HOW TO REDUCE CS RATES?

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HOW TO REDUCE CS RATES?Aboubakr ElnasharBenha
university Hospital, Egypt
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• CONTENTS
• BENEFITS OF CS
• RISKS OF CS
• BALANCING RISKS AND BENEFITS
• RISKS OF CS AND VAGINAL DELIVERY
• CSR
• REASONS FOR THE INCREASE IN CSR
• INTERVENTIONS TO DECREASE CSR
• INTERVENTIONS HAVE NO INFLUENCE ON CSR

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1. BENEFITS OF CS

• 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

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• 2. RISKS OF CS
• I. Immediate
• Anesthetic complications shock, cardiac arrest,
  acute renal failure, assisted ventilation
• Blood loss
• Bowel or bladder injury
• Amniotic or air embolism
• Scalpel damage to the baby 1-2
• (Smith 1997)

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• II. Post operative risks
• infection, or in-hospital wound disruption
• Hge that requires hysterectomy or transfusion,
• Venous thromboembolism
• Hematomae
• was increased 3-fold for CS as compared with VD
  (2.7 vs 0.9, respectively).

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• III. Risks in subsequent pregnancy
• Placenta previa /or accreta
• placenta previa increases with each subsequent
  CS, 1 with 1 prior CS
• 3 with 3 prior CS.
• Placenta accreta 10-fold increase over the last
  decades
• after 3 CS placenta previa will be
  complicated by placenta accreta in 40.
• Rupture of a uterine scar
• Recurrent CS
• increases the likelihood of most CS related
  complications, including

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• VI. Remote risks
• Infertility
• adhesions
• Bowel obstruction
• V. Neonatal complications
• combination of complications
• Neonatal RDS/Wet lung
• Neonatal intensive care unit admission
• Perinatal death.

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• 3. BALANCING RISKS AND BENEFITS
• When CS is necessary
• lifesaving for mother and baby.
• For placenta previa or uterine rupture
• CS is firmly established as the safest route of
  delivery.
• Over half of CS unnecessary
• (A consumer advocacy group and The Public Health
  Citizen's Research Group)
• For low risk pregnancies
• CS has greater risk of maternal morbidity and
  mortality than VD

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4. RISKS OF CS AND VAGINAL DELIVERY (ACOG , 2014)
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• C.S Vs vaginal delivery
• 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.No decline in cerebral palsy or shoulder
  dystocia

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• 5. CSR
• Rapid increase from 1996 through 2011 without
  clear evidence of concomitant decreases in
  maternal or neonatal morbidity or mortality
  raises significant concern that CS is overused.
• USA 23 1991
• 32 2007
• Canada 18 1991
• 31 2008
• Australia14 1995
• 29 2005
• Italy In Campania 60 2008 births
• In Rome44- 85 in some private
  clinics.
• Brazil up to 80

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CSR in Arab countries (Khawaja et al, 2009)
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• Variation across
• Arab countries
• ranging from a low of 15 to a high of nearly 55
• Nulliparous term singleton vertex
• Hospitals 10-fold variation
• Clinical practice patterns affect CSR.

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• In Egypt
• MOH hospital
• Normal Vaginal Deliveries (30) 42.8
• Cesarean sections (40) 57.2
• 90 previous CS
• 0 instrumental delivery
• Private Hospitals
• 90

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• 60 of all CS are primary cesarean
• Indications for primary CS, in order of frequency
• Labor dystocia 34
• Abnormal or indeterminate (formerly,
• Non reassuring) fetal heart rate tracing 23
• 12 57
• 3. Fetal malpresentation 17
• 4. Multiple gestation 7
• 5. Suspected fetal macrosomia 4

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• 6. REASONS FOR THE INCREASE IN CSR
• Elective CS
• Previous CS VBAC has decreased
• from a high of 28 in 1996 to 8 in 2007 USA,
  1989
• PET CSR for PET have increased, whereas IOL have
  declined.
• Breech Most are now delivered by CS.
• fetal injury
• infrequency with which a breech presentation
  meets criteria for a labor trial, almost
  guarantee that most will be delivered by CS.
  Breech (already 12 of all C/S)

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• Multiple pregnancy increased
• increased frequency of infertility the effect
  of its therapy.
• Elderly PG The average maternal age is rising,
  and older women, especially nulliparas, are at
  increased risk of cesarean delivery. an increased
  CS rate.
• Rates of labor induction continue to rise, and
  induced labor, especially among nulliparas,
  increases the cesarean delivery rate

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• Obesity has risen dramatically, and obesity
  increases the cesarean delivery risk
• Maternal medical conditions more women with
  chronic health problems (diabetes heart disease)
  are successfully carrying a baby.

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• Nonmedical factors. 
• Patient
• Patient request
• Concern for vaginal birth
• Pain
• Pelvic floor injury
• Fetal injury
• Women are having fewer children greater
  percentage of births are among nulliparas, who
  are at increased risk for CS.
• Socioeconomic status
• Convenience

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• Obstetrican
• Individual philosophy
• Malpractice litigation related to fetal injury
  during spontaneous or operative vaginal delivery
  Fear of litigation cost of litigation.
• The threat of malpractice altered the training
  of new obstetricians little exposure to managing
  birth complications
• Financial gain A linear correlation between fee
  CS
• Convenience
• The effect of Obstetric catastrophe CSR
  increased after VB with poor outcome from 21 to
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• (Turrentino 1999).

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• Selective CS
• Overuse of CS for failure to progress (dystocia)
• Increased interventions before active labor
  established.
• The frequency of instrumental delivery forceps
  and vacuum has decreased
• 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.
• CS performed primarily for fetal distress
  comprises only a minority of all such procedures.
  In many more cases, concern for an abnormal or
  nonreassuring FHR tracing lowers the threshold
  for CS.

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• 7. INTERVENTIONS TO DECREASE CSR
• CSR can be lowered without any adverse effect on
  neonatal outcome
• The Obstetrician
• single most important factor that will reduce CSR
  is physician motivation to make a change.
• Should be provided with EB clinical practice
  guidelines for CS
• Acuity-adjusted physician-specific CSR
• Supplementary fees for performing VBAC.
• Second opinion for performing all except
  emergency CS.

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• Organizational, Hospital actions
• Changing the local culture and attitudes of
  doctors regarding the interventions to reduce CSR
  across
• indications
• across community
• academic settings.
• CSR was reduced by 13 when
• audit and feedback were used
• CSR was reduced by 27 when
• audit and feedback
• second opinions and
• culture change.

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• Elective
• 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,
  2005)

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• Herpes simplex virus
• CS is not recommended for women with a history of
  herpes simplex virus infection but no active
  genital disease during labor.

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• 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 2004) (grade A )
• The routine use of early US to calculate
  gestational age significantly reduces the
  incidence of post-term pregnancy
• (grade A) Cochrane Review, 2010

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• External cephalic version
• uncomplicated singleton breech pregnancy at 36 w
  should be offered ECV.
• Exceptions
• in labour
• uterine scar or abnormality
• fetal compromise
• ruptured membranes
• vaginal bleeding
• medical conditions .
  (Grade A).

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• 2. VBAC
• should be offered and encouraged for all patients
  unless there is a separate complicating risk
  factor that justifies CS.
• safer for both mother and infant, in most cases,
  than is routine elective CS, which is major
  surgery.
• 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-2A)

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• Selection criteria
• One low-transverse CS
• Clinically adequate pelvis
• No other uterine scars or previous rupture
• Availability of anesthesia and personnel for
  emergency CS
• Continuous electronic fetal monitoring.

(II-2A)
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• Contraindications
• Patients at high risk for uterine rupture.
• Prior classical or T-shaped incision or other
  transfundal uterine surgery
• Contracted pelvis
• Medical or obstetric complication that precludes
  vaginal delivery
• Inability to perform emergency CS
• unavailable surgeon, anesthesia, sufficient
  staff, or facility
• (II-2A)

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• 3. Maternal request
• Clinician
• Not on its own an indication for CS
• Specific reasons for the request should be
  explored, discussed, and recorded
• (GPP )
• has the right to decline a request for CS in the
  absence of an identifiable reason.
• The womans decision should be respected and she
  should be offered referral for a second opinion.

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• Public
• Health awareness
• Education
• Media involvement
• Patient
• Benefits and risks of CS compared with vaginal
  birth should be discussed and recorded.
• A fear of childbirth counseling (cognitive
  behavioral therapy) reduced fear of pain in
  labour and shorter labour.

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• Selective
• 1. Continuous labor and delivery support
• presence of continuous one-on-one support during
  labor and delivery
• improved patient satisfaction
• significant reduction in CSR

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• 2. Correct diagnosis of labour
• The diagnosis of labor is made within 1 hr of
  presentation.
• Spontaneous contractions at least 2/15 min
• at least 2 of the following
• Complete effacement of cervix
• Cervical dilation 3 cm or greater
• SROM
• (NGC,2004)
• 3. Routine amniotomy should be discouraged

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• 4. 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).
• 5. Consultant obstetricians should be involved in
  the decision making for CS
• (Grade C)
• 6. 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

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• 8. INTERVENTIONS HAVE NO INFLUENCE ON CSR
• (Grade A) National Guideline Clearinghouse April
  2005

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