Monday, 21 March 2016

Caesarean section or vaginal birth?

Which is best for a baby with trisomy 18?



This question comes up all the time on trisomy groups. It came up for us. Our initial plans were to have a caesarean section, but we eventually decided to opt for vaginal birth after a lot of discussion with different professionals and taking all our circumstances into account. What I would say is that there is no clear-cut answer as to which is the best option for a baby with trisomy 18.

However, there are things that should be taken into consideration:
  1. Labour and birth is a highly risky time for babies with T18. Depending on which study you read, around 40% of babies die during labour without monitoring and interventions.
  2. Whichever type of delivery you opt for, if you receive monitoring and intervention as per any other baby, there is a good chance you'll end up with an emergency caesarean anyway. A high proportion of babies in all studies end up with a c-section. You should always be prepared for a c-section.
If your primary aim is for a live birth, DO NOT commit to a vaginal birth without appropriate monitoring and guarantees of intervention in the event of fetal distress. If you have doubt in your healthcare provider's ability or willingness to offer this, it may be safer for your baby to opt for elective caesarean section.



Things to consider when making your decision


What are your goals?


What is your goal for your baby's birth? For most parents who are opting for full treatment for their baby, the goal is for their baby to be born alive with the best chance for ongoing survival. They also don't want to put themselves/their partner at unnecessary risk, but will take some level of risk to maximise the chance for their baby.

This is not everyone's goal. If your goal is to maximise time spent with your baby alive and you are not opting for full treatment, an elective caesarean section may be the best way to achieve this. It eliminates the risks of labour to babies with T18. However, there may be limitations on how active and mobile you will be to enjoy the time with your baby, and there is a slightly higher risk to the mother. Some people in this situation may choose to opt for a monitored vaginal birth, but need to be aware that there is a chance that, if their baby becomes distressed and is delivered by emergency caesarean section, they may be too compromised to survive long without full resuscitation.

Some parents who are opting for 'palliative care only' may simply have the goal to minimise risk to the mother, and allow their baby's life to take its own course. They are open to the fact that they may have a stillbirth. They opt for a vaginal birth with no plans for intervention for the sake of the baby, although they will accept interventions for the mother. In this case, the primary decision is how much monitoring you wish for. Many families opt for no monitoring at all, feeling that it creates unnecessary stress. Some choose to listen briefly, just before delivery, to prepare for a live birth or stillbirth; some choose to listen occasionally in order to discover whether their baby has passed away; others choose full monitoring with no plans to intervene if there is a problem (although this is rare).

However, assuming your goal is to maximise your baby's chance of ongoing survival following a live birth, there are further considerations when choosing the mode of birth:
  • The health risks and benefits of caesarean section and vaginal birth
  • The mother's obstetric (pregnancy and birth) history
  • The mother's medical history
  • Any pregnancy complications
  • The baby's presenting complications
  • Other things that matter to you
  • The healthcare provider's ability and willingness to provide what you want

What should be stated first is that, in the absence of any complications, a straightforward vaginal birth is likely to have some health advantages for a mother and baby, including a baby with trisomy 18. However, there are so many complicating factors that straightforward vaginal birth is often an ideal rather than a reality, especially for babies with trisomy 18.


Health risks and benefits of caesarean section versus vaginal birth


NICE guidance on caesarean sections suggests that:

For mothers


Planned vaginal births are associated with:
  • reduced hospital stay
  • reduced risk of hysterectomy associated with postpartum haemorrhage
  • reduced risk of cardiac arrest 
Of course, the last two outcomes are vanishingly rare, and many women would not choose to give them much consideration in their decision making.

Planned caesarean sections are associated with:
  • reduced perineal and abdominal pain during birth 
  • reduced perineal and abdominal pain at 3 days postpartum
  • reduced injury to the vagina
  • reduced risk of an early postpartum haemorrhage
  • reduced risk of obstetric shock

There is no difference between the different modes of birth in:
  • perineal and abdominal pain at 4 months postpartum
  • injuries to bladder or ureter
  • injury to cervix
  • surgical injuries
  • pulmonary embolism (a blood clot in the lungs)
  • wound infections
  • uterine rupture
  • the mother needing intubation or ventilation

Studies were unclear as to whether caesarean section increased the risk of:
  • maternal death
  • deep vein thrombosis
  • needing a blood transfusion (due to blood loss)
  • infection overall
  • hysterectomy overall 
  • anaesthetic complications


For babies


Planned vaginal births are associated with:
  • reduced chance of admission to NICU
Babies born by planned caesarean section may be more likely to develop breathing difficulties and need admission to the NICU. This should be a consideration for a baby with T18 who is predisposed by T18, and possibly other health issues, to develop respiratory distress. Planned vaginal birth, even if it results in emergency c-section, may decrease the levels of respiratory distress in these babies, although there is no evidence to support this hypothesis.

There is no difference between the different mode of births in:
  • Hypoxic Ischaemic Encephalopathy (HIE) caused by hypoxia during labour
  • intracranial haemorrhage (bleeding in the brain, usually caused by trauma)
  • neonatal respiratory morbidity (although it is unclear why more c-section babies need NICU admission)

It was unclear whether mode of birth affected:
  • neonatal mortality (death of the baby in the first 28 days) (one study showed that more babies died after elective caesarean, one after vaginal birth)
  • Apgar score less than 7 at 5 minutes (a sign that a baby is likely to be in a poor condition)

In short, outcomes for healthy babies are minimally affected by mode of delivery, with a slightly increased risk of NICU admission for babies born by planned caesarean. Some rare serious outcomes for the mother are reduced for planned vaginal birth, but some short term outcomes like pain are reduced by elective caesarean section.


The mother's obstetric history


Some mothers will be strongly urged by their healthcare providers to consider an elective caesarean section. This would usually include women who have had more than one previous caesarean; it may include women who have had complicated births in the past - for example, women with a history of shoulder dystocia, 'failure to progress' or having had significant 3rd- or 4th-degree tearing in a previous birth - while women who strongly want a vaginal birth in these circumstances can of course opt for one. It is worth discussing the risks and benefits for you with your healthcare provider. Trisomy 18 factors, such as baby's small size, may affect the likelihood of these complications occurring again in this delivery, or they may not.

Some women who have had a traumatic labour or birth in the past may prefer to opt for a caesarean section. Occasionally a woman who has had a traumatic caesarean in the past may wish to avoid one. However, with the high risk of caesarean section being needed by a baby with trisomy 18, it is worth discussing your fears with your healthcare providers even if opting for a planned vaginal birth.


The mother's medical history


Some women will be advised to opt for elective caesarean section due to their own health conditions.
Women who are HIV positive with a high viral load, women who develop a first case of genital herpes simplex virus during the third trimester of pregnancy, and some women with complicated health issues such as cardiac problems may be advised to avoid vaginal birth.


Any pregnancy complications


Elective caesarean section may be advised for a woman who's baby is not head-down (or who has twins and the first baby is not head-down), for higher order multiples (triplets or more), or where a woman has a low-lying placenta (placenta praevia).

This should be no different for mothers expecting babies with trisomy 18. However, a healthcare professional whose goal is to minimise morbidity for the mother may sometimes advise a mother whose baby with T18 is presenting breech (bottom- or feet-first) to deliver vaginally. They are not concerned about the baby's outcomes and are trying to minimise complications for the mother. While you might choose to opt for a vaginal breech birth, that is in itself associated with morbidity for the baby. For a baby with T18, this may be a stress too far. If you choose this route and your goal is to maximise survival chances, make sure you have good monitoring in place and a plan for intervention agreed, including emergency c-section, if fetal distress is identified.


Some pregnancy complications are more common in trisomy 18


Most babies with trisomy 18 will be identified as being small for gestational age. Before accepting this label it is worth looking at the T18 fetal growth charts and discussing with your healthcare provider as to whether your baby is actually small for a baby with T18. There is no evidence that elective caesarean sections improve outcomes for babies with T18.

Many mothers develop polyhydramnious (too much amniotic fluid) in pregnancy. This increases the risk of the baby not coming head-first, which may suggest that a caesarean section would be the best option. It also increases the risk of the cord coming before the baby (cord prolapse), which can be life-threatening for the baby. A caesarean section before labour may minimise the risk of this outcome. Some women may choose antenatal admission, so that if their waters break and the cord comes first, they can opt for caesarean section immediately. A monitored vaginal birth in hospital is possible, but there is a risk of a crash (extreme emergency) caesarean section if a cord prolapse does happen.

Problems with placental function are common with T18. These may be confirmed by poor dopplers or signs of fetal distress on CTG (known as NST by the US people). Often, families choosing a planned vaginal birth can opt for an induction in this case, but sometimes the risk to the baby is too high, or they are already in significant distress and a caesarean section is the best option. Regular fetal monitoring late in pregnancy can detect fetal distress, and hopefully avoid a stillbirth.


The baby's presenting complications


Babies with trisomy 18 present with a wide variety of associated health problems. These include:
  • cardiac problems
  • spina bifida
  • diaphragmatic defects
  • omphalocele
  • kidney anomalies
  • cleft lip and palate 
  • lung issues such as CPAM
Some of these will have no impact on delivery choices: for example, whether or not your baby has a cleft lip and palate, or a single kidney, or cystic kidneys, should make no difference to delivery options.

In the cases of omphalocele and spinal defects, the evidence remains unclear, with research suggesting little difference in outcomes between different modes of delivery, but theoretical benefits suggested for elective caesarean sections. One study suggested that all babies with giant omphaloceles should be delivered by caesarean section. Some babies with some forms of spina bifida will present with hydrocephalus, which would mean a caesarean section. Again, theoretically, with an open spinal defect, caesarean section should avoid damage and improve outcome, but research does not support this. However, the available research is limited. If your baby has one of these anomalies, then it should be taken into account when choosing mode of delivery. Avoid healthcare professionals who believe that, if a baby has T18, elective caesarean section to improve outcome in these cases is not warranted. Your baby should be considered in the same way as any other baby with these difficulties but without an underlying chromosomal cause.

Most babies with cardiac problems can be born vaginally; however, they have a higher risk of emergency caesarean section due to fetal heart rate anomalies during labour. This is in addition to the high risk of emergency caesarean section from T18. Occasionally, healthcare providers will advise a caesarean section for a baby with congenital heart disease. It is worth asking your healthcare provider what they would advise for a baby with your baby's heart condition but without T18.

Babies with lung issues - eg. pulmonary hypoplasia caused by a diaphragmatic defect, or CPAM - may benefit from labour and vaginal birth, as there is a possible advantage to lung function in a baby having experienced some labour, and even more if they are born via an uncomplicated vaginal birth. The research, however, is far from conclusive.


Other things that matter to you


Some people are strongly attracted to one mode of birth or another. They may feel that they have always wanted to give birth 'normally'; dreamed of labouring and giving birth, and would feel cheated by a caesarean. Others may have a fear of childbirth, dread the pain and mess they associate with vaginal birth, and have always imagined themselves choosing a c-section. These feelings are still important when you are expecting a baby with T18, and should be taken into account and acknowledged.

Vaginal birth generally is associated with a quicker recovery. You are likely to get to NICU to visit your baby quicker; you are likely to be more mobile and active. If your baby is very unwell, you are more likely to be able to spend time with them and make the decisions about withdrawal of care. However, if you plan a vaginal birth and need a crash caesarean section, there is a possibility of a general anaesthetic, which could delay all this. Whichever mode of delivery you choose, it is worth discussing with your neonatal and obstetric team how they would handle a very unwell baby, if you are unable to get down to the NICU. It may be that they could bring them up to you and set up a 'NICU' in your room for your baby while you withdraw care (we were offered this in pregnancy), or work out a way to get you down to the NICU on your bed.


The healthcare provider's ability and willingness to provide what you want


If you want to maximise your baby's survival chances and you are opting for a planned vaginal birth, you need to be able to trust that your healthcare provider will:
  1. monitor you closely from very early on in labour,
  2. recognise signs of fetal distress,
  3. respond to fetal distress promptly, and
  4. be happy to perform an emergency caesarean if your baby is in distress.
Our obstetric team were wonderful in this way. We had a low threshold for caesarean and they were responsive to this. We had a clear clinical birth plan agreed by the consultant midwife and obstetrician, which was circulated before labour and was in our notes. It was respected. When I asked for a c-section, four contractions before Rumer was born, they got out the consent forms without hesitation. This is what you want. You also need to trust that they will act without you asking them, that they understand your wishes and will respond to them. If you are not sure about this; if you think they may be fobbing you off or may be slow to respond to fetal distress; if you think they are not listening and are opposed to your approach - that may be a reason for choosing elective caesarean. It is worth discussing your wishes in detail with your healthcare provider so that you have a good idea of what they are offering.

In the UK, NICE guidelines suggest that maternal-request elective caesareans should be given, so you should be able to ask and be given one or be referred to someone who will perform one. However, this is guidance, not law, so some hospitals will refuse. It is worth asking for a second opinion and discussing the NICE guidance and reasons for your request with them. If they continue to refuse, pursuing a formal complaint may be necessary.


Conclusion


So, to sum up:
  • What is your goal for this labour and birth?
  • Is there anything in your past pregnancies and births that would suggest that a caesarean section would be best?
  • Is there anything in your medical history that suggests a particular mode of birth?
  • Are there any pregnancy complications that suggest that a vaginal or caesarean birth would be better?
  • Does your baby have any conditions that mean a particular type of birth would be best?
  • Are your healthcare providers willing to offer you what you want, and do you trust them to act in accordance with your wishes?

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