Caesarian Delivery

CAESARIAN CAESARIAN DELIVERYDELIVERYBY

Dr. Malleswar Rao Kasina, MD,DGO.

HOD & CSS, Dept. of GynObs,ESI Hospital, Sanathnagar, Hyderabad, AP,

India

BYDr. Malleswar Rao Kasina,

MD,DGO.HOD & CSS, Dept. of GynObs,

ESI Hospital, Sanathnagar, Hyderabad, AP, India

Cesarean Childbirth Overview

Cesarean delivery, also known as cesarean section, is a major abdominal surgery involving 2 incisions (cuts),

One is an incision through the abdominal wall and the second is an incision involving the uterus to deliver the baby.

Cesarean delivery, also known as cesarean section, is a major abdominal surgery involving 2 incisions (cuts),

One is an incision through the abdominal wall and the second is an incision involving the uterus to deliver the baby.



History : Legend has it that the Roman leader Julius Caesar was delivered by this operation, and the procedure was named after him.

How often used : The rate for cesarean delivery increased steadily from 4.5% in 1965 to 21% in 1998.

The most frequent reasons for The most frequent reasons for performing a cesarean delivery are performing a cesarean delivery are discussed below.discussed below.

1 1 Repeat cesarean delivery:Repeat cesarean delivery:There There are 2 types of uterine incisionsare 2 types of uterine incisions——a a low transverse incision and a low transverse incision and a vertical uterine incision. vertical uterine incision.

Cesarean Childbirth Cesarean Childbirth CausesCauses


1a) A low transverse uterine incision is the approach of choice.

1b) A vertical incision on the uterus (low or high) may be used for delivering preterm babies, abnormally positioned placentas, pregnancies with more than one fetus, and in extreme emergencies.


1a In the last 20 years, studies have shown that women who have had a prior cesarean section with a low transverse incision may safely and successfully go through labor and have a vaginal delivery in later pregnancies. (VBAC)


1b In about 10% of women with vertical uterine incisions, their uterus will rupture (break open).

The uterus may rupture even before labor begins in up to 50% of these women.

Uterine rupture can be Uterine rupture can be dangerous to the fetus

even if delivery is even if delivery is accomplished immediately accomplished immediately

after a uterine rupture. after a uterine rupture.

Uterine rupture can be Uterine rupture can be dangerous to the fetus

even if delivery is even if delivery is accomplished immediately accomplished immediately

after a uterine rupture. after a uterine rupture.

2 Previous cesarean deliveries: Women with a prior history of more than 1 low transverse cesarean section, a trial of labor (TOL) is not an option, a repeat Cesarean delivery is the choice.


3 Lack of labor progression: If the woman is having adequate contractions but no change in the cervix beyond 3 cm dilation or the woman is unable to deliver the fetus despite complete dilation of the cervix and "adequate" pushing for 2-3 hours, cesarean delivery may be performed.


In a normal pregnancy, the baby is In a normal pregnancy, the baby is positioned head down in the positioned head down in the

uterus. uterus.


4 Abnormal position of the fetus & Placental causes :

i) Breech deliveryii) Oblique lieiii) Persistent Occipitoposterior positioniv) Deflexed Head (cord round the neck)v) Abruptio placentavi) Placenta praevia

C-section - : Indications C-section - : Indications


5 Fetal status: Continuous fetal heart rate monitoring in labor has not improved birth outcomes as once expected.


6 Emergency situations: If the woman is severely ill or has a life-threatening injury or illness with interruption of the normal heart or lung function, she may be a candidate for an emergency cesarean section.


7 Elective sterilization: A desire for elective sterilization is not an indication for cesarean delivery.

C-section : Procedure-1 C-section : Procedure-1

When the C-section When the C-section is planned, the is planned, the doctor may order doctor may order regional anesthetics regional anesthetics (a spinal or an (a spinal or an epidural), which epidural), which numbs only the numbs only the lower portion of the lower portion of the body. body.

C-section : Procedure-2C-section : Procedure-2

In non-emergency C-In non-emergency C-sections,sections, a horizontal a horizontal incision (a bikini cut) across incision (a bikini cut) across the abdomen, just above the the abdomen, just above the pubic area. pubic area.

In an emergency In an emergency situation,situation, a vertical cut, from a vertical cut, from below the navel to just above below the navel to just above the pubic area. A vertical cut the pubic area. A vertical cut allows quicker access to the allows quicker access to the baby baby


A vertical uterine A vertical uterine incisionincision causes less causes less bleeding and better bleeding and better access to the fetus, but access to the fetus, but renders the mother renders the mother unable to attempt a unable to attempt a vaginal delivery (must vaginal delivery (must have another repeat C-have another repeat C-section) in the future. section) in the future.


If you end up If you end up with a horizontal with a horizontal uterine incisionuterine incision, you , you will have the option of will have the option of either going through a either going through a trial of labor (TOL) or trial of labor (TOL) or electing a repeat c-electing a repeat c-section. section.


The reason for the The reason for the differences between the differences between the two is that patients with two is that patients with vertical uterine incisionsvertical uterine incisions have a much higher chance have a much higher chance of rupturing the uterus (8-of rupturing the uterus (8-10%) in the future 10%) in the future pregnancies, compared to pregnancies, compared to only 1% in those with only 1% in those with horizontal incisions. horizontal incisions.


Finally, the Finally, the surgeon cuts through surgeon cuts through the amniotic sac the amniotic sac enclosing the baby. enclosing the baby. He then allows the He then allows the amniotic fluid to amniotic fluid to escape. escape.



Cesarean Childbirth-Cesarean Childbirth-Possible ComplicationsPossible Complications

* Excessive bleeding: This is the most common complication of a cesarean delivery and may be caused by intrapartum and/or postpartum bleeding.


* Infection: The risk of infection of the uterus is much higher after cesarean delivery than after vaginal delivery.

Infection of the skin incision is much more common than infection in the incision made in the uterus, although they often occur together.


* Clots: Blood clots can form in the pelvis or the leg.

Therefore, it is imperative that if you deliver by cesarean section, you must get up and walk within 24 hours after the operation.


* Urinary function and bladder injury: Urinary retention after Cesarean

due to bladder atony could be relieved by urethral catheter for 24 hours.

Bladder injury during Cesarean can occur inadvertently.


* * Bowel function and bowel injury:Bowel function and bowel injury: Typically, bowel function after a Typically, bowel function after a cesarean section returns quickly. cesarean section returns quickly. Unrecognized bowel injury may occur Unrecognized bowel injury may occur occasionally and should be managed occasionally and should be managed appropriately.appropriately.



* * Prolonged hospital stay: Prolonged hospital stay:

When compared with normal When compared with normal vaginal delivery, Cesarean delivery vaginal delivery, Cesarean delivery requires 5 to 6 days hospital stay.requires 5 to 6 days hospital stay.


* Anesthesia & pain medications: Commonly, spinal or epidural

anesthesia is administered.

After surgery, oral and injection drugs can be used to help control the pain.

An evidence based update on An evidence based update on the technique of LSCSthe technique of LSCS

Recommended by WHO Recommended by WHO Reproductive Health Library as Reproductive Health Library as Minimally Invasive Method for a Minimally Invasive Method for a commonest surgical procedure commonest surgical procedure

done Worldwide.done Worldwide.

Cesarean Delivery Cesarean Delivery –– Ancient Ancient Medical HistoryMedical History

Evidence based Cesarean delivery-Evidence based Cesarean delivery-Misgav Ladach TechniqueMisgav Ladach Technique

Caesarean Section has been a part of human culture since ancient times and there are tales in both western and non-western culture of this procedure.

From the time when this procedure resulted in 100% maternal mortality, it has traveled a long distance acquiring many changes in the technique, anesthesia, sutures, antibiotics, indications that today we can say that maternal mortality per se because of LSCS is negligible Many modifications were put forward – some were here to stay, while others just faded away.


Micheal Stark : Director Misgav Ladach Hospital,

Israel “a refuge for the oppressed”


Steps Of Cesarean Section:

Abdominal entry : Joel Cohen’s incision /\ Midway between

umbilicus & symphysis pubis. Separation of recti easy


Principles :

Behind Joel Behind Joel –– Cohen incision as well as other steps are - the Cohen incision as well as other steps are - the approach to handling the muscles blood vessels and nerves approach to handling the muscles blood vessels and nerves

They are treated like the strings on the musical instruments, where They are treated like the strings on the musical instruments, where

the more distant you move from the insertion, the easier is the lateral the more distant you move from the insertion, the easier is the lateral

stretching due to elasticity, and therefore the damage is reduced.stretching due to elasticity, and therefore the damage is reduced.


Why ?

Pfannenstiel incision takes longer to make and Pfannenstiel incision takes longer to make and

longer to repairlonger to repair

Many bleeding vessels have to be controlledMany bleeding vessels have to be controlled

More difficulty in repeat LSCS More difficulty in repeat LSCS

More adhesionsMore adhesions


Steps Of C - Section:

Skin & sub-cutis cut

Incision in fat only in the middle 1 inch

Cut the rectus sheathalso in middle 1 inch


Steps Of C - Section: Extend the incision on

either side with scissors; like a tailor running a semi opened scissors to cut cloth

This will ensure a cut also the fiber of the sheath


Steps Of C - Section:

Muscles are separated in the middle & peritoneum punctured with fingers

All the three – peritoneum, muscle & the fat are pulled apart to allow adequate opening


Principles :Because of the placement of the incision where Because of the placement of the incision where

the fascia is not attached and moves freely over the fascia is not attached and moves freely over the muscles, there is no need to separate the the muscles, there is no need to separate the fascia from the muscles.fascia from the muscles.

Tissues are separated along connective tissue fault

lines (Langer’s lines), thus healing more completely

and rapidly


• Abdominal Packs are not used Doyen’s retractor to expose lower segment Cut the visceral peritoneum about 1-1.5 cms above the

bladder fold with knife Cut the uterus in the middle of the opened space in

peritoneum with knife

• Stretch the uterine opening as needed Deliver the child and placenta

• Exteriorize the uterus


• Start Suturing the edges form near to far

• Non-locking continues stitch

• Additional stitches only if bleeding presents

• Clean Peritoneal cavity of debris


• Rectus sheath is sutured in the form of near-far, far-near pattern

• Non-locking continues stitch


• Skin: 2-3 stitches deep mattress silk stitches

• Space in between allows draining of secretions


• Quick recovery Post operative pain – quite less Fewer adhesions Bladder not a problem in subsequent CS

• Less Blood loss

• Smaller scar with less induration


Adopting Joel-Cohen techniques of opening the abdomen performing manual manipulations, minimizing the use of instruments and suturing.

• ConciseConcise

• Very simple Very simple

• Very speedyVery speedy

Results are Results are –– self self evidentevident

- Misgav – Ladach method - Misgav – Ladach method (Stark 1996) (Stark 1996)


Principles : -Principles : - Unnecessary steps are simply not done.Unnecessary steps are simply not done. No interruptions are necessary for hemostasis

or swabbing Whole procedure is performed with a

continuous flow of movement, each step leading naturally to the next.


Time

More rapid - very short in timeMore rapid - very short in time

Theatre time and op. time Theatre time and op. time –– reduced reduced

Total op. time 18 to 20 min - 30-50% lessTotal op. time 18 to 20 min - 30-50% less


Other benefits

Complete healingComplete healing

Less short term complications such as hemorrhage, 250ml less.

• Febrile morbidity (7.7% vs. 19.8% )

• Post op. adhesions less (6.3% vs. 28%)


Women Women

Regained controls and recovered more rapidly Regained controls and recovered more rapidly

and were better able to breast feed and care of their new and were better able to breast feed and care of their new born.born.

Reduced pain and early ambulationReduced pain and early ambulation

Reduced scarring.Reduced scarring.



COST benefits

Cost beneficial Cost beneficial

Suture 2.92 ≈ 3 Vs 4.14 ≈ 4Suture 2.92 ≈ 3 Vs 4.14 ≈ 4

15 euros less costly (In European countries) 15 euros less costly (In European countries)


Technique of CS : Issues Exteriorization of uterus

• Two layer uterus closure

• Peritoneal suturing Routine antibiotics

• Uterotonics/Oxyticics


Technique of CS : Issues

• Regional Vs. General anesthesia

• Indwelling vs. intermittent catheter

• Lateral tilt to operation table

• Manual removal of placenta – Deprecated

• Post-operative wound drainage


Extra abdominal vs. intra abdominal repair of uterine incision

6 trials 1221 cases of Emergency + Elective CS Outcome measures: Blood loss, Sepsis, Costs,

Satisfaction etc.

• Marginal drop in febrile morbidity in exteriorization

group

• Hematocrit drop similar

• Sepsis similar


Peritoneal Closure Author’s ConclusionAuthor’s Conclusion

There was improved short-term postoperative outcome if the peritoneum was not closed

Long term studies following CS are limited, but data form other surgical are reassuring. There is at present no evidence to justify the time taken and cost of peritoneal closure


Abdominal Wall Closure

6 trials, 1853 cases 6 trials, 1853 cases

No difference if subcutaneous tissue sutured or not ,in terms of infection, hematoma, or serious discharge

Antibiotic prophylaxis for CSSmaill F, Hofmeyer GJ,

From The Cochrane Library , Issue 1, 2006.

Author’s ConclusionAuthor’s Conclusion

The reduction of endometritis by 2/3rd to 3 quarters and a decrease in wound infections justifies a policy of recommending prophylactic antibiotics to women undergoing elective or non-elective CS

Both Ampicillin & 1st generation cephalosporin's are similar in reducing postoperative endometritis.There is no added benefits in utilizing a more brad spectrum agent or a multiple dose regimen. There is a need for an appropriately designed randomized trial to test the optimal timing of administrating (immediately after the cord is clamped vs. pre-operative)


Lateral tilt for CSChichester, WilkinsinC, Enkin MW

From The Cochrane Library , Issue 1, 2006.


There is not enough evidence from these trials to evaluate use of tilt during CS

Early compared with delayed oral fluids and food after CS

Mangesi L, Hofmeye GJ (From The Cochrane Library , Issue 1, 2006.)


There was no evidence form the limited randomized trials reviewed, to justify a policy of withholding oral fluids after uncomplicated CS. Further research is justified

Visit Visit www.rhlibrary.com

FINALLY FINALLY Surgical technique

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

Who are involved ?

FETUS MOTHER

Childbirth

Who are involved ?

Obstetricians

FETUS MOTHER

Health system

Obstetrical Uni-HospitalMidwives

Society

Childbirth

Published ratesPublished rates

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

– 15 %15 %

– Maximum desirable rate of cesarean sectionMaximum desirable rate of cesarean section

– 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.

Factors involved in decisionFactors 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?




3.3. VBACVBAC

4.4. Cost Cost





Cotzias C, Paterson-Brown S, Fisk N. BMJ, 319,31 july Cotzias C, Paterson-Brown S, Fisk N. BMJ, 319,31 july 19991999

Weeks Nº of pregnancies Prospective Risk of fetal death

35 164 860 1:366 36 162 603 1:407 37 158 171 1:474 38 149 181 1:529 39 127 160 1:617 40 93 828 1:680 41 39 316 1:606 42 10 328 1:565 43 1 883 1:465

““Unexplained fetal deaths”Unexplained fetal deaths”

Could C-S reduce fetal death rate?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 in

útero 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

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

Could C-S reduce fetal death rate?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 fetusesMost of fetal deaths occur in non-malformed fetuses

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 Effect of Mode of Delivery in Nulliparous Women on Neonatal Intracranial InjuryWomen 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





All c-sections

Primary c-section

VBAC

Frequency of cesarean section, primary cesarean and vaginal birth post-c-section between 1989 - 2001

Martin JA, Martin JA, et al., et al., National Center for Health StatisticsNational Center for Health Statistics. 2002 . 2002

RecomendationsRecomendations

The most conservative recomendations.The most conservative recomendations.

– ACOG Technical Bulletin. Vaginal delivery after a previous cesarean birth. ACOG Technical Bulletin. Vaginal delivery after a previous cesarean birth.

• Int J Gynecol ObstetInt J Gynecol Obstet 48:127 – 129; 48:127 – 129; 1995.1995.

– ACOG Vaginal birth after a previous cesarean. ACOG Vaginal birth after a previous cesarean.

• ACOG Practice BulletinACOG Practice Bulletin N° 5:1 – 8; N° 5:1 – 8; 1999.1999.

VBACVBAC

Over 1000 reports: not one RCTOver 1000 reports: not one RCT

VBACVBAC

Over 1000 reports: not one RCTOver 1000 reports: not one RCT

Economic forces rather than patient Economic forces rather than patient

well-being, are driving the goal of fewer well-being, are driving the goal of fewer

cesarean sections ? cesarean sections ? 11

1 1 Clark S., et al., Clark S., et al., Am J Obstet Gynecol Am J Obstet Gynecol 2000;182:599-6022000;182:599-602




3.3. VBACVBAC

4.4. Cost Cost





Costs of deliveriesCosts of deliveries

CesareanCesarean delivery:delivery:

– Costs more than a vaginal delivery Costs more than a vaginal delivery

– Longer hospital stay Longer hospital stay

– Use of an operating room.Use of an operating room.

LaborLabor unit:unit: a prolonged and difficult labor, even when it a prolonged and difficult labor, even when it

results in a vaginalresults in a vaginal delivery, is more costly to an institution delivery, is more costly to an institution

than a cesarean deliverythan a cesarean delivery..

Beth Israel Deaconess Medical Center, Boston, USABeth 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

Costs of deliveries

Beth Israel Deaconess Medical Center, Boston, USABeth 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 floorPelvic 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


Pudendal nerve damagePudendal nerve damage

Soft tissue traumaSoft tissue trauma

The levator musculature traumaThe levator musculature trauma

Anal sphincter traumaAnal sphincter trauma

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

““...neurophysiologic studies have demonstrated the etiologic ...neurophysiologic studies have demonstrated the etiologic role of parturition-related nerve damage in development of role of parturition-related nerve damage in development of pelvic floor disfunction...”pelvic floor disfunction...”11


Reduction of pelvic floor Reduction of pelvic floor damagedamage

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 deliverySelectively recomending elective cesarean delivery

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

Prevention of pelvic floor Prevention of pelvic floor damagedamage




3.3. VBACVBAC

4.4. CostCost





Risk of maternal deathRisk 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 most elective cesarean delivery traditionally has been the most

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

delivery or "cesarean on demand." However, good delivery or "cesarean on demand." However, good

evidence is accumulating that this is no longer true; the evidence is accumulating that this is no longer true; the

maternal morbidity and mortality from elective cesarean maternal morbidity and mortality from elective cesarean

delivery at term before the onset of labor appear to be delivery at term before the onset of labor appear to be

similar to those associated with vaginal birth....”similar to those associated with vaginal birth....”Hannah ME, Hannah ME, LancetLancet 2000;356:1375-83 2000;356:1375-83.




3.3. VBACVBAC

4.4. CostCost





Cultural phenomena - BrazilCultural phenomena - Brazil

All birth are attended by obstetriciansAll birth are attended by obstetricians TrainingTraining Doctors work in the public and private health Doctors work in the public and private health

systemsystem Status of c-section: modern and technicalStatus of c-section: modern and technical Women’s body are perceived as sexual than Women’s body are perceived as sexual than

maternalmaternal Genitals are perceived for sexual activity than Genitals are perceived for sexual activity than

for childbearingfor childbearing Nuttall C., et al., Nuttall C., et al., BMJBMJ 2000;320:1072 2000;320:1072




3.3. VBACVBAC

4.4. CostCost





Cesarean section on demandCesarean 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

World wide debate continues on role of World wide debate continues on role of Cesarian Delivery on Maternal Cesarian Delivery on Maternal Request[CDMR].Request[CDMR].

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

Cesarean section on demandCesarean 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

Italian law mandates that women be given the Italian law mandates that women be given the

option of an elective cesarean, and about 4% option of an elective cesarean, and about 4%

of pregnant women choose it. of pregnant women choose it. 22 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

22 Tranquilli AL, et al., Tranquilli AL, et al., Am J Obstet GynecolAm J Obstet Gynecol 1997;177:245-246 1997;177:245-246

AutonomyAutonomy

Is the governing principle in medicineIs the governing principle in medicine

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

refuse a cesarean deliveryrefuse a cesarean delivery

Nobody is interested in respecting woman’s Nobody is interested in respecting woman’s

desire to refuse vaginal deliverydesire to refuse vaginal deliveryWagner M et al., Lancet 2000;356:1677-80Wagner M et al., Lancet 2000;356:1677-80

Autonomy and informed Autonomy and informed consentconsent

““...performing cesarean section for non ...performing cesarean section for non

medical reasons is ethically not medical reasons is ethically not

justified....”justified....”Committee for the Ethical Aspects of Human ReproductionCommittee for the Ethical Aspects of Human Reproduction

and Women’s Health of and Women’s Health of FIGO (1999)FIGO (1999)

ConclusionConclusion

““...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 delivered...”preference for how her baby is to be delivered...”

William Benson HarerWilliam Benson Harer

Thanks you for your Attention !

Dr.Malleswar Rao Kasina, expresses

E-mail : [email protected]

Caesarian Delivery

Documents

cesarean childbirth

cesarean childbirth

repeat cesarean delivery

prior cesarean section

emergency cesarean section

breech delivery

vaginal delivery

vertical incision