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Safe

Prevention
of the
Primary
Melinda Weiss, DO PGY3
April 1, 2016

Objectives
Describe the trend of cesarean section (CS) in

the United States


Name the most common causes of CS
Identify risk factors for CS
Recognize the difference between old and new

labor descriptions
Describe the recommended interventions to

decrease CS

Background
1996-2011: rapid increase in CS rate
2011: 1/3 women delivered via CS
No evidence of concomitant decrease in

maternal or neonatal morbidity or mortality

Balancing risks and benefits


Safest route in placenta previa or uterine

rupture
For low risk pregnancies, CS has greater risk of

maternal morbidity and mortality than VD


Difficult to isolate morbidity caused specifically

by route of delivery

RCT of breech to undergo CS or VD

3mo f/u: urinary but not fecal incontinence in VD

But this difference no longer significant at 2yr f/u

Compared to VD, CS has a _____ fold risk of

severe maternal morbidities, defined as:

hemorrhage requiring

uterine rupture

anesthetic complications: shock, cardiac arrest,


acute renal failure, assisted ventilation

VTE

major infection, or in-hospital wound disruption


or hematoma

Long term risks with CS


Subsequent pregnancies, risk of:

Placental abnormalities

Previa (1% with 1 prior CS, almost 3% with >3 prior


CS, AND >40% accreta risk)

These increase neonatal morbidity in addition to


maternal morbidity

NICU admission

Perinatal death

What is our state CS rate?

CS Rates

Variation across:

States: 23-40%

Hospitals: 7.1-69.9%

Low-risk women: 2.4-36.5%

Role of maternal charactersitics (age, weight, and


ethnicity) do NOT fully account for temporal
increase in CS or regional variation

Suggests that other potentially modifiable factors,


ie patient preferences, practice variation across
systems and practitioners likely contributes to rising
rate

What are the most common indications for CS?

Labor dystocia
NRFHT
Malpresentation
Multiple gestation
Suspected macrosomia

*2011 data

What are the most common indications for CS?

Labor dystocia
NRFHT

>50%

Malpresentation
Multiple gestation
Suspected macrosomia

*2011 data

Sowhat is abnormal labor?


Labor definitions

Old: Active phase (4cm)

Nullip: 1.2cm/hr

Multip: 1.5cm/hr

Updated: Active phase (6cm) Zheng

Nullip: 0.5-0.7cm/hr

Multip: 0.5-1.3cm/hr

From 4-6cm: women dilate the same; after 6cm,


multips dilate faster

Abnormal labor?
Prolonged latent phase

Nullip: >20 hours

Multip: >14 hours

Is prolonged latent phase indication for delivery?

Nope.

Induction

Use cervical ripening

In latent phase, if FHT is reassuring and maternal and fetal statuses


are stable, do not intervene lower CS rate

Latent phase is LONGER in IOL compared to spontaneous

3 studies have shown IOL patients in latent labor 12-18 hours with
pitocin and ROM will deliver vaginally if induction is continued

ROM and pitocin should be considered prerequisites to any


definition of failed labor induction

failed induction of labor in the latent phase can be avoided by


allowing longer durations of the latent phase (up to 24 hours or
longer) and requiring that oxytocin be administered for at least 12
18 hours after membrane rupture before deeming the induction a
failure

Effect of induction of labor


Induction rate increased 9.5%-23.1% (1990-

2008)
Comparing IOL to spontaneous labor IOL

associated with increase CS

WRONG

Comparing IOL to expectant management

no difference or decreased CS rate


Cervical ripening

New definition for first stage arrest

From ACOG PB 107 Induction of Labor


Allowing at least 12-18 hours of latent labor
before diagnosing a failed induction may
reduce the risk of cesarean delivery.

Second stage neonatal outcomes

In nullips, adverse neonatal outcomes generally have not been associated


with the duration of the second stage of labor

In a secondary analysis of a multicenter randomized study (4,126 women) none


of the following neonatal outcomes was found to be related to the duration of the
second stage (some cases >5 hours)

umbilical artery pH less than 7.0

intubation in the delivery room

need for admission to NICU

neonatal sepsis

Secondary analysis of 1,862 women enrolled in an early versus delayed


pushing trial

5-minute Apgar score of less than 4

longer duration of active pushing NOT not associated with adverse neonatal
outcomes (even in >3hours pushing)

Retrospective cohort study of 15,759 nulliparous women found no adverse


effects in second stage >4 hours

Less data in multiparous women

Second stage maternal outcomes


Higher rates of:
infection
3rd and 4th degree lacerations
Postpartum hemorhage
For each hour of second stage, chance of VD

decreases

>3 hours, only 1/4 nulliparous women and 1/3


multiparous women deliver vaginally

Second stage interventions?

Longer expectant management

Operative vaginal delivery

Overall rate has decreased in past 15 years

No difference in serious morbidity (neonatal death


or intracerebral hemorrhage) between operative
deliveries and CS

<3% of women with operative delivery go on to CS

Manual rotation of fetal occiput

Forceps

No increase in cord prolapse (731 women)

Second stage recommendations

Conflicting data?

AJOG April 2014


Currently available evidence does not support

safety of longer second stage


3 reports where data were inappropriately

adjusted for mode of delivery

NRFHT interventions

Most tracings are Cat II

Accelerations (spontaneous or elicited) are


associated with normal umbilical cord arterial pH
(>7.20)

No current data supporting interventions for


decelerations with atypical features (such as
shoulders, slow return to baseline, or variability only
within the deceleration) they have not been
associated with fetal acidemia

Recurrent variablesare not themselves


pathologic. However, if frequent and persistent, they
can lead to fetal acidemia over time (sources from 1980s-90swhat?)

Other causes
Malpresentation (Breech) : 3.7% of pregnancies, 85% of

persistent breech are delivered via CS ECV


underutilized
Suspected macrosomia: CS only offered if 5,000g non-

diabetic, 4,500g diabetic


Excessive maternal weight gain: dont do it
Twins: CS rate 53%-75% (1995-2008), even vertex

presenting twins 45-68%


HSV: suppress 3-4 weeks before delivery

References

Obstetric care consensus: Safe prevention of the


primary cesarean delivery. ACOG, SMFM. 2014.

Preventing the First Cesarean Delivery: Summary


of a Joint Eunice Kennedy Shriver National Institute
of Child Health and Human Development, Society
for Maternal-Fetal Medicine, and American College
of Obstetricians and Gynecologists Workshop, 2012

ACOG PB 109: Induction of Labor. Reaffirmed 2015.

Leveno, K., et al. Second-stage labor: how long is


too long? AJOG 214(4) 484-489. April 1, 2016.