Tuesday, April 26, 2011

C-Sections and Induced Labor: Don't Kick Out the Anesthesiologist

Full make-up? Did this woman about to give birth
 just perform Swan Lake? Maybe she's planning
on a dinner and a movie afterwards? Good luck.
Her OB-Gyn looks like she might need bi-focals.
Hold the scalpel and the Pitocin, but don't dismiss the anesthesiologist quite yet. 

Caesarean sections and induced labor don't much matter to a newborn's condition according to a new study out of upstate New York featured in the New York Times Science section (Childbirth: More Labor Interventions, Same Outcomes) and published in this month's Journal of Maternal-Fetal and Neonatal Medicine.  Rates of labor induction and primary cesarean delivery do not correlate with rates of adverse neonatal outcome in level I hospitals. I know, you were gonna read it after the kids go to sleep.  So forgive me for spoiling this cliff hanger.  

So Dr. J. Christopher Glantz, a professor of obstetrics at the University of Rochester checked out over 30,000 birth records from 10 upstate hospitals (without neonatal intensive care units).  He found that although rates of c-sections and inductions varied from institution to institution there were no differences in newborn condition in hospitals performing lots of these procedures versus few.  No differences appeared in terms of Apgar scores or need for ventilation assistance or intensive care. 

Sounds so convincing.   But of what? Interesting question.

Now some might be tempted to argue these results are proof induction and c-sections are preformed all too often.  If babies born via modern methods were as well off as others born the good old fashion way then it will be concluded the new fangled techniques didn't make a difference.  Some may go so far in proclaiming they were unnecessary in the first place.  If these procedures really improved a child's health (apparently mom's is not important here) - then we should see differences.

This study didn't compare babies born via c-section (or induction) to those born otherwise.  No, it compared whether health outcomes were linked to hospitals' induction/c-section rates.  Not the way I would have addressed the issue, but an easy method, rather simple once you have all the data.

But let's say that information is available and you have a lab full of motivated pre-med students. 

It's a good question whether induced or c-section babies should be better off or worse than their counterparts born otherwise. 

If the scalpel and Pitocin improve health and are medically necessary, then the babies should be better off - at least better off than the babies in similar conditions prior to birth.  Maybe as good as those who were good before going down the birth canal on their own. 

If the procedures are ineffective, do nothing, then the babies should be no different.

If they are potentially harmful, then worse.

If the medical procedures are medically unnecessary and non-harmful, there should be no differences.

If the procedures are medically unnecessary and harmful, then they should be...

You can see how terribly important it is to gather and account for the conditions of mom and baby before the birth.  It's complicated for sure, but necessary to draw any worthwhile conclusions.  Makes the routine practice of expectant moms being knocked out for the actual birth seem rather quaint, no?

Might we be too quick in pulling out some babies?

Perhaps but this pile of data is far from conclusive evidence a quick exit (or entrance) is worthless. It's difficult to argue anything here without a good accounting of critical factors related to birth, like why mom or doc decided to induce.  I'm frustrated and I don't have to write up a birth plan.

According to the NY Times even the study's author, Dr. J. (Julius? Jebediah? Jethrow?), "acknowledged that the study...was retrospective and could not control for all confounding factors."

Ya think? 

Another day, another lazy data dump here without many answers but plenty of loop holes.


doi/abs/10.3109/14767058.2010.514629

2 comments:

What Pale Blue Dot? said...

It doesn't really follow that the babies have to be better off for the procedures to have been effective. There isn't really a reason to suspect that need for interventions is a region-wide phenomenon and not an individual phenomenon. We cannot know whether the individual babies and mothers who received intervention would have been worse off without it, and that's not really something you can test unless you do set groups selected by the condition and then selectively use or deny intervention (which no one is going to do). All this shows is that these two interventions do not cause harm. And, frankly, given the timbre of the discussion around birth, I think that is a very successful answer.

Polly Palumbo, Ph.D. said...

Yes, well said, WPBD! That's right, it might be the moms and/or babes who got them (at least SOME of them) were in bad shape to begin with so the actual procedures made them look pretty average upon birth. So true, the "timbre of the discussion around birth" such that it is could use some sound evidence. Amen!