How to reduce CS rates? Aboubakr Elnashar

Benha university Hospital

Introduction

When CS is necessary: lifesaving for mother and

baby.

Over half of CS: unnecessary

(A consumer advocacy group and The Public Health Citizen's Research Group)

C.S:

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. CS: No decline in cerebral palsy or shoulder dystocia

Incidence No region in the world can justify CS rate higher than

15% (WHO).

Reasons for the Increase in CS 1. 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.

2. The cost of litigation.

1. The threat of malpractice has altered the training of new obstetricians: Many of these new practitioners have had little exposure to managing birth complications without resorting to CS.

4- Routine repeat CS:-

USA, 1989:

80% of previous CS had a repeat CS

75% of them can have a successful VBAC.

5- Suspected overuse of CS for non-progressive labor (dystocia)

6. Increased interventions before active labor established .

7. Maternal medical conditions

more women with chronic health problems (diabetes heart disease) are successfully carrying a baby.

8-Age:

The average age of women at birth increased: an increased CS rate.

9-Multiple pregnancy:

increased {increased frequency of infertility & the effect of its therapy}.

10-Maternal habits &life style:

higher BMI: higher CS rate

11-Nonmedical factors.

individual philosophy

training

convenience of doctor or patient

patient's socioeconomic status

peer pressure,

fear of litigation

financial gain

A linear correlation between fee & CS

An increase of 4% in the CS rate for any additional $100/section

12-The effect of Obstetric catastrophe:–

The individual CS rate increased in the same setting after VB with poor outcome from 21% to 29% (Turrentino 1999).

13-New Indications for C/S:

A-Breech (already 12% of all C/S):

Pregnant women with a singleton breech presentation at term for whom ECV is contraindicated or has been unsuccessful should be offered CS because it reduces perinatal mortality & neonatal morbidity. (Grade A )

B-Vertical transmission of HIV

Elective CS: reduction of vertical transmission by 50 - 87% (NEJM 340:977, 1999).

C-Patient request–

Maternal request is not on its own an indication for CS, and specific reasons for the request should be explored, discussed, and recorded (GPP )

An individual clinician has the right to decline a request for CS in the absence of an identifiable reason. However the woman's decision should be respected, and she should be offered referral for a second opinion (GPP ) National Guideline Clearinghouse April 2005

Advantages 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

Risks I. Immediate

Risks of anesthesia

Blood loss

Bowel or bladder injury

Amniotic or air embolism

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

II. Post operative risks

Infection

Bleeding

Neonatal RDS/Wet lung

III. Risks in subsequent pregnancy Placenta previa &/or accreta in subsequent

pregnancy

Rupture of a uterine scar in subsequent pregnancy

Risk for recurrent C/S

increases the likelihood of most CS related complications, including placenta accreta (10-fold increase over the last decades due to the rise in CS).

VI. Remote risks: Infertility due to adhesions

Bowel obstruction

Indications

1. Repeat 35%

2. Dystocia/CPD 30%

3. Breech 12%

4. Non reassuring FHR 9%

Therefore it is important to avoid the first CS

Interventions to decrease the likelihood

of CS

CS rate can be lowered without any adverse effect on neonatal outcome

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

Physicians could be provided with

EB clinical practice guidelines for CS

Acuity-adjusted physician-specific CS rates within the MCO

Supplementary fees for performing VBAC.

Second opinion for performing all except emergency CS.

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 April 2005)

2- 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 April 2004) (grade A )

3- The routine use of early US to calculate gestational age significantly reduces the incidence of post-term pregnancy (grade A) Cochrane Review

4- Appropriate use of cervical ripening agents

prior to induction of labor.

5- Correct diagnosis of labour

6- Routine amniotomy should be discouraged

7-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).

8-Consultant obstetricians should be involved in the decision making for CS (Grade C)

9-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

10-Continuous support during labour from women with or without prior training (Grade A)

11-External cephalic version:

uncomplicated singleton breech pregnancy at 36 w should be offered external cephalic version.

Exceptions include women in labour and women with a uterine scar or abnormality, fetal compromise, ruptured membranes, vaginal bleeding, or medical conditions . (Grade A).

12- When a woman requests a CS because she has a fear of childbirth, she should be offered unbiased, individualized information concerning their birth options.

Counselling (such as cognitive behavioural therapy) to help her to address her fears in a supportive manner, results in reduced fear of pain in labour and shorter labour. (Grade A)

13- VBAC

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

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

(II(II--22A)A)

Selection criteria :

One low-transverse CS

Clinically adequate pelvis

No other uterine scars or previous rupture

Continuous electronic fetal monitoring.

Availability of anesthesia and personnel for

emergency CS

(II(II--22A)A)

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 because of

unavailable surgeon, anesthesia, sufficient staff, or

facility (II(II--22A)A)

6. Patient attitude and desire

7. Patients have much to say about what is done to

them.

8. 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(II--22A)A)

Interventions have no Influence on Likelihood of CS

(Grade A) National Guideline Clearinghouse April 2005

Walking in labour

Non-supine position during the second stage of

labour

Immersion in water during labour

Epidural analgesia during labour

Conclusion CS rates can be reduced without compromising prenatal

mortality. This can be achieved by reinforcing the importance of

avoiding primary CS unless there is a medical necessity and by the following:-

1- Trial of VBAC 2-Trial of ECV for breech. 3- Induction of labour beyond 41 w. 4- Appropriate use of cervical ripening agents prior to

induction of labor. 5-Correct diagnosis of labour

6-Routine amniotomy should be discouraged

7-Consultant obstetricians should be involved in the

decision making for CS

8-Use of electronic fetal monitoring should be restricted

to high risk pregnancy

10-Continuous support during labour from women with

or without prior training

11-A partogram with a 4-hour action line

Physicians who are motivated to lower the rate

can use many strategies that may help.

It also appears that nurses and support

personnel may have skills (or perhaps just time)

that physicians lack. It would be foolish to ignore

these people who can exert a positive influence

on the incidence of CS.