Professional Documents
Culture Documents
W.H.O.: 1
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.
5.
Unnecesary C- section ?
Obstetricians
Childbirth
Health system
Midwives
Society
Obstetrical Uni-Hospital
Unnecesary C- section ?
Maternal mortality
Cultural factors Autonomy - C-section on demand?
8. Unnecesary C- section ?
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 ?
Fetal mortality and morbidity Newborn health VBAC Cost Pelvic floor damage Maternal mortality Cultural factors
8.
Unnecesary C- section ?
1: 664 forceps 1: 860 vacuum extraction 1: 907 c-section during labor 1: 1900 delivered spontaneously
Unnecesary C- section ?
Fetal mortality and morbidity Newborn health VBAC Cost Pelvic floor damage Maternal mortality Cultural factors
8.
Unnecesary C- section ?
Costs of deliveries
Beth Israel Deaconess Medical Center, Boston, USA
$ 6.800
$ 10.000
Complication
Mother: + $ 4.000
Child: + $ 2.000
Unnecesary C- section ?
Fetal mortality and morbidity Newborn health VBAC Cost Pelvic floor damage Maternal mortality Cultural factors
8.
Unnecesary C- section ?
Pelvic floor
Urinary incontinence
Fecal incontinence
Sexual dysfunction Organ prolapse
Unnecesary C- section ?
Pelvic floor
Unnecesary C- section ?
delivery
Davila GW, et al., Int Urogyneocl J 2001;12:289-291 Unnecesary C- section ?
Avoid labor Avoid passage of the fetus through the pelvis Shorten second stage Avoid routine episiotomy Forget the forceps specially in macrosomia
Unnecesary C- section ?
Fetal mortality and morbidity Newborn health VBAC Cost Pelvic floor damage Maternal mortality Cultural factors
8.
Unnecesary C- section ?
Fetal mortality and morbidity Newborn health VBAC Cost Pelvic floor damage Maternal mortality Cultural factors
8.
Unnecesary C- section ?
Fetal mortality and morbidity Newborn health VBAC Cost Pelvic floor damage Maternal mortality Cultural factors
8.
Unnecesary C- section ?
Unnecesary C- section ?
Autonomy
EUROBS STUDY
Unnecesary C- section ?
Personal choice Fear of vaginal delivery Previous CS Previous traumatic delivery Previous intrapartum fetal death First child disabled Patient were a colleague
Unnecesary C- section ?
Obstetrician's Rationale
Womans autonomy Avoid non compliance during delivery Avoid legal consequences
Unnecesary C- section ?
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
Unnecesary C- section ?
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
Unnecesary C- section ?
Unnecesary C- section ?
Unnecesary C- section ?
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%
Unnecesary C- section ?
Unnecesary C- section ?
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
Unnecesary C- section ?
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
Unnecesary C- section ?