New guidelines for the scheduled Cesarean

A new recommendation to perform elective Cesarean sections at 39 weeks or later, has been set forth by the American College of Obstetricians and Gynecologists. This comes on the heels of a study conducted by the Eunice Kennedy Shriver National Institute of Child Health and Human Development, which included 13, 258 participants and encompassed multiple large academic centers.

The study, to be published in the January 8, 2009 edition of NEJM found that babies born at 37 weeks had twice the likelihood of such complications as respiratory distress requiring mechanical ventilation, sepsis and low blood sugar. These all require attention from the Neonatal ICU and are potentially lethal. The risk decreased modestly to 1.5 times that of normal at 38 weeks. This was surprising, as the previous standard of care recommended elective delivery at 38.5-39 weeks. Therefore, in the absence of any compelling reason to deliver a patient at an earlier gestation, the firm recommendation is that elective cesarean section and/or induction be initiated at 39 weeks of pregnancy. Further, ACOG went on to say that if delivery is contemplated prior to 39 weeks, an amniocentesis should be performed to determine fetal lung maturity.

In recent years, we have seen the percentage of cesarean sections performed increase dramatically. In 2001, a large study found that vaginal deliveries had higher complication rates, like infection, than did cesarean sections. Based upon these findings, two recommendations were made: (1) Previously, any woman whom had had a previous c-section and could document a horizontal incision on the UTERUS (not the abdomen) should be offered a trial of labor for her subsequent pregnancies, so as to minimize the risk of surgery to the patient. However, at this point, the new standard of care recommended repeat cesarean sections for anyone whom had undergone a previous section. Even if the indication for the original cesarean was not likely to present itself again, a repeat elective c-section was the standard recommendation. (2) More incredibly, the new findings and standards empowered women to request and receive a cesarean without any other indication except that she preferred not to labor. The concerns regarding cesarean section at all include: maternal morbidity. The mother is at risk for infection, hemorrhage, dangers of transfusion, bladder and/or bowel injury and life-threatening complications. These are all within the initial 72-96 hours following the delivery. However, years later, the patient remains at risk for bowel obstruction and hernia formation due to aberrant scarring of the abdominal wall and cavity. Further, in many cases, once a patient undergoes a cesarean, she is likely to always be counseled to have more. Her surgical risk increases with every foray into the abdominal cavity.

This last study focuses upon the second set of concerns, and those are fetal. Pre-mature delivery carries with it the risks of: neo-natal respiratory distress syndrome, which can lead to chronic pulmonary disease; sepsis; acute bowel disease and low blood sugar. This study showed that even at 37 weeks, when most fetuses are believed to have achieved maturity, a significant percentage will go on to be pre-mature, whether delivered vaginally or by c-section. Physicians and patients must be careful not to schedule elective deliveries prior to 39 weeks for purposes of convenience. Common reasons for early delivery may include accommodating the work schedule of a loved one; trying to ensure that delivery will be performed by their own physician as opposed to a covering practitioner. While the temptation and urge to do this are understandable, there is a significant risk that is taken when deliveries are performed between 37 and 39 weeks of pregnancy.