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Published rates

W.H.O.: 1

15 % Maximum desirable rate of cesarean section

No benefit for mother and the fetus for medical reasons


1

World Health Organisation. Appropriate technology for birth. Lancet 1985;4367.

Unnecesary C- section ?

Why has the rate of cesarean delivery climbed so dramatically in the past 25 years?
1.

Lower tolerance for taking risks Fear of malpractice litigation Increased use of epidural anesthesia ?

2.

3.

4.

Increased use of electronic fetal monitoring


The convenience of physicians
Sachs BP et al., NEJM 1999;340:54 57

5.

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Who are involved ?


FETUS
MOTHER

Obstetricians

Childbirth

Health system

Midwives
Society

Obstetrical Uni-Hospital

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Factors involved in decision


1.
2. 3. 4. 5. 6. 7.

Fetal mortality and morbidity


Newborn health VBAC Cost Pelvic floor damage

Maternal mortality
Cultural factors Autonomy - C-section on demand?

8. Unnecesary C- section ?

Could C-S reduce fetal death rate?


5 times more frequent than SIDS Termination of pregnancy when fetal risks in tero are larger than the risks of the newborn: 1/500 Most of fetal deaths occur in non-malformed fetuses Womens preference: C-section of the risk is

> 1:4000 1
1

Cotzias C, et al., BMJ, 319,31 july 1999 Thornton E, et al., J Obstet Gynecol 1989;9:283-8

Unnecesary C- section ?

Factors involved in decision


1. 2. 3. 4. 5. 6. 7.

Fetal mortality and morbidity Newborn health VBAC Cost Pelvic floor damage Maternal mortality Cultural factors

8.

Autonomy - C-section on demand?

Unnecesary C- section ?

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


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

1: 664 forceps 1: 860 vacuum extraction 1: 907 c-section during labor 1: 1900 delivered spontaneously

1: 2750 c-section with no labor


Conclusion: The common risk factor for hemorrhage is abnormal labor

Unnecesary C- section ?

Factors involved in decision


1. 2. 3. 4. 5. 6. 7.

Fetal mortality and morbidity Newborn health VBAC Cost Pelvic floor damage Maternal mortality Cultural factors

8.

Autonomy - C-section on demand?

Unnecesary C- section ?

Costs of deliveries
Beth Israel Deaconess Medical Center, Boston, USA

Elective repeated cesarean delivery $ 7.700

Normal vaginal delivery


Intrapartum Cesarean:

$ 6.800
$ 10.000

Complication

Mother: + $ 4.000

Child: + $ 2.000

Unnecesary C- section ?

Factors involved in decision


1. 2. 3. 4. 5. 6. 7.

Fetal mortality and morbidity Newborn health VBAC Cost Pelvic floor damage Maternal mortality Cultural factors

8.

Autonomy - C-section on demand?

Unnecesary C- section ?

Pelvic floor

Urinary incontinence

Fecal incontinence
Sexual dysfunction Organ prolapse

Unnecesary C- section ?

Pelvic floor

Pudendal nerve damage


Soft tissue trauma The levator musculature trauma

Anal sphincter trauma

Unnecesary C- section ?

Reduction of pelvic floor damage

Minimizing forceps deliveries


Minimizing episiotomies

Allowing passive descent in the second stage


Selectively recomending elective cesarean

delivery
Davila GW, et al., Int Urogyneocl J 2001;12:289-291 Unnecesary C- section ?

Prevention of pelvic floor damage


Avoid labor Avoid passage of the fetus through the pelvis Shorten second stage Avoid routine episiotomy Forget the forceps specially in macrosomia

Repair perineal damage


Devine II, Contemporary Ob/Gyn 1999:119

Unnecesary C- section ?

Factors involved in decision


1. 2. 3. 4. 5. 6. 7.

Fetal mortality and morbidity Newborn health VBAC Cost Pelvic floor damage Maternal mortality Cultural factors

8.

Autonomy - C-section on demand?

Unnecesary C- section ?

Risk of maternal death


...the presumed increased risk of maternal death with elective cesarean delivery traditionally has been the most compelling reason to reject a policy of universal cesarean delivery or "cesarean on demand." However, good evidence is accumulating that this is no longer true; the maternal morbidity and mortality from elective cesarean delivery at term before the onset of labor appear to be similar to those associated with vaginal birth....
Hannah ME, Lancet 2000;356:1375-83. Unnecesary C- section ?

Factors involved in decision


1. 2. 3. 4. 5. 6. 7.

Fetal mortality and morbidity Newborn health VBAC Cost Pelvic floor damage Maternal mortality Cultural factors

8.

Autonomy - C-section on demand?

Unnecesary C- section ?

Factors involved in decision


1. 2. 3. 4. 5. 6. 7.

Fetal mortality and morbidity Newborn health VBAC Cost Pelvic floor damage Maternal mortality Cultural factors

8.

Autonomy - C-section on demand?

Unnecesary C- section ?

Cesarean section on demand

31% of female obstetricians would prefer a cesarean delivery for themselves 1

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

Unnecesary C- section ?

Autonomy

Is the governing principle in medicine

We respect with better eyes a womans right

to refuse a cesarean delivery

Wagner M et al., Lancet 2000;356:1677-80 Unnecesary C- section ?

EUROBS STUDY

Obstetricians attitude to a womans request for cesarean in a term uncomplicated delivery

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Patients Preference based on


Personal choice Fear of vaginal delivery Previous CS Previous traumatic delivery Previous intrapartum fetal death First child disabled Patient were a colleague

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Obstetrician's Rationale

Womans autonomy Avoid non compliance during delivery Avoid legal consequences

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Results

Patients choice-womans autonomy Cultural Medical paternalism Medical/quasi medical indication (not evidence based) Female gender Fear of litigation

Unnecesary C- section ?

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

Unnecesary C- section ?

Armed Forces-expectations

Heterogenous population Role of media Experiences of others Experiences of AMA Comparison with corporate hospitals Psychology of the patient

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Doctors View

Daycare obstetrics Manpower constraint Good trial of labor Overburdened staff Compliance with patients demand for a CS is not a rule Zero error syndrome Fear of litigation Female gender

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

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Has the primary CS rate increased?


CS rate Instrument delivery rate Fetal mortality/morbidity

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Caesarean Rate..

Year
1985 1987 1988

Total rate
11.1% 13.6% 15%

Primary CS rate
5.7% 10.6% 11.2%

1990
1994 1999 2001 2003 2004 2005 2006

11.8%
22% 36% 20% 26% 26% 29% 27%

8.4%
10.3% 26.3% 11.6% 15% 13% 14% 14%

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Where are we headed?


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

Unnecesary C- section ?

What can be done?

More involvement of AMA/specialists How? Needs to be seen More involvement of the patient Is it possible? Ideas of mid wives need to change Timely intervention Informing the patient-short and long term risks of operative delivery to be explained clearly

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Conclusion
...perhaps the time has come when the risks, benefits and costs are so balanced between cesarean section and vaginal delivery that the deciding factor should simply be the mothers preference for how her baby is to be delivered...
William Benson Harer
Unnecesary C- section ?

Conclusion
The cesarean section should not be used as an

indicator of quality of obstetrical care

Unnecesary C- section ?

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