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Editor’s comment: Prof. Dan Farine: Towards normal birth – but at what cost by Hans Peter Dietz and Stuart Campbell

I read with interest the clinical opinion paper “Towards normal birth – but at what cost” by Hans Peter Dietz and Stuart Campbell that was published in the October edition of the American Journal of Ob/Gyn. The article is interesting for a variety of different reasons; the authors seem to be passionate about the topic. They provide well thought and well researched references to support their arguments; most practicing obstetricians can relate to the fact that often patients are biased towards CD (both ways) and that proper education and informed consent are very time consuming and in certain setting are very difficult to provide.

I agree with most of the argument presented but I would like to make several other points and provide my outlook on other ones. First, not all CS are made the same. The most practical classification is probably the one proposed by Robson. I was adopted by the Canadian SOGC and recently by FIGO. Its use allows a different framework for advising primipara, multipara and VBAC.

The use of an informed consent – in my center we had an elaborate consent form for VBAC. The patients who were encouraged to have a VBAC and/or wanted it were asked to sign a consent form outlining the risks. About 2/3 changed their mind by reading the consent. At the time we were disappointed as it “sabotaged” our attempts to increase our VBAC rate.

I am not sure that most readers know what is the risk of a compromised baby following labour in their centers. The reference I like most was derived by Silver in an American MFM study. He found that the risk is 1:1,000 for vaginal deliveries and an additional 1:000 for VBAC. In a survey we performed many years ago most women thought these were reasonable risks. However, for them personally it was too high. The information we have is often incorrect and skewed. I will mention two examples. The first is the rate of CS by request. Many databases classify them under psychological reasons and not for what they really are – a patient wish. In some other studies there is no distinction between patients who wish a CD and another acceptable indication and those without such an indication. The other is defining VBAC – a friend of mine in a major teaching center in the USA explained to me that he does VBAC “for at least 30 minutes”.

The economic analysis is probably inaccurate. Patients with elective CS stay in my center for 2 days similarly to those with vaginal deliveries. The length of stay is longer for the vaginal delivery as labour takes at least a day and non elective CD is more likely to have a longer stay.

There are some good medical reasons to opt for a vaginal delivery. One is the risk of invasive placenta. The paper by Silver showed that this risk is significantly increased starting with the 4th CD . However, the large number of CDs made this major complication from an extremely rare event about 20-30 years ago to a common complication nowadays. The risk for the baby maybe also increased. There is good data linking caesarean birth to several possible long term risks for the baby that include diabetes, asthma allergies etc.
I like this Clinical opinion as it is outlined from the perspective of clinical obstetrics. The arguments and the literature presented are current and relevant to the issue that is probably the most important in obstetrics.

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Commentaries by Editor Prof. Jim Thornton