Prof.Dr.S.Cansun DEMIR Turkish Society of Obstetrics and Gynecology

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Prof.Dr.S.Cansun DEMIRTurkish Society of
Obstetrics and GynecologyÇukurova University
Faculty of Medicine
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Labor

• Natural and Normal Physiological Process
• Dystocia 23.6
• Functional Dystocia 11.1
• Failure in Dilatation and Descensus
• Arrest Dilatation and Descensus
• Ineffective Expulsion
• Mechanical Dystocia 12.5
• Cephalo-pelvic Disproportion
• Fetal Macrosomia
• Pelvic Anatomic Problems
• Fetal Malpresentation

American Journal of Obstetrics Gynecology.
195(1)121-128, July 2006.
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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 19854367.
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Optimum C/S Rate ?

• Some authors have proposed an ideal rate of all
  cesarean deliveries (such as 15 percent) for a
  population.
• There is no consistency in this ideal rate, and
  artificial declarations of an ideal rate should
  be discouraged.
• Goals for achieving an optimal cesarean delivery
  rate should be based on maximizing the best
  possible maternal and neonatal outcomes,taking
  into account available medical and health
  resources and maternal preferences.
• Thus, optimal cesarean delivery rates will vary
  over time and across different populations
  according to individual and societal
  circumstances.

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Healthy People 2000 1

• Department of Health and Human Services
• 15 by the year 2000

....the advantages of a safe vaginal delivery
over a cesarean delivery are clear a vaginal
delivery is associated with lower maternal and
neonatal morbilidity and it costs less...
1 Healthy People 2000 DHHS publication Nº. (PHS)
91-50212.
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C/S Rates Rises all over the World.
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The Total cesarean, Primary cesarean and vaginal
birth after cesarean rates in the United States
from 1989 to 2006. Source U.S. National Center
for Health Statistics
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Country Rate
LOW RATE OF CESAREAN LOW RATE OF CESAREAN
Cambodia 1.0
Haiti 1.7
Nigeria 1.7
Uganda 2.6
Eritrea 2.7
Uzbekistan 3.0
Indonesia 4.1
MODERATE RATE MODERATE RATE
United Kingdom 21.4
Canada 22.5
Ireland 23.3
Germany 23.7
Switzerland 24.3
United States 24.4
Cuba 28.5
Portugal 30.2
Chile 30.2
HIGH RATE HIGH RATE
Italy 36.0
Brazil 36.7
Mexico 39.1
China 40.5
Turkey 46.0
Betran AP, Merialdi M, Lauer JA, et al. Rates of
cesarean section analysis of global, regional
and national estimates. Paediatr Perinat
Epidemiol. 20072198113.
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Why has the rate of cesarean delivery climbed so
dramatically in the past 25 years?

1. Lower tolerance for taking risks
2. Fear of malpractice - litigation
3. Increased use of epidural anesthesia ?
4. Increased use of electronic fetal monitoring
5. The convenience of physicians

Sachs BP et al., NEJM 199934054 57
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Factors of taking C/S
Absolute
Dystocia
Fetal Distress
Breech Presentation ???
Previous Section ???
Relative
Maternal Age
Demand of Sterilization
Fear of litigation from Complications
Intraparturial EFM
Additional Factors
Time of day at delivery
Lack of Experience about operative delivery among seniors
C-section on Mothers Request Stress Incontinance, Ano-genital sphincter insufficiency Disturbance in sexual function Literate High social level in status Urban or Metropolitian localization
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C/S RATES IN TURKEY,2009
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Indications of C/S in Turkey
Source National
Maternal Mortality Survey,2005
KAYNAK2005 Ulusal Anne Ölümleri Çalismasi
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Cesarean on Demand

• In 2005
• The C/S rate in USA is 30.3 among all
  deliveries.
• 62 of these cases were Primary Elective C/S .
• C/S Rates varies by mothers request or demand
  was 4-18.

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What is C/S on Demand? Definition

• The incidence of cesarean delivery without
  medical or obstetric indications is increasing in
  the World, and a component of this increase is
  cesarean delivery on maternal request.
• Given the tools available,the magnitude of this
  component is difficult to quantify.

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Cesarean section on demand

• Until quality evidence becomes available, any
  decision to perform a cesarean delivery on
  maternal request should be carefully
  individualized and consistent with ethical
  principles.

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Cesarean section on demand

• Given that the risks of placenta previa and
  accreta rise with each cesarean delivery,
  cesarean delivery on maternal request is not
  recommended for women desiring several children.

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Cesarean section on demand

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

1 Al-Muffti et al. Eur J Obstet Gynecol Reprod
Biol 1997731-4
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Rising C/S rate in Turkey.The reasons 1

• Physicians attidutes
• C/S easy access and lower risk
• Time saving procedure ( 12-16 hours-vs 35-45
  minutes) To avoid from intrapartum long-term
  follow-up of parturient in labor wardand not to
  take any responsibility of labor complications.
• Malpractice and fear of litigation pushes them to
  take more Sections.Elective Caserean Section as
  an indication recorded into the statistical data.
  
• Not to able to control the unset of labor during
  very heavy clinical work in the day time,and also
  the extra and out of time.

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Rising C/S rate in Turkey.The reasons ..2

• To believe that C/S is minimizing perinatal
  neurologic injury and also prevents maternal
  adverse outcomes as pelvic relaxation syndrom
  with urinary incontinance.
• The reflexion of physicians preference on the
  gravidas as to direct them for Section seems to
  be another important factor.
• Normal delivery needs more labour-intensive work
  but not satisfactory rate of return .

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Rising C/S rate in Turkey.The reasons ..3

• The Social Background and Communal Factors
• IVF-ET cycles and pregnancies.Multiple gestation.
  
• Higher prevalence of maternal obesity and
  related obstetric problems as hypertansion,
  diabetes,systemic diseases and dystocia.
• Extensive use of Electro-fetal Monitorization and
  prenatal ultrasonography (Fetal Macrosomia-15
  false positive)
• Cesarean rates are higher among the gravidas
  cared by obstetricians ,when compared by
  midwifery during antenatal period.

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Rising C/S rate in Turkey.The reasons ..4

• Maternal attidutes
• Inadequate antenatal booking and lack of
  antenatal clinics results misunderstanding at
  choosing the mode of delivery
• Not to show enough respect to the parturients
  confidence during labour in the ward,frequency
  of painful vaginal exams ,Lack of private
  seperations and rooms for labour
• Negative approach and the quality of
  correspondance during admission to the labor ward
• The patients and also the obstetricians adversely
  affected againts normal delivery because of bad
  consequences of obstetric complications which
  recognized by community.

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Conclusion

• The cesarean section should not be used as an
  indicator of quality of obstetrical care
• We do not have a good definition of unnecesary
  c-section

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Comments 1

• High quality of Maternal Schooling.Prenatal
  Courses on training how to manage spontanous
  delivery and experienced trainers must be on this
  field. Encouragement and Education.
• Normal labor should be cared and followed by
  Obstetricians or Midwifes whose only is focused
  on this subject.Certification and Responsibility.
• Physical Conditions of Labor wards and hospital
  must be modernized and Patient Friendly Structure
  could be built.

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Comments 2

• Gravida must be treated honestly as she feels
  herself in confidence at labor. During the
  delivery the criterias which declared by WHO
  should be applied. ( No Routine enema,limited
  number of vaginal exams for low risk
  pregnants,unnecessary Kristeller Manoeuvre,No
  restriction to take fluids during labor).
• Midwifery System should be progressed and rebuilt
  as they will be responsible of normal spontanous
  deliveries .The Education of Midwifes must be in
  the responsibility of University and Teaching
  Hospitals which updated and upgraded.

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Comments - 3

• Continuous Professional and Postgraduate
  Education for midwifes and labor staff .
• Obligatory Intrapartum Fetal Monitorization.
  Physicians and Midwifes must be educated on IFM.
• The responsibility of labor Ward must belongs to
  Academic Staff (Obstetricians and Midwifes ).
• Full Physicological Support and Obstetric
  follow-up .

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Comments 4

• Facility of Rapid consultation of parturient
  with obstetrician if necessary because of
  dystocia and other complications appeared at
  delivery.
• Guidelines about Normal Vaginal Delivery and
  Labor Care must be setup in the labor Wards.
• Induction of Labor

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• Thank you very much for your attention