Correspondence

Elective Primary Cesarean Delivery

N Engl J Med 2003; 348:2364-2365June 5, 2003

Article

To the Editor:

Minkoff and Chervenak (March 6 issue)1 have omitted mention of a substantial, life-threatening risk associated with elective primary (and repeated) cesarean delivery. Bland2 and others3 have demonstrated that labor offers great benefits for the transition of the fetal lungs from fluid-secreting intrauterine organs to fluid-absorbing, air-breathing, extrauterine ones. A change from chloride excretion to sodium absorption by the pulmonary epithelium, mediated by β-adrenergic receptors, results in lungs that are far less susceptible to fluid retention, airway compression (by fluid “cuffs” around bronchioles), and air trapping — transient tachypnea of the newborn.

Although this condition is usually benign, it can result in delays in normal newborn accomplishments, a considerable oxygen requirement, and ultimately, persistent pulmonary hypertension of the newborn necessitating mechanical ventilation, inhaled nitric oxide, or extracorporeal membrane oxygenation. Levine et al.4 have defined an increase by a factor of nearly five in the rate of persistent pulmonary hypertension of the newborn among infants born by elective cesarean delivery, as compared with those delivered vaginally. This risk must be considered in any discussion regarding the subjection of all women and their babies to cesarean delivery. We suggest that elective cesarean deliveries be delayed until the onset of labor in order to reduce the risk of neonatal complications.

Roger E. Sheldon, M.D., M.P.H.
Marilyn B. Escobedo, M.D.
University of Oklahoma College of Medicine, Oklahoma City, OK 73190

4 References

1. 1

   Minkoff H, Chervenak FA. Elective primary cesarean delivery. N Engl J Med 2003;348:946-950
   Full Text | Web of Science | Medline

2. 2

   Bland RD. Loss of liquid from the lung lumen in labor: more than a simple “squeeze.“ Am J Physiol Lung Cell Mol Physiol 2001;280:L602-L605
   Web of Science | Medline

3. 3

   Norlin A, Folkesson HG. Alveolar fluid clearance in late-gestational guinea pigs after labor induction: mechanisms and regulation. Am J Physiol Lung Cell Mol Physiol 2001;280:L606-L616
   Web of Science | Medline

4. 4

   Levine EM, Ghai V, Barton JJ, Strom CM. Mode of delivery and risk of respiratory diseases in newborns. Obstet Gynecol 2001;97:439-442
   CrossRef | Web of Science | Medline

To the Editor:

Minkoff and Chervenak address the provocative issue of elective primary cesarean delivery, but the long-term maternal morbidity from subsequent elective cesarean delivery requires further clarification. Placenta accreta is now the primary reason for peripartum hysterectomy in subsequent pregnancies.1 This finding is attributed to increasing rates of cesarean delivery in the United States. Although the American College of Obstetricians and Gynecologists recently reported a rate of placenta accreta of 1 in 2500, data from our institution and other tertiary care centers demonstrate a higher rate, approaching 1 in 1000.2,3 Peripartum hysterectomy, a lifesaving procedure used for women with placenta accreta, carries the risk of additional long-term complications, such as hepatitis C associated with multiple blood transfusions.3,4

A woman with one previous cesarean delivery who chooses vaginal delivery for her next pregnancy requires special consideration. Her risk of uterine rupture is 1 in 192 during spontaneous labor, and the risk increases to 1 in 130 if oxytocin is used.5 The patient who desires elective primary cesarean delivery needs to be fully informed that future pregnancies with a “scarred” uterus can have catastrophic results.

David S. Cole, M.D.
Ashlesha K. Dayal, M.D.
Cynthia Chazotte, M.D.
Albert Einstein College of Medicine, Bronx, NY 10461

5 References

1. 1

   Dildy GA III. Postpartum hemorrhage: new management options. Clin Obstet Gynecol 2002;45:330-344
   CrossRef | Web of Science | Medline

2. 2

   Placenta accreta. ACOG committee opinion. No. 266. Washington, D.C.: American College of Obstetricians and Gynecologists, January 2002.
   

3. 3

   Zelop CM, Harlow BL, Frigoletto FD Jr, Safon LE, Saltzman DH. Emergency peripartum hysterectomy. Am J Obstet Gynecol 1993;168:1443-1448
   Web of Science | Medline

4. 4

   Kastner ES, Figueroa R, Garry D, Maulik D. Emergency peripartum hysterectomy: experience at a community teaching hospital. Obstet Gynecol 2002;99:971-975
   CrossRef | Web of Science | Medline

5. 5

   Lydon-Rochelle M, Holt VL, Easterling TR, Martin DP. Risk of uterine rupture during labor among women with a prior cesarean delivery. N Engl J Med 2001;345:3-8
   Full Text | Web of Science | Medline

Author/Editor Response

We appreciate the additional details provided by Dr. Cole and colleagues and Drs. Sheldon and Escobedo in regard to our discussions of potential respiratory complications for the child and complications of subsequent pregnancies for the mother in cases of elective primary cesarean delivery. We believe that their emphasis on risks related to these deliveries reinforces the two key points we tried to make: consent should be full and informed, and the evidence does not support the routine recommendation of elective cesarean delivery.

That said, we do not believe that these additional counseling points should tip the balance away from allowing a woman who has been fully informed of the risks by her obstetrician to have her request for elective surgery honored. We agree with Sheldon and Escobedo that transient tachypnea of the newborn is linked to the timing and mode of delivery and that the risk of persistent pulmonary hypertension may also be increased in the setting of elective surgery. However, we are hesitant to ascribe an increase by a factor of five in the risk of persistent pulmonary hypertension of the newborn to the use of elective surgery, if that surgery is performed at a gestational age that accords with the guidelines of the American College of Obstetricians and Gynecologists, since it was not uniformly performed at such a gestational age in the study they cite.1 We would also await empirical data before agreeing with their supposition that a need for extracorporeal membrane oxygenation may be anything more than an extremely rare complication of elective cesarean delivery.

In regard to the points raised by Cole et al., as we noted in our article, we recognize that the complications associated with elective surgery may not be sustained until a woman's next pregnancy. However, insofar as uterine rupture with a vaginal delivery after a cesarean delivery is concerned, we suspect that many women who would choose an elective cesarean delivery for a first pregnancy would not request a vaginal delivery for succeeding pregnancies. In any event, the rates of rupture that Cole cites are relevant not only to women who undergo elective cesarean delivery, but to the 23 percent of American women who undergo cesarean delivery for other reasons as well.

Howard Minkoff, M.D.
Maimonides Medical Center, Brooklyn, NY 11219
hminkoff@maimonidesmed.org

Frank A. Chervenak
Weill Medical College of Cornell University, New York, NY 10021

1 References

1. 1

   Levine EM, Ghai V, Barton JJ, Strom CM. Mode of delivery and risk of respiratory diseases in newborns. Obstet Gynecol 2001;97:439-442
   CrossRef | Web of Science | Medline