ABCDs of Childbirth Avoiding Birth By Cesarean. B J Snell, PhD, CNM, FACNM Marlin D. Mills MD, MCC MOD March 18, 2014

Transcription

1 ABCDs of Childbirth Avoiding Birth By Cesarean B J Snell, PhD, CNM, FACNM Marlin D. Mills MD, MCC MOD March 18, 2014

2 Disclosures We want to thank our mothers and children - and those that have allowed us into the special time of their births! We are honored to be the messengers for work done by the dedicated and bright individuals throughout our discipline. And I also thank my Mother! And None of the artwork displayed is mine.

3 Goals of today s discussion To review briefly the influences in the rise of the cesarean delivery rate and what can we learn from this history. What are the risks of cesarean delivery vs vaginal delivery. Why the focus on the NTSV patient. Where are the variations in cesarean delivery rates and how might those variation be reduced. Re-visit / redefine ways to avoid a cesarean delivery when vaginal delivery is anticipated.

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6 How did we get such a high Cesarean delivery rate?

7 How did we get such a high Cesarean delivery rate? Transverse uterine/vaginal incisions Munro Kerr Low cervical/ LUS cesarean Early 1900 s Industrialization and urbanization results in epidemic of Rickets. 1930s Safe Milk program of adding Vitamin D to milk eliminated rickets, however, the rate of delivery by cesarean did not decrease

8 How did we get such a high Cesarean delivery rate? 1940 Penicillin, discovered in 1928, by Alexander Fleming becomes a drug Hill-Burton Act Hospital and Medical Research Financing 1950 s - Concept of taking wage increases in the form of health insurance benefits

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10 How did we get such a high Cesarean delivery rate? Little and Freud Defined Cerebral Palsy and related the occurrence to events of childbirth. 1970s Development of the concept of the fetus as a patient Electronic fetal monitoring Scalp sampling for acidosis Ultrasound s Regional Anesthesia Spinal, Epidural 1970 Cesarean delivery rate was 5%, by 1988 this had increased to 24.7 %

11 Background/Influences Most common admission diagnosis to hospitals in US Childbirth Most common surgery performed in US Cesarean Section Moved from pregnancy/childbirth as a normal process to a fear based high-risk until proven otherwise process

12 Background/Influences Technology Monitoring Pharmaceuticals Medications and anesthesia Societal expectations From everyone does it (birth) versus no one can do it (birth)

13 Background/Influences Professional shifts Midwifery led care converted to physician managed care Woman driven care converted to control driven care Support was foundation for care with woman as the center of focus converted to technology being the foundation and the center of focus

14 US Delivery Rates

15 What has the trend been? Data on scar separation was no different in 70 s-80 s when VBACs were promoted then in 2000 when VBACs were too risky The data for VBACs with spontaneous labor did not change the change was in those where prostaglandin ripening and oxytocin were used.

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17 Operative Vaginal Delivery rates

18 Risks associated with Cesarean Delivery The 90s 90% of patients delivering by cesarean delivery will deliver their next pregnancy by cesarean 90% of patient delivering by vaginal delivery will deliver their next pregnancy by vaginal delivery.

19 Delivery risks Obstetric Care Consensus. Safe prevention of the primary cesarean delivery Obstet Gynecol 123 (3):

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22 Risks of previous cesarean delivery The risk of placenta accreta is highest in patients with both prior cesarean birth and placenta previa (placenta previa also increases with prior cesarean births). Silver, et al. reported proportionaly increased risk of placenta accreta with higher numbers of prior cesareans in women with or without placenta previa (See Table). CMQCC. Placenta Previa and Placenta Accreta by Number of Cesarean Deliveries Cesarean Delivery Previa Previa*: Accreta N (%)No Previa : Accreta N (%) First (3.3%) 2 (0.03%) Second (11%) 26 (0.2%) Third (40%) 7 (0.1%) Fourth (61%) 11 (0.8%) Fifth 6 4 (67%) 2 (0.8%) >6 3 2 (67%) 4 (4.7%) Silver RM, Maternal morbidity associated with multiple repeat cesarean deliveries. Obstetrics and Gynecology 2006 Jun;107(6):

23 Should there be a benchmark? WHO has said over 15% reflects an unhealthy society In US, 33% is national average (1 in 3) In our area the rate is well over 40% in many institutions 15-25% cannot be attributed to high-risk patients! That many women cannot have broken systems

24 Is there a lower threshold for performing cesarean section? Beliefs that c/s protects both mother and baby from adverse events Different views on management of labor and delivery (birth) Organizational barriers -> VBAC Professional barriers -> OOH birth Societal intolerance for poor outcomes Too many experiences of blaming individual or system for poor outcome

25 Total Rate vs Categorized Rate Context of the discussion will be low risk, term pregnancies While the total rate is 33% it is important to drill down to identify those factors that are most related to the outcome Many providers and institutions are aware of the published literature that identifies rates and opinions but there is little knowledge of own or individual institution rates In past there have been two large categories that have been used as indication for cesarean section Fetal distress (intolerance to labor) Dystocia

26 Most important factors Reduce the primary cesarean section rate! Term breeches at this point a sacred cow Maternal request what is maternal request today becomes medical indication in the future! Literature has not provided good evidence and indications remain opinion based Quality monitoring program to review individually and as group/institution Need to determine how to categorize

27 Quality/Risk Management Program Two types of data available Epidemiologic/demographic data Interventions versus events versus outcomes Cesarean section indications have been difficult to define and implement consistently Prelabor cesarean section should be classified based on fetal, maternal or non medical indications Elective versus emergency (non-elective) Elective planned, carried out in regular working hours, >39 weeks gestation, in woman that is not in labor or has been induced Non-elective reason for c/s to be described

28 Robson, et al, 2012 Studied overall caesarean section rate in the National Maternity Hospital for /9250 (21.4%) and developed a TGCS allowing for the critical assessment of perinatal care Discussions about reducing caesarean section rates without taking other factors into account are at best inappropriate and at worst dangerous it is not that a caesarean section rate is high or low but rather whether it is appropriate or not, after considering all the relevant information.

29 Category TGCS and Contribution to Overall C/S Rate Contribution 1. Nulliparous, single cephalic, 37 weeks, in spontaneous 1.9 labour 2. Nulliparous, single cephalic, 37 weeks, induced or CS 5.1 before labour 3. Multiparous (excluding prev. C/S), single cephalic, 37 weeks, 0.3 in spontaneous labour 4. Multiparous (excluding prev. CS), single cephalic, 37 weeks, 1.2 induced or CS before labour 5. Previous C/S, single cephalic, 37 weeks All nulliparous breeches All multiparous breeches (including previous c/s) All multiple pregnancies (including previous c/s) All abnormal lies (including previous c/s All single cephalic < 36 weeks (including previous c/s) 1.4

30 Reducing C/S Of the categories above, 1, 2, and 5 contributed to twothirds of the cesarean sections Nulliparous, single cephalic, 37 weeks, in spontaneous labour (1.9) Nulliparous, single cephalic, 37 weeks, induced or CS before labour (5.1) Previous C/S, single cephalic, 37 weeks (6.2)

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32 Let s reduce the Cesarean rate, but how? Keep it simple Successful vaginal delivery in the first birth increases success with subsequent births Focus on the main sources of variation Stratify Risk NTSV rate meets all of the above qualifications 40% of all births accounts for 98% of institutional variation and 60% of the rise in cesarean deliveries over the last 10 years. Brennan DJ Am J Obstet Gynecol 2009: 201:308 e1-8

33 Birth Rates

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35 Indications with the greatest effect on Cesarean Delivery (NTSV) rate Failed Induction Arrest of labor Indeterminate (non-reassuring) fetal heart rate pattern Malpresentation Obstet Gynecol

36 Induction of Labor Evaluate for indications of induction of labor prior to the onset of labor Induction of labor at 41 0/7 weeks gestation indicated, to reduce the risk of cesarean If induction indicated, use cervical ripening techniques. Obstet Gynecol

37 Friedman Curve: An Obstetrical Landmark 1955 Primigravid Labor A graphicostatistical analysis 504 births CS rate 1.8% Low forceps rate 51.2% 14 breech 4 twins 4 stillbirths Oxytocin use 13.8% Caudal anesthesia 8.4%

38 Reassessing the Labor Curve in Nulliparous Women Zhang J, Troendle JF, Yancey MK. Am J Obstet Gynecol Oct;187(4): nullipara, Singleton, term, vertex presentations Spontaneous onset of labor Repeated-measures regression with 10 th order polynomial function to produce the average labor curve

39 First Stage End Reassessing the labor curve in nulliparous women. Zhang J, Troendle JF, Yancey MK. Am J Obstet Gynecol Oct;187(4):

40 The Natural History of the Normal First Stage of Labor Zhang J, Troendle J, Mikolajczyk R, Sundaram R, Beaver J, Fraser W. Obstet Gynecol Apr;115(4): ,838 nullipara Singleton, term, vertex presentations Spontaneous onset of labor Delivered between CS rate 2.6% Induction rate 7.1% Forceps 73% Repeated measures, 8 th degree polynomial

41 First Stage End Reassessing the labor curve in nulliparous women. Zhang J, Troendle JF, Yancey MK Am J Obstet Gynecol Oct;187(4):

42 First Stage End Impact of fetal gender on the labor curve. Cahill AG, Roehl KA, Odibo AO, Zhao Q, Macones GA. Am J Obstet Gynecol Apr;206(4):335.e1-5. Epub 2012 Jan

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44 Average labor curves by parity in singleton, term pregnancies with spontaneous onset of labor, vaginal delivery and normal neonatal outcomes. P0: nulliparas; P1: women of parity 1; P2+: women of parity 2 or higher.

45 First stage of labor 1. Do not use previous definitions of prolonged latent phase. Instead up to 24 hours or longer may be considered or At least hours of oxytocin after ruptured membranes. Slow, but progressive labor in the first stage of labor should not be an indication for cesarean 6 cm should be considered the threshold for active phase of labor.

46 Diagnosis of Active Phase Beyond 6 cm dilated Ruptured membranes Arrest Failure to progress after 4 hours with adequate uterine activity or Failure to progress with 6 hours of oxytocin, with inadequate uterine activity and no cervical change.

47 Second stage of labor Diagnose arrest of second stage of labor only after: At least 2 hours of pushing in multiparous women At least 3 hours of pushing in nulliparous women Add an additional hour if epidural used or malposition present, as long as progress is present. Operative vaginal delivery is a safe alternative to cesarean, by experienced and well trained physicians. Consider manual rotation of fetal malposition Obstet Gynecol

48 Electronic Fetal Heart Rate Monitoring Category II algorithm Amnioinfusion for variable decelerations Consider scalp stimulation Obstet Gynecol

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50 Significant decelerations Variable decelerations lasting longer than 6 seconds and reaching a nadir more than 60 bpm below the baseline Variable decelerations lasting longer than 60 seconds and reaching a nadir less than 60 bpm regardless of the baseline Any late decelerations of any depth Any prolonged deceleration, as defined by NICHD. Due to the broad heterogeneity inherent in this definition, identification of a prolonged deceleration should prompt discontinuation of the algorithm until the deceleration is resolved

51 Malpresentation Document fetal presentation at 36 0/7 weeks Consider external cephalic version Obstet Gynecol

52 Suspected fetal Macrosomia Cesarean delivery for >5000 gms in women without diabetes, or 4500 gms with diagnosis of diabetes Consider only selective use of ultrasound to estimate fetal weight in the term patient. Obstet Gynecol

53 Other Avoid excessive weight gain Consider vaginal delivery for twin gestations where the presenting twin is vertex. Encourage research and training to better guide decisions regarding cesarean delivery. Obstet Gynecol

54 Let s reduce the Cesarean rate, but how? Avoid the term elective cesarean. If it is non-medically indicated, say so. Wait for spontaneous labor. In medically indicated inductions, with an unfavorable cervix, use cervical ripening techniques. Follow labor and FHR algorithms to reduce variation in management.

55 Let s reduce the Cesarean rate, but how? Labor Manager: Hospitalist Dedicated group member Midwife When discussing a first cesarean with a patient, counseling should include the effect on subsequent pregnancies, uterine rupture, placenta accreta.

56 The 3 or 4 Ps The traditional 3-Ps: The Passage The Passenger The Power A fourth P Psyche: for women who feel overwhelmed, the psychological stress added to the physical stress interferes with labor progress -fear -mothers confidence in her ability -support she receives -response from health care workers -labor environment

57 The New 3 Ps Patients Providers Payors

58 Changing culture Patients Education regarding risks Peer support for decision to labor, value of vaginal birth Reducing fear, education regarding the process of labor, realistic expectations Monitored Exposure role of a birth attendant, doula

59 Changing Culture Leadership Clear expectations Hard Stops Effective Peer review, provide comparative data Identify successes Consider alternatives for low risk patients OB Fears of liability, bad outcomes Competing pressures, 2 places at the same Experience and confidence Nursing Value of labor support and influence on success Flexibility, patience Experience

60 Quality Measures for NTSV Rate of Non-Medically indicated Inductions Rate of Non-Medically indicated Cesarean Deliveries Rate of cesarean deliveries for Dystocia, not meeting accepted criteria Rate of cesarean deliveries for intermediate fetal heart rate patterns.

61 Data: NTSV C/S Rate by Provider 0% 25% 50% 75% 100%

62 Choice of Cesarean in ambiguous cases Fuglenes, D Am J Obstet Gynecol 2009; 200: 48.e1-48.e physicians surveyed with 5 ambiguous clinical scenarios Questions to measure risk attitude Fear index Complaints to employers Criticism by colleagues Litigation threats Complaints to the System of Compensation to Patients Complaints to the Board of Health Supervision

63 Choice of Cesarean in ambiguous cases Fuglenes, D Am J Obstet Gynecol 2009; 200: 48.e1-48.e8. The choice for cesarean across the scenarios ranged from 8-60%. In scenario # 1-24% strongly preferred cesarean delivery whereas 7% strongly preferred vaginal delivery In some scenarios, preference for cesarean increased when informed that the patient was either a physician or a lawyer The fear index (perceived risk of complaints or malpractice litigation was a clear determinant of choice of cesarean in ambiguous cases

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65 Things that promote vaginal birth in women in spontaneous labor Do not admit until in active labor Use ambulation and upright positions Continuous labor support Non-pharmacologic methods of pain relief Use of pain scale Nutrition rather than IV fluids exclusively Allowing woman to maintain control Quiet, respectful environment

66 Mother-Friendly Childbirth Initiative Developed by the Coalition for the Improvement of Maternity Services, 1996 Evidence-based mother-, baby-, and family-friendly model focuses on prevention and wellness as the alternatives to high-cost screening, diagnosis, and treatment programs Based on 7 evidence based concepts Underlying principles/cornerstones that affect mother-friendly care Normalcy of birth philosophy physiologic birth Empowerment Autonomy Do no harm Responsibility 10 Steps to achieve Mother-Friendly Care while it is not the cumbersome process of the Baby-Friendly Initiative it is a roadmap to improve care and can impact cesarean section rate

67 Other factors that impact spontaneous labor and vaginal birth Electronic fetal monitoring impedes Water immersion support Friedman curve impedes Racial differences play a role (Hispanic and American Indian) Midwifery managed care support Use of amniotomy and oxytocin impedes (unless only option) Birth Center (non-hospital based) - support

68 Birth Centers-A Viable Option Examines outcomes of birth center care in the present maternity care environment prospective cohort study of women receiving care in 79 midwifery-led birth centers in 33 US states from 2007 to 2010 Analysis was by Intention-to-treat 15,574 women who planned and were eligible for birth center birth at the onset of labor Originally 22,403 completed records in data base 13.4% were tx during antepartum period for complication with pregnancy Stapleton 2013 JMWH

69 Birth Centers-Outcomes of Care Results: based on 15,574 who were eligible for BC admission 84% gave birth at the birth center 4% tx prior to admission to birth center; 12% tx after admission to birth center 93% gave birth as SVD 1% assisted vaginal 6% cesarean section 2.4% postpartum transfer after birth in BC 2.6% newborn transfer after birth in BC 1.9% emergent transfer of either mother or baby

70 Beachside Birth Center Overall C/S rate - 7.5%

71 Labor management has been controlled by the clock Use of information from the 1950s dominate management (beginning to change) No good benchmark On The Clock Fear based system you never get sued for doing a C/Section

72 Solutions So here is where we are Where are we going How are we going to get there

73 Reducing C/S Rates Encourage culture change Develop a system to categorize women in labor so that comparisons can be made and identification of those categories that will give the best bang for the buck Utilize evidence based practices and eliminate non-evidence based interventions Provide a mother-friendly system of care eliminating the restrictions now found in traditional care Utilize collaborative care models, the evidence is there!

74 VBAC Success Calculator MU/VGBirthCalc/vagbirth.html Am J Perinatol November ; 26(10): doi: /s

75 Final Tip Never miss a chance to SHUT UP! Thank You! Mark Twain