Tienchin Ho

Elective Repeat Cesarean Sections

A New England Journal of Medicine article this month discusses outcomes for babies born by elective repeat cesarean section. Here is a link to a New York Times article about the study.

In this study, data on 19 university hospitals was taken from the Eunice Kennedy Shriver National Institute of Child Health and Human Development cesarean registry. The investigators looked at 28,867 patients with prior cesarean sections who had repeat cesarean sections. Patients who had cesareans before 37 weeks were excluded from the study. Those who were in labor or already had spontaneous rupture of membranes were also excluded.

Then, for each case, the investigators determined the reasons for the cesarean section. Only cesareans without a medical reason were considered elective.

Some of the reasons they found were:
multiple gestations
non vertex presentation
major malformations
maternal medical problems such as heart disease or HIV
prior uternie incision that was not low transverse
non-reassuring fetal heart tracing or fetal testing
suspected macrosomia (abnormally large baby)
placenta previa or abruption

There were 13,258 elective repeat cesarean sections done after 36 weeks (46% of all repeat cesarean sections).

Distribution of elective repeat cesarean sections by gestational age:
37 weeks          834 pts     6.3% of all elective cesareans
38 weeks        3909         29.5%
39 weeks        6512         49.1%
40 weeks        1385         10.4%
41 weeks          505           3.8%
>= 42 weeks     113           0.9%

Then the investigators tracked the babies' outcomes.

They looked for:
death
breathing problems
hypoglycemia
severe newborn infection
seizures
hypoxis ischemic encephalopathy
CPR
signs of severe stress
admission to the neonatal ICU
hospitalization for 5 days or more

They found that babies born by elective repeat cesarean section before 39 weeks were at higher risk for having these problems.

babies born at:
37 weeks    15.3% had problems       had 2.1 times the risk of problems compared to 39 weeks
38                11.0%                                1.5
39                 8.0%                                 ----     
40                 7.3%                                 0.9
41               11.3%                                 1.4
>=42           19.5%                                 2.5

The researchers concluded from their study two things.

First, that elective repeat cesarean sections before 39 weeks is common (one-third of all repeat elective cesarean sections).

Second, earlier cesareans have an increased risk of neonatal complications.

So, what does all this mean to a pregnant woman trying to make decisions?
If there are no medical problems, this study suggests that she can minimize the risk of problems with baby by scheduling the cesarean section after reaching 39 weeks.

In real life, however, there are two situations I can think of that make it difficult to apply this study. First, if a woman really wants an elective repeat cesarean section, how does she know she isn't going to go into labor before 39 weeks? There would be pressure to have a cesarean section sooner rather than later to make sure she was really going to get an elective repeat cesarean section. This is the sort of decision that may seem easy for those of us who are not pregnant but can be excruciating for women who are.

Second, this study was based on trained reviewers looking at medical records. Unrecorded conversations between providers and patients may include soft indications. For example, if I tell a mother that baby feels big, I haven't officially diagnosed macrosomia on the record, but I implied it to the mother. This may be the final straw for a woman to decide on an early repeat cesarean. In this study, her case would still be considered an elective repeat cesarean section. The woman, however, may feel her cesarean is medically indicated. She may feel it is better to have the cesarean earlier than 39 weeks to avoid having a big baby. This study suggests that by doing this, the baby will be at increased risk for complications. Given the known inaccuracies of predicting birth weight, I think using the possibility of a big baby as a medical indication for cesarean section before 39 weeks is problematic but more common than suggested by this study.

The Newborn Hearing Test

Partial or complete hearing loss delays or prevents language, cognitive, and social-emotional development. Groups such as the National Association of the Deaf advocate testing before three months of age and starting family-centered intervention by six months of age. Without automatic testing, the average child with hearing loss is not discovered until over two years old. Parent and physician observation do not usually detect hearing loss even if profound.

To find infants with hearing loss sooner, California requires hospitals with intermediate or intensive care nurseries to offer testing before a baby goes home. Usually the test is done with the infant asleep in the nursery separate from the parents. Testing can also be done as an outpatient at a hospital or a physician’s office. Testing requires informed consent. Insurance companies may or may not cover newborn hearing tests. There are no good studies that show that testing every infant leads to better long term outcomes.

Two types of testing are available, otoacoustic emissions (OAEs) and auditory brainstem response (ABR). OAEs use the sounds that are reflected back from the ear to check for problems with the structures of the ear such as the eardrum, the ear canal, and the hair cells. A small probe placed in the ear records sounds from the ear over time. OAE testing can be done with the infant in your lap or nursing as long as baby is not vocalizing.  The equipment for OAEs testing is much less expensive than that for ABR testing.

ABR uses electrodes similar to those used for brain EEGs and cardiac EKGs. These stickers send information back to a computer that monitors brain activity in response to sounds. To have a normal ABR result, the outer ear structures, the auditory nerve, and the auditory pathways in the brain must all function. ABR testing requires baby to be very still.

Here is one home birth mother's point of view on newborn hearing tests.

In Fresno you can get outpatient hearing tests at these locations:

Community Regional Medical Center
Newborn Audiology
Tammy Vawter
2823 Fresno St, 3rd Floor
Fresno CA 93721
(559) 459-2807

Children’s Hospital of Central California
Audiology Services
(559) 353-6801

Valley Pediatric Medical Group
7130 N Sharon #101
Fresno CA 93720
(559) 436-8606

Central California Ear, Nose, and Throat Medical Group
1351 E Spruce Ave Suite 100
Fresno CA 93720
(559) 432-3303

Academy of Breastfeeding Medicine

The Academy of Breastfeeding Medicine is a worldwide organization of physicians who support breastfeeding. They have developed protocols that address some common newborn problems that may impact breastfeeding success. Here are some examples:

Protocol #15
Anesthesia and Analgesia for the Breastfeeding Mother

Anesthesia makes the patient unaware. Drugs used for induction of general anesthesia such as propofol, midazolam, etomidate or thiopental are only in the bloodstream for minutes. The same is likely true for anesthetic gases. The transport of these drugs into breastmilk is likely low to nil.

Analgesia reduces pain. Meperidine (Demerol) is consistently associated with infant sedation. Because the body breaks meperidine down into substances that hang around for a long time, transfer into milk and infant sedation can occur up to 36 hours after the dose.

Hydrocodone and codeine have been used in millions of breastfeeding mothers. Occasional cases of neonatal sedation have been documented, but these are rare and generally related to higher doses. Breastfeeding mothers should take just what is needed to control the pain.

Although morphine does transfer to breastmilk in low levels, the infant does not absorb it well. Fentanyl has extremely low levels in breastmilk. Sufentanil and remifentanil are likely similar to fentanyl in their impacts on breastfeeding. These drugs have not been associated with infant sedation.

Nonsteroidal anti-inflammatory drugs (NSAIDS) include ibuprofen (Motrin, Advil), ketorolac (Toradol), naproxen (Naprosyn, Aleve, Anaprox), and celecoxib (Celebrex). Ibuprofen, ketorolac, and naproxen interfere with the body's ability to clot and should be avoided if there is a bleeding problem. These drugs all have low levels in breastmilk and are not associated with sedation.

It is difficult to separate epidural analgesia out from all the other factors that cause breastfeeding problems. Epidural analgesia can include non-sedating medications such as bupivicaine as well as narcotics such as fentanyl. When epidural analgesia has been used for labor, particular care to provide mothers with good breastfeeding support and close follow-up after postpartum hospitalization should be taken.

Women have differing levels of pain tolerance. Pain that exceeds a woman’s ability to cope, or pain magnified by fear and anxiety, may produce suffering in labor. Suffering in labor may lead to dysfunctional labors, poorer psychologic outcomes, and increased risk of
postpartum depression, all of which may have a negative effect on breastfeeding.

Protocol #1:
Guidelines for Glucose Monitoring and Treatment of Hypoglycemia (Low Blood Sugar) in Breastfed Babies

For babies who have no symptoms, begin breastfeeding within 30 to 60 minutes of life and continue as frequently as baby requests. Recheck blood sugar levels. Avoid forced feedings. If blood sugar level remains low despite feedings, begin giving glucose intravenously. Breastfeeding may continue during IV glucose treatment.

For babies who have symptoms of low blood sugar, start giving glucose intravenously. Do not rely on oral feedings to correct extremely low sugar levels or if it is symptomatic. Encourage frequent breastfeeding.

Keeping the infant skin-to-skin with the mother to keep baby warm is easily done with an IV and lessens the calories a baby needs to maintain it's body temperature.

Newborn Medications

Vitamin K

Vitamin K prevents potentially life-threatening bleeding from vitamin K deficiency that occurs between 0.25% and 1.7% of healthy babies. Both a single injection (0.5 – 1.0 mg) at birth and a series of oral doses (1 – 2 mg) at birth, one week, and 3-4 weeks of life are available.

There are specific times in a newborn's life when bleeding due to vitamin K deficiency tends to occur. Early vitamin K deficiency bleeding, within the first 24 hours after birth, is very rare. It is usually related to a maternal vitamin K deficiency which can be caused by medication. Giving the baby vitamin K after birth usually can't prevent this type of bleeding. It is best treated by correcting the mother's vitamin K levels before the birth.

Classic vitamin K deficiency bleeding occurs two to seven days after birth and is most commonly seen in exclusively breastfed babies. Most infant formulas contain vitamin K supplements. Supplementing mother's intake of vitamin K does increase levels in breastmilk. Delayed cord clamping and avoiding cuts and bruises minimize the loss of clotting factors that contain vitamin K.

Late onset vitamin K deficiency bleeding occurs one to six months after birth and is usually associated with liver problems or medications. Sometimes, however, in Asian breastfed infants, it occurs for reasons that are not understood. The vitamin K injection given in hospitals is directed at preventing classic and late onset types of bleeding.

Most hospitals automatically provide a single injection of vitamin K at birth. You can also postpone the injection until after the initial period of alertness. You can also arrange to have the vaccine done at your pediatrician’s office or obtain a prescription for the oral doses to be given at home.

Antibiotic Eye Ointment

Both gonorrhea and chlamydia infections of the birth canal can be passed on to the baby at the time of birth. Because infections may have mild or no symptoms, women with infections may not know it. In the United States, chlamydial infections are more common than gonococcal infections.

Testing can be done during prenatal care by gently wiping the vagina or cervix with a cotton-tipped swab and sending it to a lab. Treatment is oral antibiotics for seven days and repeat testing later in pregnancy. 30 – 40% of babies born to moms with an active gonorrhea or chlamydia infection will develop an eye infection. Although chlamydial eye infections are generally less severe, gonococcal eye infections can lead to blindness or death without treatment. Before the use of 2% silver nitrate eye drops by Dr. Carl Crede in 1888, gonorrhea was the leading cause of blindness.

Today, hospitals automatically treat babies’ eyes with a single application of antibiotic ointment (erythromycin 0.5% or tetracycline 1%) as soon as they are born. Once the membranes have ruptured, even babies born by cesarean section risk infection. So they are also routinely treated in a hospital. Unless an antibiotic-resistant strain is present, the risk of gonococcal eye infection after antibiotic ointment preventative treatment is less than 1 out of 1000.

Chlamydial eye infections are not as responsive to antibiotic ointment prevention. Some researchers are now recommending povidone-iodine 2.5% solution. This treatment is also less irritating to baby’s eyes than silver nitrate drops or antibiotic ointments. There are no documented cases of resistance to povidone-iodine and it is also effective against gonorrhea.

You may choose to delay eye treatments until after baby goes to sleep to avoid blurring baby’s vision. Or you may choose to decline the treatment. If you do not want the treatment, remind the hospital staff as close to the time of birth as possible since this is not their usual routine.

Hepatitis B Vaccine

Hepatitis B is a virus that attacks the liver. Some people who are infected have no symptoms. Some people develop cirrhosis, liver failure, or liver cancer. With your permission, a blood test to check for infection can be done during pregnancy. Health care providers are required to report positive cases to the local health department.

Hepatitis B virus is transmitted through blood, semen, vaginal secretions or saliva. A mother with hepatitis can transmit the virus to her baby during birth. Approximately 5-6% of mothers with hepatitis B will transmit hepatitis to their baby. The risk is higher for mothers who have both hepatitis and HIV. Cesarean section has not been shown to decrease this risk.

The hepatitis B vaccine is a series of injections that can prevent a baby from becoming infected after exposure during birth. It is most effective when the first dose is given within 48 hours of birth.

Most hospitals automatically give the vaccine immediately after birth. You can also postpone the injection until after the initial period of alertness. You can also arrange to have the vaccine done at your pediatrician’s office.