C Section

Do we have a definition of an unnecessary cesarean section?
-Dr. Mario SebastianiAsociacin Argentina de Ginecologa y Obstetricia Psicosomtica Servicio de Obstetricia. Hospital Italiano de Buenos Aires. Argentina
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 1985;4367.
Unnecesary C- section ?
Outcome based study

Sweden: 1

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 1999;15:123 - 35
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

birth weight infants
1 Joffe
M, et al., J Epidemiol Community Health 1994;48:406 - 11
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 N. (PHS) 91-50212.
Latin America
Grafic I: Incidence of ceasarean secton in Latin American

W.H.O.
Chile Brazil Mxico Argentina Uruguay El Salvador Paraguay Bolivia 0 5 10 15 20 25 30 35 40
Belizn JM, et al, BMJ 1999;319:1397 -402
Grafic I: Incidence of ceasarean secton in Latin American

W.H.O.
Chile Brazil Mxico Argentina Uruguay El Salvador Paraguay Bolivia 0 5 10 15 20 25 30 35 40
Rates and implications of caesarean sections in Latin America: ecological study

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
Why has the rate of cesarean delivery climbed so dramatically in the past 25 years?
1.
Lower tolerance for taking risks Fear of malpractice litigation Increased use of epidural anesthesia ?
2.
3.
4.
Increased use of electronic fetal monitoring

The convenience of physicians
Sachs BP et al., NEJM 1999;340:54 57
5.
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


Vaginal Birth = Quality Caserean Section = Clasical indicaton or failure
Is there a different view ?

Who are involved ?

FETUS
MOTHER
Childbirth
Who are involved ?

FETUS
MOTHER
Obstetricians
Childbirth
Health system
Midwives
Society
Obstetrical Uni-Hospital
Factors involved in decision

1. 2. 3. 4. 5. 6. 7.
Fetal mortality and morbidity Newborn health VBAC Cost Pelvic floor damage Maternal mortality Cultural factors
8.
Autonomy - C-section on demand?
Unexplained fetal deaths

Cotzias C, Paterson-Brown S, Fisk N. BMJ, 319,31 july 1999
Weeks 35 36 37 38 39 40 41 42 43
N 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 C-S reduce fetal death rate?

5 times more frequent than SIDS Termination of pregnancy when fetal risks in tero 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 Unnecesary C- section ?
Could C-S reduce fetal death rate?

5 times more frequent than SIDS Termination of pregnancy when fetal risks in tero 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
> 1:4000 1
1
Cotzias C, et al., BMJ, 319,31 july 1999 Thornton E, et al., J Obstet Gynecol 1989;9:283-8

1. 2. 3. 4. 5. 6. 7.
8.
Effect of Mode of Delivery in Nulliparous Women on Neonatal Intracranial Injury

Towner D et al., NEJM 1999;341:23

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

1. 2. 3. 4. 5. 6. 7.
8.
Frequency of cesarean section, primary cesarean and vaginal birth post-c-section between 1989 - 2001
VBAC
30 25 20 % 15 10 5 0 89 91 93
All c-sections
Primary c-section
95 Ao
97
99
2001
Martin JA, et al., National Center for Health Statistics. 2002 Unnecesary C- section ?
Recomendations
The most conservative recomendations.
ACOG Technical Bulletin. Vaginal delivery after a previous cesarean birth.
Int J Gynecol Obstet 48:127 129; 1995.
ACOG Vaginal birth after a previous cesarean.
ACOG Practice Bulletin N 5:1 8; 1999.
VBAC
Over 1000 reports: not one RCT
VBAC
Over 1000 reports: not one RCT
Economic forces rather than patient wellbeing, are driving the goal of fewer
cesarean sections ? 1
1 Clark
S., et al., Am J Obstet Gynecol 2000;182:599-602

1. 2. 3. 4. 5. 6. 7.
8.
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.
Costs of deliveries
Beth Israel Deaconess Medical Center, Boston, USA
Elective repeated cesarean delivery $ 7.700
Normal vaginal delivery

Intrapartum Cesarean:
$ 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:
$ 6.800
$ 10.000
Complication
Mother: + $ 4.000
Child: + $ 2.000
Difficulties in the estimation of costs
Poor quality: what resources were included in their cost estimate Lack of progress of labor > more hospital
lenght > medical costs > nursing costs

Charges are not the same as costs Long term sequelae: Pelvic floor - Fetal mortality - Newborn trauma
Malkin J, et al., Birth 2001;28:208-9

1. 2. 3. 4. 5. 6. 7.
8.
Pelvic floor
Urinary incontinence
Fecal incontinence
Sexual dysfunction Organ prolapse
Pelvic floor

Pudendal nerve damage

Soft tissue trauma The levator musculature trauma
Anal sphincter trauma
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 2001;12:289-291
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 2001;12:289-291 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

1. 2. 3. 4. 5. 6. 7.
8.
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. Unnecesary C- section ?

1. 2. 3. 4. 5. 6. 7.
8.
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 2000;320:1072

1. 2. 3. 4. 5. 6. 7.
8.
Cesarean section on demand
31% of female obstetricians would prefer a cesarean delivery for themselves 1
Al-Muffti et al. Eur J Obstet Gynecol Reprod Biol 1997:73:1-4
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 2
Al-Muffti et al. Eur J Obstet Gynecol Reprod Biol 1997:73:1-4 Tranquilli AL, et al., Am J Obstet Gynecol 1997;177:245-246
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 2000;356:1677-80
Autonomy and informed consent
Full and umbiased information (better=efficacy and worse=risks)
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 2000;356:1677-80
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) Unnecesary C- section ?
Ambiguity of terms
Natural as desirable
Natural as hazardous
C-section as safe C-section as beneficial for doctors
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
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
What do we need
1.
RCT: intention of labor vs elective c-section
2.
To accept that is a cultural phenomena

Need of a medical and non medical
3.
approach
4.
Informed Consent
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.
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
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
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
Thank you.
-Dr. Mario SebastianiAsociacin Argentina de Ginecologa y Obstetricia Psicosomtica Servicio de Obstetricia. Hospital Italiano de Buenos Aires. Argentina

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Do we have a definition of an unnecessary cesarean section?

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;4367.

Outcome based study

59 hospitals 1988 - 1992

Perinatal mortality Rate of asphixia

Minimum cesarean section rate is optimal

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

Outcome based study

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

More intervensionist approach in low

M, et al., J Epidemiol Community Health 1994;48:406 - 11

Healthy People 2000 1

Department of Health and Human Services 15 % by the year 2000

Healthy People 2000; DHHS publication N. (PHS) 91-50212.

Grafic I: Incidence of ceasarean secton in Latin American

Belizn JM, et al, BMJ 1999;319:1397 -402

Grafic I: Incidence of ceasarean secton in Latin American

Belizn JM, et al, BMJ 1999;319:1397 -402

Rates and implications of caesarean sections in Latin America: ecological study

Over 850.000 unnecesary c-sections are performed

Increased use of electronic fetal monitoring

Difficulties for the analysis

Difficulties for the analysis

Medical and non medical reason

Difficulties for the analysis

Is there a different view ?

Who are involved ?

Who are involved ?

Factors involved in decision

Autonomy - C-section on demand?

Unexplained fetal deaths

Could C-S reduce fetal death rate?

Cotzias C, et al., BMJ, 319,31 july 1999 Unnecesary C- section ?

Could C-S reduce fetal death rate?

Factors involved in decision

Autonomy - C-section on demand?

Effect of Mode of Delivery in Nulliparous Women on Neonatal Intracranial Injury

1: 2750 c-section with no labor

Factors involved in decision

Autonomy - C-section on demand?

The most conservative recomendations.

ACOG Technical Bulletin. Vaginal delivery after a previous cesarean birth.

Int J Gynecol Obstet 48:127 129; 1995.

ACOG Vaginal birth after a previous cesarean.

ACOG Practice Bulletin N 5:1 8; 1999.

Over 1000 reports: not one RCT

Over 1000 reports: not one RCT

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

Factors involved in decision

Autonomy - C-section on demand?

Labor unit: a prolonged and difficult labor, even

Elective repeated cesarean delivery $ 7.700

Normal vaginal delivery

Elective repeated cesarean delivery $ 7.700

Normal vaginal delivery

Difficulties in the estimation of costs

lenght > medical costs > nursing costs

Malkin J, et al., Birth 2001;28:208-9

Factors involved in decision

Autonomy - C-section on demand?