declaration - suyajna incidence of cs...declaration statutory warning! the contents of this lecture...

DECLARATION STATUTORY WARNING!

THE CONTENTS OF THIS LECTURE ARE NEITHER MY PERSONAL OPINIONS NOR CRITISISM OF ANY INDIVIDUAL, HOSPITAL, INSTITUTION, STATE OR COUNTRY.

REDUCING INCIDENCE OF CS MYTH or REALITY

SUYAJNA

INTRODUCTION

C SECTION

CLASSIFICATION OF CS

Ø 1. INDICATED CS

Ø 2. NON-INDICATED CS: Ø  a. CSMD Ø  b. Lack of FACILITY Ø  c. Lack of obstetrical skill Ø  Ø  d. NON MEDICAL REASONS

HISTORY OF C SECTION

Bindusara, 320 BC, his mother – wife of Chandragupta Maurya accidentally consumed poison during labor, operated by CHANAKYA.

Etymology of the name of Julius Caesar ?? His mother AURELIA lived through his

childbirth and his DEATH 1500..Jakob Nufer of Switzerland , pig gelder

Who is primitive ?

Ø Successful Caesarean section by indigenous healers in Kahura, Uganda.

As observed by R. W. Felkin in 1879.

LANDMARKS in Modern CS

Ø  1876.. Eduardo Porro Ø  1881..Ferdinand Adolf Kehrer Ø  1882.. Max Saumlnger of Leippzig Ø  1912.. Kronig… Munro Kerr

NORMAL DELIVERY ?

NORMAL DELIVERY ??

VAGINAL C S

IS HUMAN PELVIS FIT FOR VD

Humankind has been delivering babies for millions of years…

Homo Habilis “Handy man”

walked the earth - 1,750,000 years ago

NO CS

Homo Erectus

BIPED The female pelvis became adaptively narrower in the region of the vaginal canal, making labor anatomically

more difficult. The narrow birth canal, and the greater size of the head

of the human fetus when compared to other mammals, made human labor the most painful among primates.

PELVIS OF ‘LUCY’

"Lucy" skeleton 3-million-year old Australopithicus afarensis, 1974, has a

much narrower pelvic opening. In comparison to H. Erectus

Homo Erectus – Gona - 2008

birth canal and brain size were co-evolving, to give birth to larger babies - to adapt to the pressure of external

environmental factors.

Homo Sapiens – ‘WISE MAN’

a new anatomical adaptation compensated the narrowing of the pelvis

Homo sapiens in relation to the greater relative size of the brain of NB:

greater immaturity of the central nervous system (CNS)

WHY C S ?

Ø Up to 1850 : to save the baby

Ø Up to 1950 : to save the mother

Ø Up to 2000 : to save the baby

Ø Beyond 2000 : to save the DOCTOR

IS THE TOPIC RELEVANT ?

C. Section Rise Not evolution

Cesarean Delivery: ‘Epidemic’ DISEASE ?

0

5

10

15

20

25

%

1970 1975 1980 1985 1990 1995 1998

C/SPrimary C/SRepeat C/S

VANISHING VAGINAL DELIVERY

HEY.. WHAT IS VAGINAL DELIVERY ?

RISING TRENDS OF CS

Ø 1. INDICATED CS

Ø 2. NON-INDICATED CS: Ø  a. CSMD Ø  b. Lack of FACILITY Ø  c. Lack of obstetrical skill Ø  Ø  d. NON MEDICAL REASONS

INCREASE IN INDICATED CS

1. LIE – POSITIONS – PRESENTATIONS

PREVIOUS LSCS

CPD FOETAL DISTRESS

The rise in caesarean section rate: the same indications but a lower

threshold. Leitch CR, Walker JJ.

Br J Obstet Gynaecol 1998 Jun;105(6):621-6.

Ø  The results of this study show that the rate of Cesarean sections in Scotland increased by over three-

folds in the period from 1962 to 1992, with no apparent cause to justify this increase other than a lowered threshold of acceptance of the procedure in obstetric practice.

2. PREVIOUS LSCS

CAN WE VBAC

NO

0

5

10

15

20

25

30

89 91 93 95 97 99 2001Año

%

All c-sections

Primary c-section

VBAC

Frequency of cesarean section, primary cesarean and vaginal birth post-c-section between 1989 - 2001

Martin JA, et al., National Center for Health Statistics. 2002

PLANNED VBAC ?

VBAC

Over 1000 reports:

not one RCT

VBAC..ACOG- ‘immediately available’ - practice bulletin no. 54, 2006

BECAUSE UTERINE RUPTURE MAY BE CATASTROPHIC VBAC SHOULD BE

ATTEMPTED IN INSTITUTIONS........

ACOG Practice Bulletin N° 5:1 – 8; 1999.

Less Restrictive VBAC Guidelines - 115 July 21, 2010

WHAT DECIDES VBAC ? Ø  Over 1000 reports: not one RCT

Economic forces

rather than

patient well-being,

are driving the goal of

fewer cesarean

sections ? Clark S., et al., Am J Obstet Gynecol 2000;182:599-602

Conservatism in Obstetrics

“No matter how carefully the uterine incision is

sutured, we can never be certain that the cicatrized uterine wall will stand a

subsequent pregnancy and labor without rupture. This means that the usual rule is

“once a cesarean, always a cesarean”

Edwin Craigin, 1916

CRAIGIN WAS RIGHT !!

He was referring ONLY to classical cesarean scars

L.S.C.S. SCARS ?

3. Assessment of CPD

WASTE OF

TIME

CAN YOU ASSESS CPD ?

ICAN

NO

CPD ABSOLUTE RELATIVE

CPD AT THE BRIM BELOW THE BRIM

ABSOLUTE

SIZE

Ø CONTRACTED PELVIS

Ø BIG BABY 4500 Gm - BIG HEAD

RELATIVE

Ø DEFLEXION- MAL POSITION Ø SOL … INTRINSIC - EXTRINSIC HIGH INCLINATION

Ø CORD ROUND THE NECK - AXE

DO YOU ASSESS CPD ?

NO WE GUESS CPD !

VISUAL ASSESSMENT OF CPD

CPD - VIMS SCENARIO

Ø PG: WHICH UNIT …?

Ø ASSISTANT PROFESSOR: WHAT TIME ..?

Ø PROFESSOR: HEY.. GET A SCAN…

NOT SEEN ANYBODY ASSESSING

IN LAST TEN YEARS…

4. FOETAL DISTRESS

FHR

CTG

pH MSL

APGAR

CORD ROUND THE NECK

NEW INDICATION FOR CS

REPLACING CPD

JOYCE MORGAN 1948

a. INCREASE IN CSMD

MEDIA HYPE

MOST USER FRIENDLY FOR DTO

C.S. WOMAN’S BIRTH RIGHT

Ø C.S. BY CHOICE

Ø C.S. ON REQUEST

Ø C.S. ON DEMAND

"Should doctors perform an elective caesarean section on

request?" !BMJ,1998

Ø November 27, 1999 issue of the British Medical Journal, a feminist Professor of English laments "medical and social prejudices against women sidestepping their biblical sentence to painful childbirth are still with us"

Ø  and a consumer advocate states "I do not believe that anyone has the right to demand women give birth vaginally."

20%

CAESAREAN BY CHOICE

Ø  "With a scheduled Caesarean section, you and your doctor have agreed to a time at which you will enter the hospital in a fairly calm and leisurely fashion, and he or she will extract your baby

through a small slit at the top of your pubic hair. There are a lot of reasons to schedule a caesarean section… women elect to have a caesarean because they want to maintain the vaginal tone of a teenager, and their doctors find a medical explanation that will suit the insurance company." !

Ø  Lovine V,"The Girlfriend's Guide to Pregnancy"

C.S. BIRTH RIGHT OF WOMEN

ANY TAKERS ? 0NLY 4% ITALIAN PREGNANT WOMEN OPTED FOR C.S. BY CHOICE !

b. HANDICAPPED OBSTETRICIAN

LACK OF

SKILL TRANSMISSION

PG SYNDROME CUTTING CHANCES

BUT WHOM TO CUT ?

MATHEMATICS GONE WRONG

ONE CRORE PLUS

HOW MANY CS ?

0NE THOUSAND !

c. LACK OF FACILITY

FACILITY TO CONDUCT CS AVAILABLE EVERY WHERE WITH CRASH COURSES IN CS

OPERATIVE VAGINAL DELIVERY

ALMOST VANISHED……

d. UNNECESSARY CESAREAN SECTION

true or false ?

Or..INEVITABLE CS?

Death by Medicine By Gary Null, PhD; Carolyn Dean MD, ND; Martin Feldman, MD; Debora

Rasio, MD; and Dorothy Smith, PhD

Approximately 4 million births occur annually, with 24% (960,000) delivered by cs. Netherlands, only 8% of births are delivered

by cesarean section.

This suggests 6,40,000 unnecessary cesarean sections—entailing three to four times higher mortality 20 times greater morbidity than vaginal delivery are performed annually in the US.

The US cesarean rate rose from just 4.5% in 1965 to 24.1% in 1986.

Sakala contends that an “uncontrolled pandemic of

medically unnecessary cesarean births is occurring.”

Estimating the proportion of unnecessary Cesarean sections in Ohio using birth certificate data. Koroukian SM, Trisel B, Rimm AA. J Clin Epidemiol 1998 Dec;51(12):1327-34. The results of this study show that approximately

40% of Cesarean sections performed in Ohio have no medical indication that justifies their use and are therefore, unnecessary.

WHO IS BENEFITTED ?

WHO reports: "In the United States the profit motive explained hospital-specific cesarean section rates that

were high even by United States standards."

WHY INCREASE IS NOT WELCOME

Ø  U.S. there is a four fold risk of death compared to vaginal birth.

Ø  England, emergency cesarean birth has a nine fold risk of death when compared to vaginal and elective

cesareans have a threefold risk.

Ø Women are twice as likely to be re-hospitalized within 60 days of birth when compared with women who have a vaginal birth.

IS IT EVIDENCE BASED ?

NO

YOUR CHANCES OF CS

DEPENDS ON WHERE U R

R U LUCKY ?

SELECT YOUR PLACE OF DELIVERY

WORLD MAP OF CORRUPTION

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 ;340:54 – 57

Reasons for Couples choose C-Section

Ø Concern for safety of infant Ø Fear of pain and pushing the baby Ø Perception that a C-section is safer than

vaginal delivery. Ø Social convenience Ø Damage to perineal floor Ø Prior complicated/traumatic births Ø Stress & anxiety TRUE /

FALSE

CEREBRAL PALSY



vaginal delivery. Ø Social convenience Ø Damage to perineal floor Ø Prior complicated/traumatic births Ø StrTRUE / FALSE

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 2000;356:1375-83.

OBSTETRIC CALAMITY

HANNAH M E

TBT

Hannah ME, Hannah WJ, Hewson SA, Hodnett ED, Saigal S, Willan AR.

Lancet.2000 Oct 21;356(9239):1375-83. ...

MATERNAL MORTALITY

MATERNAL MORBIDITY

CS MORBIDITY

AFTERMATH OF CS

PLACENTA ACCRETA



vaginal delivery. Ø Social convenience Ø Damage to perineal floor Ø Prior complicated/traumatic births Ø Stress & anxiety TRUE /

FALSE

PELVIC FLOOR DAMAGE

NO

PERINEAL DAMAGE

YES

COSMETIC GYNAEC SURGERY

PELVIC FLOOR DISORDERS

Ø  « Does caesarean section prevents from pelvic floor disorders ? »

Ø  Urinary and fecal incontinence, POP, sexual dysfunction

Ø  Hypothesis :

Ø  - Vaginal delivery is the etiology of pelvic floor dysfunction

Ø  - Caesarean section - avoid vaginal delivery

Ø  - Conclusion : Cs prevents from pelvic floor dysfunction

Ø  First point…

Ø  Vaginal delivery is not the unique etiology of pelvic floor dysfunction

Ø  BMI > 30 g/m2 = risk factor of urinary incontinence at long term follow-up

[Fritel, BJOG, 2005]

Caesarean section is unable to prevent all

urinary incontinence vaginal delivery not the only etiology of urinary incontinence

Pregnancy itself plays a major role

Deffieux et al, 2010

Cohort study n=949

Does cesarean section prevents from pelvic floor disorders ?

Short term follow-up

Does C-section prevents from sexual dysfunction ?

Cochrane Database

Meta-analysis

Elective C-section vs vaginal delivery

3 studies (n=2396)

At 3 months post-partum Perineal pain RR 0.32 [95% CI 0.1-0.5] ** Dyspareunia RR 0.91 [95% CI 0.7-1.1] NS At 2 years post-partum Sexual dysfunction RR 0.95 [95% CI 0.6-1.4] NS Perineal pain RR 0.65 [95% CI 0.3-1.1] NS Unhappiness with sex RR 0.87 [95% CI 0.5-1.5] NS



Anal sphincter injury during vaginal delivery

Sultan et al NEJM 1993

PRIMA study 1219 primiparous women Faltain et al. Obstet Gynecol 2005

0/I II III/IV CS N=313

N=671 N=81 N=154

Fecal incontinence 8% 15% 19% 8% Urinary incontinence 10% 12% 12% 5% Perineal pain 4% 7% 7% 1% Dyspareunia 27% 41% 54% 29%

Vaginal delivery


The prevalence of fecal incontinence is not different

following normal vaginal delivery and C-section

100% CS - IS IT A SOLUTION?

0

20

40

60

80

100

120

25% CS 100% CS

sphincter tear andincontinenceno sphincter tear andincontinencesphincter tear noincontinenceno sphincter tear noincontinence

250 C-section deliveries should be performed

…to prevent one case of fecal incontinence related to anal

sphincter injury

CS TO PREVENT PFD

Scientific data is insufficient to justify an

elective cesarean section in order to avoid

pelvic floor symptoms

VIMS-BELLARY

Ø 8% in 1980 Ø 38% in 2011

ANALYSIS

Published rates

Ø W.H.O.: – 15 %

– Maximum desirable rate of cesarean section

– No benefit for mother and the fetus for medical reasons

World Health Organisation. Appropriate technology for birth. Lancet 1985;436-7.

Sweden Ø 59 hospitals

Ø 1988 - 1992 –  Perinatal mortality

–  Rate of asphixia

Eckerlund I, et al., Int J Technol Asses Health Care 1999;15:123 - 35

Minimum cesarean section rate is optimal

No benefit

Outcome based study

England Ø 17 maternity units (one health region) Ø 1988 Ø 36727 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 1994;48:406 - 11

Outcome based study

Healthy People 2000

Ø Department of Health and Human Services

Ø 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

morbidity and it costs less...”

Healthy People 2000; DHHS publication Nº. (PHS) 91-50212.

Who are involved ?

MOTHER

Childbirth

BEFORE 1950

Who are involved ?

FETUS MOTHER

Childbirth

1950 - 1980

Who are involved ?

Obstetricians

FETUS MOTHER

Health system

Obstetrical Uni-Hospital Midwives

Society

Childbirth

BEYOND 1980

Difficulties for the analysis

Ø Which is the optimun cesarean rate?

Ø Many stategies to reduce the rates

Vaginal Birth =

Quality Caserean Section

= Clasical indicaton or

failure Medical and non medical reason

Factors involved in decision

1.  Fetal mortality and morbidity 2.  Newborn health 3.  VBAC 4.  Pelvic floor damage 5.  Maternal mortality

MEDICAL

ELECTIVE C.SECTION

Ø 1. A TERM SINGLETON BREECH Ø 2. A TWIN PREGNANCY WITH FIRST

TWIN BREECH Ø 3. HIV Ø 4. BOTH HIV & HEPATITIS C Ø 5. PRIMARY GENITAL HERPES IN THE

THIRD TRIMESTER Ø 6. GRADE 3 AND 4 PLACENTA PRAEVIA RCOG GUIDELINES

CATEGORISATION OF INDICATIONS C.Section

GRADE 1. IMMEDIATE THREAT TO THE LIFE OF THE WOMAN OR BABY

GRADE 2. MATERNAL OR FOETAL COMPROMISE NOT IMMEDIATELY LIFE THREATENING.

GRADE 3. NO MATERNAL OR FOETAL COMPROMISE - NEEDS EARLY DELIVERY

GRADE 4. DELIVERY TIMED TO SUIT THE WOMAN OR STAFF.

RCOG - NCEPOD

VIMS-BELLARY 2004

1350 C.S. 10 consultants

Individual c.s.-

varied from 45 to 200 !

2011…….3210

Factors involved in decision

1.Cost 2.Cultural factors 3.Autonomy - C-section on demand?

NON-MEDICAL

Beth Israel Deaconess Medical Center, Boston, USA

Ø Elective repeat cesarean delivery $ 7.700

Ø Vaginal delivery $ 6.800

Ø  Intrapartum Cesarean: $ 10.000

INDIA : Vaginal Delivery- Rs. 2000 to Rs. 10000=00

C.Section - Rs. 10000 to Rs. 25000=00

GOVT. HOSPITALS – COST ??

Cost of delivery

Cultural phenomena - Brazil Ø All birth are attended by obstetricians Ø Training Ø Doctors work in the public and private health

system Ø Status of c-section: modern and technical Ø Women’s body are perceived as sexual

than maternal Ø Genitals are perceived for sexual activity

than for childbearing Nuttall C., et al., BMJ 2000;320:1072

Cesarean section on demand

Ø 31% of female obstetricians would prefer a

cesarean delivery for themselves

Ø LADY DOCTOR’S SYNDROME

Al-Muffti et al. Eur J Obstet Gynecol Reprod Biol 1997:73:1-4

Cesarean section on demand

Ø  31% of female obstetricians would prefer a cesarean

delivery for themselves 1

Ø 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 1997:73:1-4 2 Tranquilli AL, et al., Am J Obstet Gynecol 1997;177:245-246

Autonomy and informed consent

“...performing cesarean section for non medical

reasons is ethically not justified....”

Committee for the Ethical Aspects of Human Reproduction and Women’s Health of FIGO (1999)

Autonomy

Ø We respect with better eyes a woman’s

right to refuse a cesarean delivery

Ø Nobody is interested in respecting woman’s

desire to refuse vaginal delivery

Wagner M et al., Lancet 2000;356:1677-80

confusion

Ø Women’s involvement with the decision preceeding c.s. and

their degree of satisafaction. Mould TAJ et al, Br J Obstet Gynaecol 1999

Ø What is natural ? What is normal….. change it to “open concept of good” Whackerhausen S. Br J Obstet Gynaecol 1999

Ambiguity of terms

Ø Natural as desirable

Ø Natural as hazardous

Ø C-section as safe

Ø C-section as beneficial

for doctors

Inconsistencies in clinical decisions in

obstetrics. Barrett JF, Jarvis GJ, Macdonald HN, Buchan PC, Tyrrell SN,

Lilford RJ. Lancet 1990 Sep 1;336(8714):549-51.

Ø The results of this study show that 30% of Cesarean sections performed in an English teaching hospital were unnecessary.

Inconsistencies in clinical decisions in obstetrics.

Barrett JF, Jarvis GJ, Macdonald HN, Buchan PC, Tyrrell SN, Lilford RJ.

Lancet 1990 Sep 1;336(8714):549-51.

Ø  Even more importantly, when physicians were presented at different times with the same information, their opinion as to whether perform or not a Cesarean section was inconsistent in

25% of cases. These data indicate that clinical decisions in obstetrics are often influenced by physicians' personal reasons rather than by medical factors

Conclusion NOT CONCENSUS

“...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

mother’s preference for how her baby is to be

delivered...” William Benson Harer

The cesarean section should not be used as

an indicator of quality of obstetrical care

C.Section will continue to stay at

Conclusion

What do we need

1.  RCT: intention of labor vs elective c-section

2.  To accept that is a cultural phenomena

3.  Need of a medical and non medical approach

4.  Informed Consent

REDUCE

The REDUCE Campaign:

Research and Education to Decrease Unnecessary

Cesarean Sections

British government urging doctors to dissuade

unnecessary Caesarean births

Women's Health News

Published: Saturday, 1-May-2004

ICAN The International

Cesarean Awareness Network, Inc. (ICAN)

is a nonprofit organization founded by Esther Booth Zorn in 1982. ICAN's mission is to improve maternal-child health

by preventing unnecessary cesareans

through education, providing support for cesarean recovery, and promoting Vaginal Birth After Cesarean (VBAC).

. CONGRATULATIONS

to ICAN Chapter Director Krista Cornish Scott on the birth of Colum David on

August 15th!

Colum is an HBAC (Home Birth After Cesarean) baby

Should Early C-Section Be Banned?

Some have accused stars such as Victoria “Posh Spice” Beckham, Claudia Schiffer, Elizabeth Hurley and Madonna of endangering their babies for vanity by choosing early C-sections over old-fashioned childbirth in order to avoid abdominal stretching. “There has been a spike in these designer C-sections

"Too Posh to Push,"

Ø  MIDDLE CLASS mothers are 26% more likely to opt for a C.S. than those from the working class.

Ø Women like ‘ POSH SPICE’ VICTORIA BECKHAM are ‘ too posh to push’

DESIGNER C. SECTIONS.

Thank you

Suyajna @ yahoo.com www.suyajna.com

DISCUSSION WILL CONTINUE

And the cesarean sections…

WHAT IS GENTLEMAN DOING ?

PREPARING 3 x 6 FOR …

VAGINAL DELIVERY

PREPARING 3 x 6 FOR …

OBSTETRICIAN

NO…. FUTURE IS ….

EVD EASY VAGINAL DELIVERY

SCS SAFE CESAREAN SECTION

FUTURE

OBSTETRCIS NO LONGER AN

ART

OBSTETRICS WILL BE

SCIENCE WITH COATING OF EBM

ANC

ULTRASONOGRAM

VAGINAL DELIVERY ….

Ø CUMBERSOME Ø STRESSFULL

Ø NIGHT ORIENTED Ø UNPREDICATBLE

Ø HAUNTING UNEXPLAINED FOETAL DEATHS

Ø DIRTY…..KIRI….KIRI….

SALT TO WOUND…

CORD ROUND THE NECK

POSTDATISM HESITANT LABOR DELAY IN DESCENT UNEXPECTED FOETAL DEATHS

COMPRESSION……..OCCLUSION

2012…..

Ø INCREASE THE RATE

Ø INCREASE THE RATE

INDICATIONS FOR VD

NO EVIDECE BASED

INDICATIONS

NO RCT

MODERN OBSTETRICS

Ø WHO CONCEIVES ? Ø PATIENT.

Ø  WHO DELIVERS ?

OBSTETRICIAN.

Ø SO ALLOW MIDWIVES TO DELIVER….

SOLUTION…. ANY TAKERS…

DELIVERY SHOULD BE CONDUCTED BY MIDWIVES

REDUCE INSTITUTIONAL DELIVERY

So C.s. are here to stay ….. Can we make C S SAFER ?

WHO's 'Safe Surgery Saves Lives' initiative came out with a 24-point checklist on 25-06-2008

declaration - suyajna incidence of cs...declaration statutory warning! the contents of this lecture...

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