C-Section - Do we have a definition of an Do we have a definition of an unnecessary cesarean section-Dr Mario SebastianiAsociación Argentina de

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Unformatted text preview: Do we have a definition of an Do we have a definition of an unnecessary cesarean section? -Dr. Mario SebastianiAsociación Argentina de Ginecología y Obstetricia Psicosomática Servicio de Obstetricia. Hospital Italiano de Buenos Aires. Argentina Published rates W.H.O.: 1 • 15 % • Maximum desirable rate of cesarean Maximum section section • No benefit for mother and the fetus for No medical reasons medical 1 World Health Organisation. Appropriate technology for birth. Lancet 1985;436­7. 1985;436­7. Unnecesary C­ section ? Outcome based study Sweden: 1 59 hospitals 1988 ­ 1992 • Perinatal mortality Perinatal • Rate of asphixia No benefit Minimum cesarean section rate is optimal Eckerlund Eckerlund 1 Unnecesary C­ section ? I, et al., Int J Technol Asses Health Care 1999;15:123 ­ 35 Int Outcome based study England 1 17 maternity units (one health region) 1988 36.727 singleton pregnancies • CS rates should be 10 - 12 % • More intervensionist approach in low Joffe infants pidemiol E birth weightM, et al., J Epidemiol Community Health 1994;48:406 ­ 11 1 Unnecesary C­ section ? 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 Unnecesary C­ section ? Healthy People 2000; DHHS publication Nº. (PHS) 91­50212. publication Latin America Grafic I: Incidence of ceasarean secton in Latin American W.H.O. Unnecesary C­ section ? Belizán JM, et al, BMJ 1999;319:1397 ­402 Belizán BMJ Grafic I: Incidence of ceasarean secton in Latin American W.H.O. W.H.O. Unnecesary C­ section ? Belizán JM, et al, BMJ 1999;319:1397 ­402 Belizán BMJ “Rates and implications of caesarean sections Rates in Latin America: ecological study” in Belizán JM, et al, BMJ 1999;319:1397 ­402 Belizán BMJ 12 of 19 Latin American countries 81% of the deliveries 81% C-S rates above 15% (16,8% - 40%) Better socioeconomic conditions = higher C-S rates Over 850.000 unnecesary c-sections are performed Over each year in LA each Unnecesary C­ section ? Why has the rate of cesarean delivery climbed so dramatically in the past 25 years? 1. Lower tolerance for taking risks 2. 2. Fear of malpractice litigation 3. Increased use of epidural anesthesia ? use 4. Increased use of electronic fetal monitoring monitoring 5. The convenience of physicians Unnecesary C­ section ? Sachs BP et al., NEJM 1999;340:54 – 57 Sachs NEJM Difficulties for the analysis Which is the optimun cesarean rate? Many stategies to reduce the rates Unnecesary C­ section ? Difficulties for the analysis Which is the optimun cesarean rate? Many stategies to reduce the rates Vaginal Birth = Quality Caserean Section = Clasical indicaton or failure Medical and non medical reason Unnecesary C­ section ? Difficulties for the analysis Which is the optimun cesarean rate? Many stategies to reduce the rates Vaginal Birth = Quality Caserean Section = Clasical indicaton or failure Is there a different view ? Unnecesary C­ section ? Who are involved ? FETUS MOTHER Childbirth Unnecesary C­ section ? Who are involved ? FETUS Obstetricians MOTHER Childbirth Obstetrical Uni-Hospital Midwives Society Unnecesary C­ section ? Health system Factors involved in decision 1. Fetal mortality and morbidity 2. Newborn health 3. VBAC 4. Cost Cost 5. 5. Pelvic floor damage Pelvic 6. 6. Maternal mortality 7. Cultural factors Autonomy ­ C­section on demand? 8. Unnecesary C­ section ? “Unexplained fetal deaths” Cotzias C, Paterson­Brown S, Fisk N. BMJ, 319,31 july 1999 Weeks 35 36 37 38 39 40 41 42 43 Unnecesary C­ section ? Nº of pregnancies Prospective Risk of fetal death 164 860 1:366 162 603 1:407 158 171 1:474 149 181 1:529 127 160 1:617 93 828 1:680 39 316 1:606 10 328 1:565 1 883 1:465 Could C­S reduce fetal death rate? 5 times more frequent than SIDS Termination of pregnancy when fetal risks in útero Termination are larger than the risks of the newborn: 1/500 1/500 Most of fetal deaths occur in non­malformed Most fetuses fetuses Cotzias C, et al., BMJ, 319,31 july 1999 Unnecesary C­ section ? Could C­S reduce fetal death rate? 5 times more frequent than SIDS Termination of pregnancy when fetal risks in útero Termination are larger than the risks of the newborn: 1/500 1/500 Most of fetal deaths occur in non­malformed Most fetuses fetuses Women’s preference: C­section of the risk is Women’s > 1:4000 1 Cotzias C, et al., BMJ, 319,31 july 1999 1 Unnecesary C­ section ? Thornton E, et al., J Obstet Gynecol 1989;9:283­8 Obstet Factors involved in decision 1. Fetal mortality and morbidity 2. Newborn health 3. VBAC 4. Cost Cost 5. 5. Pelvic floor damage Pelvic 6. 6. Maternal mortality 7. Cultural factors Autonomy ­ C­section on demand? 8. Unnecesary C­ section ? “Effect of Mode of Delivery in Nulliparous Women on Neonatal Intracranial Injury” Towner D et al., NEJM 1999;341:23 Towner NEJM 1: 664 forceps 1: 1: 860 vacuum extraction 1: 907 c­section during labor 1: 1900 delivered spontaneously 1: 1: 2750 c­section with no labor Conclusion: The common risk factor for hemorrhage is abnormal labor Unnecesary C­ section ? Factors involved in decision 1. Fetal mortality and morbidity 2. Newborn health 3. VBAC 4. Cost Cost 5. 5. Pelvic floor damage Pelvic 6. 6. Maternal mortality 7. Cultural factors Autonomy ­ C­section on demand? 8. Unnecesary C­ section ? 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 National 2002 Unnecesary C­ section ? Recomendations The most conservative recomendations. • ACOG Technical Bulletin. Vaginal delivery after a ACOG previous cesarean birth. • • Int J Gynecol Obstet 48:127 – 129; 1995. 1995. ACOG Vaginal birth after a previous cesarean. ACOG • ACOG Practice Bulletin N° 5:1 – 8; 1999. 1999. Unnecesary C­ section ? VBAC Over 1000 reports: not one RCT Unnecesary C­ section ? VBAC Over 1000 reports: not one RCT Economic forces rather than patient well­ being, are driving the goal of fewer being, cesarean sections ? 1 1 Unnecesary C­ section ? Clark S., et al., Am J Obstet Gynecol 2000;182:599­602 2000;182:599­602 Factors involved in decision 1. Fetal mortality and morbidity 2. Newborn health 3. VBAC 4. Cost Cost 5. 5. Pelvic floor damage Pelvic 6. 6. Maternal mortality 7. Cultural factors Autonomy ­ C­section on demand? 8. Unnecesary C­ section ? Costs of deliveries Cesarean delivery: delivery: • • Longer hospital stay Longer • Costs more than a vaginal delivery Costs Use of an operating room. Labor unit: a prolonged and difficult labor, even unit: when it results in a vaginal delivery, is more when costly to an institution than a cesarean delivery. costly Unnecesary C­ section ? Costs of deliveries Beth Israel Deaconess Medical Center, Boston, USA Elective repeated cesarean delivery $ 7.700 Normal vaginal delivery Intrapartum Cesarean: Intrapartum Unnecesary C­ section ? $ 6.800 $ 10.000 Costs of deliveries Beth Israel Deaconess Medical Center, Boston, USA Elective repeated cesarean delivery $ 7.700 Normal vaginal delivery Intrapartum Cesarean: Intrapartum Complication • Mother: + $ 4.000 Mother: • Child: + $ 2.000 Unnecesary C­ section ? $ 6.800 $ 10.000 Difficulties in the estimation of costs Poor quality: what resources were included in their cost estimate in Lack of progress of labor > more hospital Lack lenght > medical costs > nursing costs lenght Charges are not the same as costs costs Long term sequelae: Pelvic floor ­ Fetal mortality ­ Newborn trauma Unnecesary C­ section ? Malkin J, et al., Birth 2001;28:208­9 Birth Factors involved in decision 1. Fetal mortality and morbidity 2. Newborn health 3. VBAC 4. Cost 5. 5. Pelvic floor damage Pelvic 6. 6. Maternal mortality 7. Cultural factors Autonomy ­ C­section on demand? 8. Unnecesary C­ section ? Pelvic floor Urinary incontinence Fecal incontinence Sexual dysfunction Organ prolapse Unnecesary C­ section ? Pelvic floor Pudendal nerve damage Soft tissue trauma The levator musculature trauma Anal sphincter trauma Unnecesary C­ section ? Pelvic floor Pudendal nerve damage Soft tissue trauma The levator musculature trauma Anal sphincter trauma “...neurophysiologic studies have demonstrated the ...neurophysiologic etiologic role of parturition-related nerve damage in development of pelvic floor disfunction...”1 development 1 Unnecesary C­ section ? Davila GW, et al., Int Urogyneocl J 2001;12:289­291 Int Reduction of pelvic floor damage Minimizing forceps deliveries Minimizing episiotomies Allowing passive descent in the second stage Selectively recomending elective cesarean Selectively delivery delivery Davila GW, et al., Int Urogyneocl J 2001;12:289­291 Davila Int Unnecesary C­ section ? 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 1999:119 Devine Contemporary Unnecesary C­ section ? Factors involved in decision 1. Fetal mortality and morbidity 2. Newborn health 3. VBAC 4. Cost 5. 5. Pelvic floor damage Pelvic 6. 6. Maternal mortality 7. Cultural factors Autonomy ­ C­section on demand? 8. Unnecesary C­ section ? Risk of maternal death “...the presumed increased risk of maternal death with ...the 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....” associated Unnecesary C­ section ? Hannah ME, Lancet 2000;356:1375­83. Hannah Lancet Factors involved in decision 1. Fetal mortality and morbidity 2. Newborn health 3. VBAC 4. Cost 5. 5. Pelvic floor damage Pelvic 6. 6. Maternal mortality 7. Cultural factors Autonomy ­ C­section on demand? 8. Unnecesary C­ section ? Cultural phenomena ­ Brazil All birth are attended by obstetricians Training Doctors work in the public and private health Doctors system system Status of c­section: modern and technical Women’s body are perceived as sexual than Women’s maternal maternal Genitals are perceived for sexual activity than Genitals for childbearing for Unnecesary C­ section ? Nuttall C., et al., BMJ 2000;320:1072 Nuttall BMJ Factors involved in decision 1. Fetal mortality and morbidity 2. Newborn health 3. VBAC 4. Cost 5. 5. Pelvic floor damage Pelvic 6. 6. Maternal mortality 7. Cultural factors Autonomy ­ C­section on demand? 8. Unnecesary C­ section ? Cesarean section on demand 31% of female obstetricians would prefer a 31% cesarean delivery for themselves 1 1 Unnecesary C­ section ? Al­Muffti et al. Eur J Obstet Gynecol Reprod Biol 1997:73:1­4 1997:73:1­4 Cesarean section on demand 31% of female obstetricians would prefer a 31% cesarean delivery for themselves 1 Italian law mandates that women be given the Italian option of an elective cesarean, and about 4% of pregnant women choose it. 2 1 2 Unnecesary C­ section ? Al­Muffti et al. Eur J Obstet Gynecol Reprod Biol 1997:73:1­4 1997:73:1­4 Tranquilli AL, et al., Am J Obstet Gynecol 1997;177:245­246 Am Autonomy Is the governing principle in medicine We respect with better eyes a woman’s right We to refuse a cesarean delivery to Nobody is interested in respecting woman’s Nobody desire to refuse vaginal delivery desire Wagner M et al., Lancet 2000;356:1677­80 Unnecesary C­ section ? Autonomy and informed consent Full and umbiased information Full (better=efficacy and (better=efficacy worse=risks) Do we have the time to inform ? Male dominated obstetric model Does a woman have an inalienable “right” to Does choose a C­S ? Wagner M et al., Lancet 2000;356:1677­80 Wagner Unnecesary C­ section ? Autonomy and informed consent “...performing cesarean section for non medical ...performing reasons is ethically not justified....” reasons Committee for the Ethical Aspects of Human Reproduction and Women’s Health of FIGO (1999) FIGO Unnecesary C­ section ? Ambiguity of terms Natural as desirable Natural as hazardous C­section as safe C­section as beneficial for doctors Unnecesary C­ section ? Natural (phylosophy of terms) To approve or excuse a behavior. Unnatural Ecologist’s feeling against the danger of the Ecologist’s nature nature Natural is everything that belong to the Natural Universe (animate or liveless, rational o irrational) (Stuart Mill) Dynamic and historical concept Unnecesary C­ section ? 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) (Savater) Natural Artificial is better than natural. Which is the Artificial meaning of arts? (Savater) (Savater) Human Life is precisely to be different from Human nature nature Unnecesary C­ section ? What do we need 1. RCT: iintention of labor vs elective c­section ntention vs 2. To accept that is a cultural phenomena To cultural 3. Need of a medical and non medical Need approach approach 4. Informed Consent Unnecesary C­ section ? To think A change in the birth of human specie has been change 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. but This controversy must not be solved replacing This vaginal birth with c­section, but stimulating women’s informed consent regarding the aspects of birth. aspects Unnecesary C­ section ? To think The nature of birth is related with the female’s The function as a reproductive agent. Is the same for the women’s condition? for 9 month not natural and then a natural birth Have we done a damage? You can do....but , should you do it? Women’s selection for vaginal birth Unnecesary C­ section ? Conclusion “...perhaps the time has come when the risks, ...perhaps 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...” delivered...” Unnecesary C­ section ? William Benson Harer Conclusion The cesarean section should not be used as an The indicator of quality of obstetrical care indicator We do not have a good definition of unnecesary We c­section c­section Unnecesary C­ section ? Thank you. Thank you. -Dr. Mario SebastianiAsociación Argentina de Ginecología y Obstetricia Psicosomática Servicio de Obstetricia. Hospital Italiano de Buenos Aires. Argentina ...
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