Caesarean Study Ppt

Unnecesary C- section ?Unnecesary C- section ?Unnecesary C- section ?

Published rates

W.H.O.:W.H.O.: 11

• 15 %15 %

• Maximum desirable rate of cesarean Maximum desirable rate of cesarean

sectionsection

• No benefit for mother and the fetus for No benefit for mother and the fetus for

medical reasonsmedical reasons

11 World Health Organisation. Appropriate technology for birth. World Health Organisation. Appropriate technology for birth. Lancet Lancet 1985;436 7.1985;436 7.


Why has the rate of cesarean delivery climbed

so dramatically in the past 25 years?

1.1. Lower toleranceLower tolerance for taking risks for taking risks

2.2. Fear of malpractice litigationFear of malpractice litigation

3.3. IncreasedIncreased use of epidural anesthesia ?use of epidural anesthesia ?

4.4. Increased use of electronic fetalIncreased use of electronic fetal monitoringmonitoring

5.5. The convenience of physiciansThe convenience of physicians

Sachs BP et al., Sachs BP et al., NEJMNEJM 1999;340:54 – 57 1999;340:54 – 57


Who are involved ?

Obstetricians

FETUS MOTHER

Health system

Obstetrical Uni-HospitalMidwives

Society

Childbirth


Factors involved in decision

1.1. Fetal mortality and morbidityFetal mortality and morbidity

2.2. Newborn healthNewborn health

3.3. VBACVBAC

4.4. Cost Cost

5.5. Pelvic floor damage Pelvic floor damage

6.6. Maternal mortalityMaternal mortality

7.7. Cultural factorsCultural factors

8.8. Autonomy - C-section on demand?Autonomy - C-section on demand?


Could C-S reduce fetal death rate?

5 times more frequent than SIDS5 times more frequent than SIDS

Termination of pregnancy when fetal risks Termination of pregnancy when fetal risks in útero in útero

are larger than the risks of the newborn: are larger than the risks of the newborn: 1/5001/500

Most of fetal deaths occur in non-malformed Most of fetal deaths occur in non-malformed

fetusesfetuses

Women’s preference: C-section of the risk is Women’s preference: C-section of the risk is

> 1:4000 > 1:4000 11

Cotzias C, et al.,Cotzias C, et al., BMJ BMJ, 319,31 july 1999, 319,31 july 1999

11 Thornton E, et al., Thornton E, et al., J Obstet GynecolJ Obstet Gynecol 1989;9:283-8 1989;9:283-8





3.3. VBACVBAC

4.4. Cost Cost






“Effect of Mode of Delivery in Nulliparous Women on Neonatal Intracranial Injury”

1: 664 forceps 1: 664 forceps

1: 860 vacuum extraction1: 860 vacuum extraction

1: 9071: 907 c-section during labor c-section during labor

1: 1900 delivered spontaneously 1: 1900 delivered spontaneously

1: 27501: 2750 c-section with no labor c-section with no labor

Towner D et al., Towner D et al., NEJMNEJM 1999;341:23 1999;341:23

Conclusion:Conclusion: The common risk factor for The common risk factor for

hemorrhage is abnormal laborhemorrhage is abnormal labor





3.3. VBACVBAC

4.4. Cost Cost






Beth Israel Deaconess Medical Center, Boston, USA

ElectiveElective repeated cesarean delivery $ 7.700 repeated cesarean delivery $ 7.700

Normal vaginal delivery $ 6.800Normal vaginal delivery $ 6.800

Intrapartum Cesarean: $ 10.000 Intrapartum Cesarean: $ 10.000

ComplicationComplication

• Mother: + $ 4.000 Mother: + $ 4.000

• Child: + $ 2.000Child: + $ 2.000

Costs of deliveries





3.3. VBACVBAC

4.4. CostCost






Pelvic floor

Urinary incontinenceUrinary incontinence

Fecal incontinenceFecal incontinence

Sexual dysfunctionSexual dysfunction

Organ prolapseOrgan prolapse


Pudendal nerve damagePudendal nerve damage

Soft tissue traumaSoft tissue trauma

The levator musculature traumaThe levator musculature trauma

Anal sphincter traumaAnal sphincter trauma

Pelvic floor


Reduction of pelvic floor damage

Minimizing forceps deliveriesMinimizing forceps deliveries

Minimizing episiotomiesMinimizing episiotomies

Allowing passive descent in the second stageAllowing passive descent in the second stage

Selectively recomending elective cesarean Selectively recomending elective cesarean

deliverydelivery

Davila GW, et al., Davila GW, et al., Int Urogyneocl JInt Urogyneocl J 2001;12:289-291 2001;12:289-291


Avoid laborAvoid labor

Avoid passage of the fetus through the pelvisAvoid passage of the fetus through the pelvis

Shorten second stageShorten second stage

Avoid routine episiotomyAvoid routine episiotomy

ForgetForget the forceps specially in macrosomia the forceps specially in macrosomia

Repair perineal damageRepair perineal damage

Devine II, Devine II, Contemporary Ob/GynContemporary Ob/Gyn 1999:119 1999:119

Prevention of pelvic floor damage





3.3. VBACVBAC

4.4. CostCost






Risk of maternal death““...the presumed increased risk of maternal death with ...the presumed increased risk of maternal death with

elective cesarean delivery traditionally has been the elective cesarean delivery traditionally has been the

most compelling reason to reject a policy of universal most compelling reason to reject a policy of universal

cesarean delivery or "cesarean on demand." cesarean delivery or "cesarean on demand."

However, good evidence is accumulating that this is However, good evidence is accumulating that this is

no longer true; the maternal morbidity and mortality no longer true; the maternal morbidity and mortality

from elective cesarean delivery at term before the from elective cesarean delivery at term before the

onset of labor appear to be similar to those onset of labor appear to be similar to those

associated with vaginal birth....”associated with vaginal birth....”

Hannah ME, Hannah ME, LancetLancet 2000;356:1375-83 2000;356:1375-83.





3.3. VBACVBAC

4.4. CostCost









3.3. VBACVBAC

4.4. CostCost






Cesarean section on demand

31% of female obstetricians would prefer a 31% of female obstetricians would prefer a

cesarean delivery for themselves cesarean delivery for themselves 11

11 Al-Muffti et al. Al-Muffti et al. Eur J Obstet Gynecol Reprod Biol Eur J Obstet Gynecol Reprod Biol 1997:73:1-41997:73:1-4


Autonomy

Is the governing principle in medicineIs the governing principle in medicine

We respect with better eyes a woman’s right We respect with better eyes a woman’s right

to refuse a cesarean deliveryto refuse a cesarean delivery

Wagner M et al., Lancet 2000;356:1677-80Wagner M et al., Lancet 2000;356:1677-80


EUROBS STUDY

Obstetrician’s attitude to a woman’s request Obstetrician’s attitude to a woman’s request for cesarean in a term uncomplicated deliveryfor cesarean in a term uncomplicated delivery


Patient’s Preference based on

Personal choice Personal choice Fear of vaginal deliveryFear of vaginal delivery Previous CSPrevious CS Previous traumatic deliveryPrevious traumatic delivery Previous intrapartum fetal deathPrevious intrapartum fetal death First child disabledFirst child disabled Patient were a colleaguePatient were a colleague


Obstetrician's Rationale

Woman’s autonomyWoman’s autonomy Avoid non compliance during deliveryAvoid non compliance during delivery Avoid legal consequencesAvoid legal consequences


Results

Patient’s choice-woman’s autonomyPatient’s choice-woman’s autonomy CulturalCultural Medical paternalismMedical paternalism Medical/quasi medical indication (not Medical/quasi medical indication (not

evidence based)evidence based) Female genderFemale gender Fear of litigationFear of litigation


In principle, existence of clinical uncertainty In principle, existence of clinical uncertainty about alternative treatment strategies makes about alternative treatment strategies makes a good case for allowing the patient’s a good case for allowing the patient’s preferences to prevail.preferences to prevail.


Armed Forces-expectations…

Heterogenous populationHeterogenous population Role of mediaRole of media Experiences of othersExperiences of others Experiences of AMAExperiences of AMA Comparison with corporate hospitalsComparison with corporate hospitals Psychology of the patientPsychology of the patient


Doctor’s View… Daycare obstetricsDaycare obstetrics Manpower constraintManpower constraint Good trial of laborGood trial of labor Overburdened staffOverburdened staff Compliance with patient’s demand for a CS is not a Compliance with patient’s demand for a CS is not a

rulerule Zero error syndromeZero error syndrome Fear of litigationFear of litigation Female genderFemale gender


Adverse outcome in obstetrics inspite of best Adverse outcome in obstetrics inspite of best care is not accepted by anyone.care is not accepted by anyone.


Has the primary CS rate increased? CS rateCS rate Instrument delivery rateInstrument delivery rate Fetal mortality/morbidityFetal mortality/morbidity


Caesarean Rate……..

Year Total rate Primary CS rate

1985 11.1% 5.7%

1987 13.6% 10.6%

1988 15% 11.2%

1990 11.8% 8.4%

1994 22% 10.3%

1999 36% 26.3%

2001 20% 11.6%

2003 26% 15%

2004 26% 13%

2005 29% 14%

2006 27% 14%


Where are we headed?

Can we blindly follow the West?Can we blindly follow the West? Can we do CS on demand?Can we do CS on demand?


What can be done?

More involvement of AMA/specialists How? More involvement of AMA/specialists How? Needs to be seenNeeds to be seen

More involvement of the patient Is it possible?More involvement of the patient Is it possible? Ideas of mid wives need to changeIdeas of mid wives need to change Timely interventionTimely intervention Informing the patient-short and long term Informing the patient-short and long term

risks of operative delivery to be explained risks of operative delivery to be explained clearlyclearly


Conclusion

““...perhaps the time has come when the risks, ...perhaps the time has come when the risks,

benefits and costs are so balanced between benefits and costs are so balanced between

cesarean section and vaginal delivery that the cesarean section and vaginal delivery that the

deciding factor should simply be the mother’s deciding factor should simply be the mother’s

preference for how her baby is to be preference for how her baby is to be

delivered...”delivered...”William Benson HarerWilliam Benson Harer


The cesarean section should not be used as an The cesarean section should not be used as an

indicator of quality of obstetrical careindicator of quality of obstetrical care

Conclusion

Caesarean Study Ppt

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