Safe prevention of the primarycesarean delivery

ACOG/SMFM OBSTETRIC CARE CONSENSUS, 2014

Aboubakr ElnasharBenha university , Egypt

Aboubakr Elnashar

Balancing risks and benefits

CS can be lifesaving for the fetus, the mother, or both in certain cases

For placenta previa or uterine rupture: CS is firmly established as the safest route of delivery.

For low risk pregnancies: CS has greater risk of maternal morbidity and mortality than VD

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Risk of severe maternal morbidities:hge that requires hysterectomy or transfusion,

uterine rupture

anesthetic complications: shock, cardiac arrest, acute renal failure, assisted ventilation venous thromboembolism

major infection, or in-hospital wound disruption or hematomae was increased 3-fold for CS as compared with VD (2.7% vs 0.9%, respectively).

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long-term risks associated with CS

placental abnormalities:

placenta previa, in future pregnancies increases with each subsequent CS, from 1% with 1 prior CS to almost 3% with 3 prior CS.

after 3 CS, the risk that a placenta previa will be complicated by placenta accreta is nearly 40%.

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Neonatal complications

{combination of complications}

neonatal intensive care unit admission perinatal death.

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CSRRapid increase in CSR 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% 2007Canada: 18% 1991 31% 2008

Australia:14% 1995 29% 2005

Italy: In Campania: 60% 2008 births In Rome:44%- 85% in some private clinics.

Developing countries i.e. Brazil …it is up to 80%Aboubakr Elnashar

The epidemic of CS is a matter deserving international attention.

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Khawaja et al, 2009

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Indications for primary CSVariation 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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Maternal characteristics

Age, weight, and ethnicity:do not account fully for increase in the CSR or its regional variations.

Other factors: likely contribute to the increasing CSR.

1.Patient preferences

2. Practice variation among hospitals, systems, and health care providers

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Indications for primary CS, in order of frequency1.Labor dystocia: 34%2.Abnormal or indeterminate (formerly,Non reassuring) fetal heart rate tracing: 23%

3. Fetal malpresentation: 17%4. Multiple gestation: 7%

5. Suspected fetal macrosomia: 4%

Arrest of labor and abnormal or indeterminate fetal heart rate tracing accounted for more than half ofall primary CS

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Safe reduction of the rate of primary cesarean deliveries (2014)

require different approaches for each of these, as well as other, indications.

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Maternal request

Public:Health awareness, education, media involvement

Patient:1.Benefits and risks of CS compared with vaginal birth should be discussed and recorded.

2. A fear of childbirth: counselling (cognitive behavioural therapy) {:reduced fear of pain in labour and shorter labour}.

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Clinician:

has the right to decline a request for CS in the absence of an identifiable reason.

The woman’s decision should be respected and she should be offered referral for a second opinion.

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Herpes simplex virus

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

Continuous labor and delivery support

presence of continuous one-on-one support during labor and delivery was associated with improved patient satisfaction and a statistically significant reduction in the rate of cesarean delivery.

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Organizational actionsChanging the local culture and attitudes of doctors regarding the

A. systemic interventions to reduce CSR across indications and across community and academic settings. CSR was reduced by 13% when audit and feedback were used

CSR was reduced by 27% when audit and feedback were used as part of a multifaceted intervention, which involved second opinions and culture change.

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“B. Specific interventionCulture of defensive practiceWe shouldn't be blamed.

Our approach must be understood.

We doctors are often sued for events and complications that cannot be classified as malpractice. So we turn to defensive medicine.

We will keep acting this way as long as medical mistakes are not de-penalized. We are not martyrs. So if a pregnant woman is facing an even minimum risk, we suggest she gets a C-section "

Italian gynaecologyst Enrico Zupi, whose clinic in Rome, Mater Dei, was under media attention for carrying a record of Caesarian sections (90% over total birth)

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A necessary component of culture change will be tort reform because the practice environment is extremely vulnerable to external medicolegal pressures. Studies have demonstrated associations between CSR and malpractice premiums and state-level tort regulations, such as caps on damages.

اصل ح الضرر

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Evidence-based approaches changes in individual clinician practice patterns, development of clinical management guidelines implementation of systemic approaches at the organizational level and regional level, and tort reforme to ensure that unnecessary cesarean deliveries are reduced. Conduct research to provide a better knowledge base to guide decisions regarding CS and to encourage policy changes that safely lower the rate of primary cesarean delivery

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ConclusionThe most common indications for primary CS include, in order of frequency, labor dystocia, abnormal or indeterminate fetal heart rate tracing, fetal malpresentation, multiple gestation, and suspected fetal macrosomia.

Safe reduction of the rate of primary CS will require different approaches for each of these, as well as other, indications.

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1. Definition of labor dystocia should be revisted because recent data show that contemporary labor progresses at a rate substantially slower than what was historically taught.

2. Improved and standardized FHR interpretation and management

3. Increasing women’s access to nonmedical interventions during labor, such as continuous

labor and delivery support

4. External cephalic version for breech 5. Trial of labor for women with twin gestations

when the first twin is in cephalic presentationAboubakr Elnashar

Thank youAboubakr Elnashar