delivery: What are we doing?

October 1, 2009

Delivering a baby before 39 weeks with no clear medical indications may be doing more harm than good.

In 1990, 10% of all pregnancies were induced but by 2006 the induction rate had more than doubled to 22.5% of all pregnancies.2 Why the increase? Have we improved neonatal or maternal outcome with this intervention? Although fetal deaths at 28 weeks or more decreased between 1990 and 2003, there has been no further change since 2003.3 Maternal mortality has not decreased since 1982.

Certainly many of these inductions have appropriate indications and one change in practice since 1990 has been the increased use of early ultrasound, which has improved the dating of pregnancies. One benefit of improved dating is knowing when a woman becomes postterm; no doubt many of these inductions reflect the trend to induce by 41 weeks rather than wait until 42 or 43 weeks. The birthrate at greater than 40 weeks decreased coincident with this increase in inductions, suggesting that part of the increase in inductions is related to postdates inductions, a legitimate reason for an increase in inductions.2 Unfortunately, the rate of low birthweight deliveries has increased since 1990 to 8.3% in 2006, and the percentage of singleton births at 37 to 39 weeks has increased from 41% in 1990 to 55% in 2006.2 These increases are concerning in light of the increase in inductions and high percentage of elective CDs that occurred at less than 39 weeks.

Perhaps the expertise of our neonatal colleagues has given obstetricians false reassurance and lowered our threshold for induction or planned CD before 39 weeks. Neonatologists and their nurseries are excellent but, their expertise is not good enough to warrant elective delivery of women before 39 weeks. Is a 15% risk of neonatal adverse outcome that could include death worth a maternal intervention that has no benefit?

As physicians, we should be using good judgment. The primary philosophy directing our profession is do no harm. Delivering a woman before 39 weeks with no good reason to believe that there is maternal or neonatal benefit is potentially doing harm to both mother and neonate. Share these risks with your patients. Refrain, restrain, do no harm.

DR. KILPATRICK is Theresa S. Falcon Cullinan Professor and Head, Department of Obstetrics and Gynecology, Vice Dean, College of Medicine, University of Illinois at Chicago, Chicago, IL. She is also a member of the Contemporary OB/GYN editorial board.

REFERENCES

1. Tita AT, Landon MB, Spong CY, et al. Timing of elective repeat cesarean delivery at term and neonatal outcomes. N Engl J Med. 2009: 360;111-120.

2. Martin J, Hamilton B, Sutton P, et al. Births: Final Data for 2006. Natl Vital Stat Rep. 2009;57:1-102.

3. MacDorman M, Kirmeyer S. Fetal and perinatal mortality, United States, 2005. Natl Vital Stat Rep. 2009;57:1-19.

4. Grobman WA. Elective induction: When? Ever? Clin Obstet Gynecol. 2007:50;537-546.