PQCNC SIVB LS1 C-Section Overview

8/7/2019 PQCNC SIVB LS1 C-Section Overview

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What Do the National Data Tell Us?


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32.3 in 2008!


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0

5

10

15

20

25

30

35

2001 2003 2005 2007 2008

North Carolina

Wake County

Orange

Mecklenburg


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0

5

10

15

20

25

30

PRIMARY CESAREAN RATE 2008 (Not identical to NTSV Rate)


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0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

Primary Cesarean Ranking in North Carolina

2 1020 43 45 47 49 51 61 73 85 88


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Maternal request Medical-legal concerns Increasing age of pregnant women Increasing complications in pregnancy Maternal obesity Provider preference Induction of labor protocols Training of providers Increased payment for CS v Vaginal Birth VBAC standards
mailto:[email protected]


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Cesarean Birth in the US: Epidemiology, Trends and OutcomesClinics in Perinatology June 2008 McDorman, et al

Rates of no indicated risk CesareansSurrogate for maternal request
mailto:[email protected]


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AMA 2003malpracticecrisis states: Arkansas Connecticut Florida Georgia

Illinois Kentucky Mississippi Missouri Nevada NJ NY NC

Ohio Oregon Penn Texas Washington West Virginia Wyoming

Of the five states with highest rates of CS, four are among AMAs 2003malpractice crisis states Of 19 malpractice crisis states, four in highest CS rate group, eight insecond highest group; five in middle group; two in second lowest group


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Declerq et al: No evidence to supportincreasing rates of maternal health problemsas significant cause of rising CS rates

Difficult to disentangle from maternal age-related increases in CS rates

Treat medical problems medically; surgicalproblems, surgically

Robert Cefalo


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BMI < 30 BMI 30 &39.9 BMI 40Oxytocin duration if induced 6.5 hr 7.7 hr 8.5 hr

Time in active labor 14.9 hr 16 hr 19.3 hr

Time in active labor if del vag 14.4 hr 15.2 hr 17.8 hr

Birth Weight 3286 3399 3489

CS 21.3% 29.8% 36.5%

CS for FTP 12.4% 12.0% 22%

36 week of greater, Para 3, singletons; secondary analysisof an RCT

Effect of maternal obesity on duration & outcomes of PGCervical ripening and labor induction. Pevzner et al, Obstetrics &Gynecology, Dec 2009


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No differences: EGA at birth, low 5 min Apgar, congenitalmalformations, intubation of infant, LOS in NICU, PPV

All maternal complications in obese diabetic v non-diabetic motherBaron et al.Journal of Maternal Fetal Neonatal Medicine. 2010; 8; 906-913.

34.9 35Induction 17% 29.4%

Prior CS 10.4% 15.0%

Cesarean 15.9% 26.2%

OR Time 56.4 min 65.2 min

Surgical site infx 3.3% 13.8%

Macrosomia 14.6% 28.6%Apgar@1


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CS rates in privately insured vs publically fundedpatients Closer relationship between doctor/patient therefore

may be harder to withhold a cesarean

Older population in private hospitals

Racial disparities favor private situation Higher rates of cesarean deliveries before

midnight

Different practice styles

Non-random distribution of patients with private doctorsExplaining sources of payment differences in US Cesarean Rates: Why do

privately insured mothers receive more cesareans than mothers who are notprivately insured? Grant D. Health Care Management Science , 2005.


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Increased rate of induction National Center for Health Statistics 2003

Percent of IOL among all U.S. births: 1989 -- 8%

2003 -- 21.6 %

1.31 OR for CS if IOL vs. spontaneous labor Bryant et al; Ped and perinatal epidem. 2009

International analysis in 9 countries looking atclassification of CS, >47,000 births evaluated 38% of all CS in induced nulliparous womenBrennan et al. Comparative analysis of international cesarean delivery rates

using 10-group classification identifies significant variation inspontaneous labor. AJOG 2009

Induction of Labor


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Among patients admitted1-2 cm dilatedOverall Foley (7) Cytotec(1) Cervidil(8) NoRipeningVaginal 49 2 1 6 40

CS 1st

Stage13 2 0 2 9

CS 2nd

Stage2 3 0 0 2

74% Vaginal 28%Vaginal

100%Vaginal

75%Vaginal

78%Vaginal

Among 1st stage c-sections: 5/13 were at 1-3 cmand average birth weight was 2915 grams with alllatent phase CS done for FTP

Sample of data from one hospital inPQCNCs 39 Weeks Project


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1992-2001 at a single hospital in the UK No change in demographics of patients,

birthweight, documented malposition

Increased preference for vacuum over forceps

in 2nd stage: O.2 VE/1 Forceps (1992)1.9 VE/1 Forceps (2001)

Increase failure of operative vaginal delivery

attempts Decreased number of attempts over all

Changing trends in operative deliveryperformed at full dilation over a 10 yrperiod. J Ob GYN 2010 May, Loudon

Provider Training


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Increased reimbursement for CS v vaginal birthlikely not a big factor:

Increasing reimbursement by $1000 for CSassociated with little more than 1% increase inCS rates in model

Physician Financial Incentives and CesareanDelivery: New conclusions from thehealthcare cost & utilization project. DarrenGrant. Journal of Health Economics 2009.


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1985: 5%

1996: 28.3%

2006: 8.5%

NIH 2010 consensus conference: Concernsover liability have a major impact on thewillingness of physicians & healthcare

institutions to offer TOL.


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Hospitals capable of emergency cesarean withresources immediately available

TOLAC not contraindicated with twins,unknown scar if likely LTCS, two prior CS, lowvertical scar

ECV, induction (no cytotec) reasonableoptions

Most women with one prior LTCS should becounseled about VBAC and offer TOLAC


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http://www.bsc.gwu.edu/mfmu/vagbirth.html Increased likelihood of success

Prior vaginal birth Spontaneous labor

Decreased likelihood of success Recurrent indication for initial CS (Dystocia) Increased age Non-white ethnicity EGA > 40 Preeclampsia Short interpregnancy interval Increased neonatal birth weight

Increased risk of uterine rupture Single layer closure with prior surgery Interpregnancy inteval < 18 months Varying data on uterine wall thickness measured at 37-38

weeksnot ready for prime time
http://www.bsc.gwu.edu/mfmu/vagbirth.htmlhttp://www.bsc.gwu.edu/mfmu/vagbirth.html


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Neonatal Respiratory Morbidity RatesNeonatal Length of Stay

LeastSuccessTOL

CS withLabor

CS withoutLabor

FailedVBAC

Most


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Index pregnancy

Peripartum hysterectomy Primary CS v vaginal delivery:

OR 6.48 Repeat CS v vaginal delivery:

OR 3.69 Peripartum hysterectomy and

cesarean delivery: a population-

based study. Stivanello. Act ObGyn Scan 2010 March

Endometritis 7-10% rates

Wound Infections 5-15%

Post Partum Hemorrhage dueto atony, requiring transfusion

Bateman, Anethesia and Analgesia,May 2010


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NSVD Op. Vag CS no Labor CS w/laborTTN 2.5% 3% 6-7% 5%

RDS 1% 1% 5% 3%

IVH 0.2% 0.1% 0.6% 0.4%

Injury 2% 12% 0.8% 2%

Why higher risk of IVH with CS with NO labor?Those at higher risk for IVH get a CS?CS not as atraumatic as we think?

Why higher risk of neonatal injury with operativedelivery?

Initially declined but over 8 years, rate increasedAssumed to be due to operator experience


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Abnormalplacentation

by prior CS

Abnormalplacentation

with previa

# ofprior CS Clark1985(n=29)MFMU2006(N=91)

None 5% 3.3%

One 24% 11.0%

Two 47% 40%

Three 40% 61%

Four orMore

67% 67%

# of priorCS % of 143None 0.2

One 0.3

Two 0.6

Three 2.3

Four 2.3

Five ormore

6.7


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Maternal Mortality Elective repeat C/S 13.4/100,000

TOL 3.8/100,000


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NTSV(Nulliparous, term, singleton, vertex)


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Nulliparous, > 37 weeks, Singleton, Vertex

OBIndications

for CS

CS byMaternalRequest

NTSV


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Patient education regarding normal course oflabor

Await spontaneous labor

Avoid inductions with unfavorable cervix

Effective cervical ripening using same technique Induce >41 weeks

Admit patients in active labor, not prodromal

Standardize effective pitocin protocol

Labor support

Be patient with prodromal labors


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PQCNC SIVB LS1 C-Section Overview

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