HOW TO REDUCE CS RATES? Aboubakr Elnashar

Benha university Hospital, Egypt

Aboubakr Elnashar

CONTENTS

1. BENEFITS OF CS

2. RISKS OF CS

3. BALANCING RISKS AND BENEFITS

4. RISKS OF CS AND VAGINAL DELIVERY

5. CSR

6. REASONS FOR THE INCREASE IN CSR

7. INTERVENTIONS TO DECREASE CSR

8. INTERVENTIONS HAVE NO INFLUENCE ON

CSR

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1. BENEFITS OF CS

1. Mother:

Relative safety

Accommodating the concerns and wishes

Avoiding damage to the pelvic floor

2. Fetus:

Reduced risk

3. Obstetrician:

Convenience to in terms of timing& duration of delivery

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2. RISKS OF CS

I. Immediate

Anesthetic complications: shock, cardiac arrest,

acute renal failure, assisted ventilation

Blood loss

Bowel or bladder injury

Amniotic or air embolism

Scalpel damage to the baby: 1-2% (Smith 1997)

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II. Post operative risks

infection, or in-hospital wound disruption

Hge that requires hysterectomy or transfusion,

Venous thromboembolism

Hematomae

was increased 3-fold for CS as compared with VD

(2.7% vs 0.9%, respectively).

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III. Risks in subsequent pregnancy

Placenta previa &/or accreta

placenta previa: increases with each subsequent CS,

1% with 1 prior CS

3% with 3 prior CS.

Placenta accreta: 10-fold increase over the last

decades

after 3 CS: placenta previa will be complicated by

placenta accreta in 40%.

Rupture of a uterine scar

Recurrent CS

increases the likelihood of most CS related

complications, including Aboubakr Elnashar

VI. Remote risks: Infertility {adhesions} Bowel obstruction

V. Neonatal complications

{combination of complications}

Neonatal RDS/Wet lung

Neonatal intensive care unit admission

Perinatal death.

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3. BALANCING RISKS AND BENEFITS

When CS is necessary:

lifesaving for mother and baby.

For placenta previa or uterine rupture:

CS is firmly established as the safest route of

delivery.

Over half of CS: unnecessary (A consumer advocacy group and The Public Health Citizen's Research

Group)

For low risk pregnancies:

CS has greater risk of maternal morbidity and

mortality than VD

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4. RISKS OF CS AND VAGINAL DELIVERY (ACOG , 2014)

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C.S Vs vaginal delivery:

1. Risk to the mother's health: greater

2. Maternal recovery: slow

3. Costs: heavy economic& social price.

4. Mortality rate: 2-4 times of vaginal births.

5.No decline in cerebral palsy or shoulder dystocia

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5. CSR

Rapid increase from 1996 through 2011 without clear evidence of concomitant decreases in maternal or neonatal morbidity or mortality: raises significant concern that CS is overused. USA: 23%: 1991 32%: 2007 Canada: 18%: 1991 31%: 2008 Australia:14%: 1995 29%: 2005 Italy: In Campania: 60% 2008 births In Rome:44%- 85% in some private clinics. Brazil: up to 80%

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CSR in Arab countries (Khawaja et al, 2009)

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Variation across

Arab countries:

ranging from a low of 15% to a high of nearly 55%

Nulliparous term singleton vertex

Hospitals: 10-fold variation

Clinical practice patterns affect CSR.

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In Egypt

MOH hospital:

Normal Vaginal Deliveries (30) = 42.8%

Cesarean sections (40)= 57.2%

90% previous CS

0% instrumental delivery

Private Hospitals:

≥90%

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60% of all CS are primary cesarean

Indications for primary CS, in order of frequency

1. Labor dystocia: 34%

2. Abnormal or indeterminate (formerly,

Non reassuring) fetal heart rate tracing: 23%

1+2 = 57%

3. Fetal malpresentation: 17%

4. Multiple gestation: 7%

5. Suspected fetal macrosomia: 4%

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6. REASONS FOR THE INCREASE IN CSR

Elective CS:

Previous CS: VBAC has decreased

from a high of 28% in 1996 to 8% in 2007 USA,

1989:

PET: CSR for PET have increased, whereas IOL

have declined.

Breech: Most are now delivered by CS.

{fetal injury

infrequency with which a breech presentation meets

criteria for a labor trial, almost guarantee that most

will be delivered by CS. Breech (already 12% of all

C/S)

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Multiple pregnancy: increased

{increased frequency of infertility & the effect of its

therapy}.

Elderly PG: The average maternal age is rising,

and older women, especially nulliparas, are at

increased risk of cesarean delivery. an increased

CS rate. Rates of labor induction continue to rise, and induced labor, especially among

nulliparas, increases the cesarean delivery rate

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Obesity: has risen dramatically, and obesity

increases the cesarean delivery risk

Maternal medical conditions: more women with

chronic health problems (diabetes heart disease)

are successfully carrying a baby.

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Nonmedical factors.

Patient:

Patient request

Concern for: vaginal birth

Pain

Pelvic floor injury

Fetal injury

Women are having fewer children: greater percentage of births are among nulliparas, who are at increased risk for CS.

Socioeconomic status

Convenience

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Obstetrican:

Individual philosophy

Malpractice litigation related to fetal injury during spontaneous or operative vaginal delivery: Fear of litigation & cost of litigation.

The threat of malpractice: altered the training of new obstetricians: little exposure to managing birth complications

Financial gain: A linear correlation between fee & CS

Convenience

The effect of Obstetric catastrophe:– CSR increased after VB with poor outcome from 21% to 29%

(Turrentino 1999).

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Selective CS:

Overuse of CS for failure to progress (dystocia)

Increased interventions before active labor

established.

The frequency of instrumental delivery: forceps and

vacuum has decreased

Increased use of electronic fetal monitoring :

When physicians observe disturbing patterns on the monitor they tend to respond conservatively with a "better safe than sorry" attitude which results in CS.

CS performed primarily for “fetal distress” comprises only a minority of all such procedures. In many more cases, concern for an abnormal or “nonreassuring” FHR tracing lowers the threshold for CS.

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Reasons are

Complex

Medicalization

Fear of Litigations

Maternal request

Demographics/ Ethnicity

Increasing Maternal

Age

Smaller Family size

Doctors’ decision

Privatisation of Care

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7. INTERVENTIONS TO DECREASE CSR

CSR can be lowered without any adverse effect on neonatal outcome

The Obstetrician:

single most important factor that will reduce CSR is physician motivation to make a change.

Should be provided with EB clinical practice

guidelines for CS

Acuity-adjusted physician-specific CSR

Supplementary fees for performing VBAC.

Second opinion for performing all except

emergency CS.

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Organizational, Hospital actions

Changing the local culture and attitudes of

doctors regarding the interventions to reduce

CSR across

indications

across community

academic settings.

CSR was reduced by 13% when

audit and feedback were used

CSR was reduced by 27% when:

audit and feedback

second opinions and

culture change.

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Elective: 1. Standardize indications for CS& inductions

Many indications for CS, especially prior to labour,

can& should be questioned:

Macrosomia

Maternal age

Parity

CPD

Breech .

Shoe size, maternal height& estimations of fetal

size (US or clinical examination) do not accurately

predict CPD: should not be used to predict "failure to

progress" during labour.

(Grade B) (National Guideline Clearinghouse, 2005)

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Herpes simplex virus

CS is not recommended for women with a history of herpes

simplex virus infection but no active genital disease during

labor.

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Women with an uncomplicated pregnancy should be offered induction of labour beyond 41 w because this reduces the risk of perinatal mortality and the likelihood of CS

(NICE Clinical Guideline 2004) (grade A )

The routine use of early US to calculate gestational age significantly reduces the incidence of post-term pregnancy

(grade A) Cochrane Review, 2010

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External cephalic version:

uncomplicated singleton breech pregnancy at 36 w should be offered ECV.

Exceptions

in labour

uterine scar or abnormality

fetal compromise

ruptured membranes

vaginal bleeding

medical conditions . (Grade A).

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2. VBAC

should be offered and encouraged for all patients unless there is a separate complicating risk factor that justifies CS.

safer for both mother and infant, in most cases, than is routine elective CS, which is major surgery.

Patient acceptance of VBAC is important

{it would be unethical to insist on a VBAC trial in a patient adamantly opposed to such a trial}.

(II-2A)

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Selection criteria :

One low-transverse CS

Clinically adequate pelvis

No other uterine scars or previous rupture

Availability of anesthesia and personnel for

emergency CS Continuous electronic fetal monitoring.

(II-2A)

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Contraindications

1. Patients at high risk for uterine rupture.

2. Prior classical or T-shaped incision or other

transfundal uterine surgery

3. Contracted pelvis

4. Medical or obstetric complication that precludes

vaginal delivery

5. Inability to perform emergency CS

{unavailable surgeon, anesthesia, sufficient staff, or

facility} (II-2A)

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3. Maternal request

Clinician: Not on its own an indication for CS Specific reasons for the request should be explored, discussed, and recorded (GPP ) has the right to decline a request for CS in the absence of an identifiable reason. The woman’s decision should be respected and she should be offered referral for a second opinion.

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Public:

Health awareness

Education

Media involvement

Patient:

Benefits and risks of CS compared with vaginal

birth should be discussed and recorded.

A fear of childbirth: counseling (cognitive behavioral

therapy) {:reduced fear of pain in labour and shorter

labour}.

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Selective: 1. Continuous labor and delivery support

presence of continuous one-on-one support during

labor and delivery:

improved patient satisfaction

significant reduction in CSR

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2. Correct diagnosis of labour

The diagnosis of labor is made within 1 hr of presentation.

Spontaneous contractions at least 2/15 min &

at least 2 of the following:

Complete effacement of cervix

Cervical dilation 3 cm or greater

SROM (NGC,2004)

3. Routine amniotomy should be discouraged

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4. A partogram with a 4-hour action line should be used to monitor progress of labour of women in spontaneous labour with an uncomplicated singleton pregnancy at term

(grade A).

5. Consultant obstetricians should be involved in the decision making for CS

(Grade C)

6. Use of electronic fetal monitoring should be restricted to high risk pregnancy and better understanding of the fetal monitor & what actually constitutes fetal distress

(grade B ) National Guideline Clearinghouse April 2005

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8. INTERVENTIONS HAVE NO INFLUENCE ON CSR (Grade A) National Guideline Clearinghouse April 2005

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