Metrorragia de 1

1
Do we have a definition of an unnecessary
cesarean section?
-Dr. Mario Sebastiani-
Asociación Argentina de Ginecología y Obstetricia
Psicosomática Servicio de Obstetricia. Hospital
Italiano de Buenos Aires. Argentina
2
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.
3
Sweden 1
Outcome based study

• 59 hospitals
• 1988 - 1992
• Perinatal mortality
• Rate of asphixia

No benefit
Minimum cesarean section rate is optimal
1 Eckerlund I, et al., Int J Technol Asses
Health Care 199915123 - 35
4
England 1
Outcome based study

• 17 maternity units (one health region)
• 1988
• 36.727 singleton pregnancies

• CS rates should be 10 - 12
• More intervensionist approach in low
• birth weight infants

1 Joffe M, et al., J Epidemiol Community Health
199448406 - 11
5
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.
6
Latin America
7
Grafic I Incidence of ceasarean secton in Latin
American
W.H.O.
Belizán JM, et al, BMJ 19993191397 -402
8
Grafic I Incidence of ceasarean secton in Latin
American
W.H.O.
Belizán JM, et al, BMJ 19993191397 -402
9
Rates and implications of caesarean sections in
Latin America ecological study
Belizán JM, et al, BMJ 19993191397 -402

• 12 of 19 Latin American countries
• 81 of the deliveries
• C-S rates above 15 (16,8 - 40)
• Better socioeconomic conditions higher C-S
  rates
• Over 850.000 unnecesary c-sections are performed
  each year in LA

10
Why has the rate of cesarean delivery climbed so
dramatically in the past 25 years?

• Lower tolerance for taking risks
• Fear of malpractice litigation
• Increased use of epidural anesthesia ?
• Increased use of electronic fetal monitoring
• The convenience of physicians

Sachs BP et al., NEJM 199934054 57
11
Difficulties for the analysis

• Which is the optimun cesarean rate?
• Many stategies to reduce the rates

12
Difficulties for the analysis

• Which is the optimun cesarean rate?
• Many stategies to reduce the rates

Medical and non medical reason
13
Difficulties for the analysis

• Which is the optimun cesarean rate?
• Many stategies to reduce the rates

Is there a different view ?
14
Who are involved ?
15
Who are involved ?
16
Factors involved in decision

• Fetal mortality and morbidity
• Newborn health
• VBAC
• Cost
• Pelvic floor damage
• Maternal mortality
• Cultural factors
• Autonomy - C-section on demand?

17
Cotzias C, Paterson-Brown S, Fisk N. BMJ, 319,31
july 1999
Unexplained fetal deaths
18
Could C-S reduce fetal death rate?

• 5 times more frequent than SIDS
• Termination of pregnancy when fetal risks in
  útero are larger than the risks of the newborn
  1/500
• Most of fetal deaths occur in non-malformed
  fetuses

• Cotzias C, et al., BMJ, 319,31 july 1999

19
Could C-S reduce fetal death rate?

• 5 times more frequent than SIDS
• Termination of pregnancy when fetal risks in
  útero 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
• gt 14000 1

• Cotzias C, et al., BMJ, 319,31 july 1999
• 1 Thornton E, et al., J Obstet Gynecol
  19899283-8

20
Factors involved in decision

• Fetal mortality and morbidity
• Newborn health
• VBAC
• Cost
• Pelvic floor damage
• Maternal mortality
• Cultural factors
• Autonomy - C-section on demand?

21
Effect of Mode of Delivery in Nulliparous Women
on Neonatal Intracranial Injury
Towner D et al., NEJM 199934123

• 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
22
Factors involved in decision

• Fetal mortality and morbidity
• Newborn health
• VBAC
• Cost
• Pelvic floor damage
• Maternal mortality
• Cultural factors
• Autonomy - C-section on demand?

23
Frequency of cesarean section, primary cesarean
and vaginal birth post-c-section between 1989 -
2001
VBAC
All c-sections
Primary c-section
Martin JA, et al., National Center for Health
Statistics. 2002
24
Recomendations

• The most conservative recomendations.
• ACOG Technical Bulletin. Vaginal delivery after a
  previous cesarean birth.
  
• Int J Gynecol Obstet 48127 129 1995.
• ACOG Vaginal birth after a previous cesarean.
  
• ACOG Practice Bulletin N 51 8 1999.

25
VBAC

• Over 1000 reports not one RCT

26
VBAC

• Over 1000 reports not one RCT
• Economic forces rather than patient well-being,
  are driving the goal of fewer
  cesarean sections ? 1

1 Clark S., et al., Am J Obstet Gynecol
2000182599-602
27
Factors involved in decision

• Fetal mortality and morbidity
• Newborn health
• VBAC
• Cost
• Pelvic floor damage
• Maternal mortality
• Cultural factors
• Autonomy - C-section on demand?

28
Costs of deliveries

• Cesarean delivery
• Costs more than a vaginal delivery
• Longer hospital stay
• Use of an operating room.
• Labor unit a prolonged and difficult labor,
  even when it results in a vaginal delivery, is
  more costly to an institution than a cesarean
  delivery.

29
Beth Israel Deaconess Medical Center, Boston,
USA
Costs of deliveries

• Elective repeated cesarean delivery 7.700
• Normal vaginal delivery
  6.800
• Intrapartum Cesarean
  10.000

30
Beth Israel Deaconess Medical Center, Boston,
USA
Costs of deliveries

• Elective repeated cesarean delivery 7.700
• Normal vaginal delivery
  6.800
• Intrapartum Cesarean
  10.000
• Complication
• Mother 4.000
• Child 2.000

31
Difficulties in the estimation of costs

• Poor quality what resources were included in
  their cost estimate
• Lack of progress of labor gt more hospital lenght
  gt medical costs gt nursing costs
• Charges are not the same as costs
• Long term sequelae Pelvic floor - Fetal
  mortality - Newborn trauma

Malkin J, et al., Birth 200128208-9
32
Factors involved in decision

• Fetal mortality and morbidity
• Newborn health
• VBAC
• Cost
• Pelvic floor damage
• Maternal mortality
• Cultural factors
• Autonomy - C-section on demand?

33
Pelvic floor

• Urinary incontinence
• Fecal incontinence
• Sexual dysfunction
• Organ prolapse

34
Pelvic floor

• Pudendal nerve damage
• Soft tissue trauma
• The levator musculature trauma
• Anal sphincter trauma

35
Pelvic floor

• Pudendal nerve damage
• Soft tissue trauma
• The levator musculature trauma
• Anal sphincter trauma

...neurophysiologic studies have demonstrated
the etiologic role of parturition-related nerve
damage in development of pelvic floor
disfunction...1
1 Davila GW, et al., Int Urogyneocl J
200112289-291
36
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
200112289-291
37
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 1999119
38
Factors involved in decision

• Fetal mortality and morbidity
• Newborn health
• VBAC
• Cost
• Pelvic floor damage
• Maternal mortality
• Cultural factors
• Autonomy - C-section on demand?

39
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 20003561375-83.
40
Factors involved in decision

• Fetal mortality and morbidity
• Newborn health
• VBAC
• Cost
• Pelvic floor damage
• Maternal mortality
• Cultural factors
• Autonomy - C-section on demand?

41
Cultural phenomena - Brazil

• All birth are attended by obstetricians
• Training
• Doctors work in the public and private health
  system
• Status of c-section modern and technical
• Womens body are perceived as sexual than
  maternal
• Genitals are perceived for sexual activity than
  for childbearing

Nuttall C., et al., BMJ 20003201072
42
Factors involved in decision

• Fetal mortality and morbidity
• Newborn health
• VBAC
• Cost
• Pelvic floor damage
• Maternal mortality
• Cultural factors
• Autonomy - C-section on demand?

43
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
44
Cesarean section on demand

• 31 of female obstetricians would prefer a
  cesarean delivery for themselves 1
• Italian law mandates that women be given the
  option of an elective cesarean, and about 4 of
  pregnant women choose it. 2

1 Al-Muffti et al. Eur J Obstet Gynecol Reprod
Biol 1997731-4 2 Tranquilli AL, et al., Am J
Obstet Gynecol 1997177245-246
45
Autonomy

• Is the governing principle in medicine
• We respect with better eyes a womans right to
  refuse a cesarean delivery
• Nobody is interested in respecting womans desire
  to refuse vaginal delivery

Wagner M et al., Lancet 20003561677-80
46
Autonomy and informed consent

• Full and umbiased information (betterefficacy
  and worserisks)
• Do we have the time to inform ?
• Male dominated obstetric model
• Does a woman have an inalienable right to
  choose a C-S ?

Wagner M et al., Lancet 20003561677-80
47
Autonomy and informed consent

• ...performing cesarean section for non medical
  reasons is ethically not justified....

Committee for the Ethical Aspects of Human
Reproduction and Womens Health of FIGO (1999)
48
Ambiguity of terms

• Natural as desirable
• Natural as hazardous
• C-section as safe
• C-section as beneficial for doctors

49
Natural (phylosophy of terms)

• To approve or excuse a behavior. Unnatural
• Ecologists feeling against the danger of the
  nature
• Natural is everything that belong to the Universe
  (animate or liveless, rational o irrational)
  (Stuart Mill)
• Dynamic and historical concept

50
Artificial (phylosophy of terms)

• What is produced by the arts and human technics
• Learned, modified. Natural is biologic.
• Natural in humans is not to be as much. (Savater)
• Artificial is better than natural. Which is the
  meaning of arts? (Savater)
• Human Life is precisely to be different from
  nature

51
What do we need

• RCT intention of labor vs elective c-section
• To accept that is a cultural phenomena
• Need of a medical and non medical approach
• Informed Consent

52
To think

• A change in the birth of human specie has been
  produced in the last years The same happened in
  terms of fertilization. It is not mediated by a
  natural evolution, Darwinian, but by an
  artificial evolution of human being.
• This controversy must not be solved replacing
  vaginal birth with c-section, but stimulating
  womens informed consent regarding the aspects of
  birth.

53
To think

• The nature of birth is related with the females
  function as a reproductive agent. Is the same for
  the womens condition?
• 9 month not natural and then a natural birth
• Have we done a damage?
• You can do....but , should you do it?
• Womens selection for vaginal birth

54
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
55
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

56
Thank you.
-Dr. Mario Sebastiani-
Asociación Argentina de Ginecología y Obstetricia
Psicosomática Servicio de Obstetricia. Hospital
Italiano de Buenos Aires. Argentina