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What Do the National Data Tell Us?
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32.3 in 2008!
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0
5
10
15
20
25
30
35
2001 2003 2005 2007 2008
North Carolina
Wake County
Orange
Mecklenburg
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0
5
10
15
20
25
30
PRIMARY CESAREAN RATE 2008 (Not identical to NTSV Rate)
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0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
Primary Cesarean Ranking in North Carolina
2 1020 43 45 47 49 51 61 73 85 88
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Maternal request Medical-legal concerns Increasing age of pregnant women Increasing complications in pregnancy Maternal obesity Provider preference Induction of labor protocols Training of providers Increased payment for CS v Vaginal Birth VBAC standards
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Cesarean Birth in the US: Epidemiology, Trends and OutcomesClinics in Perinatology June 2008 McDorman, et al
Rates of no indicated risk CesareansSurrogate for maternal request
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AMA 2003malpracticecrisis states: Arkansas Connecticut Florida Georgia
Illinois Kentucky Mississippi Missouri Nevada NJ NY NC
Ohio Oregon Penn Texas Washington West Virginia Wyoming
Of the five states with highest rates of CS, four are among AMAs 2003malpractice crisis states Of 19 malpractice crisis states, four in highest CS rate group, eight insecond highest group; five in middle group; two in second lowest group
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Declerq et al: No evidence to supportincreasing rates of maternal health problemsas significant cause of rising CS rates
Difficult to disentangle from maternal age-related increases in CS rates
Treat medical problems medically; surgicalproblems, surgically
Robert Cefalo
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BMI < 30 BMI 30 &39.9 BMI 40Oxytocin duration if induced 6.5 hr 7.7 hr 8.5 hr
Time in active labor 14.9 hr 16 hr 19.3 hr
Time in active labor if del vag 14.4 hr 15.2 hr 17.8 hr
Birth Weight 3286 3399 3489
CS 21.3% 29.8% 36.5%
CS for FTP 12.4% 12.0% 22%
36 week of greater, Para 3, singletons; secondary analysisof an RCT
Effect of maternal obesity on duration & outcomes of PGCervical ripening and labor induction. Pevzner et al, Obstetrics &Gynecology, Dec 2009
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No differences: EGA at birth, low 5 min Apgar, congenitalmalformations, intubation of infant, LOS in NICU, PPV
All maternal complications in obese diabetic v non-diabetic motherBaron et al.Journal of Maternal Fetal Neonatal Medicine. 2010; 8; 906-913.
34.9 35Induction 17% 29.4%
Prior CS 10.4% 15.0%
Cesarean 15.9% 26.2%
OR Time 56.4 min 65.2 min
Surgical site infx 3.3% 13.8%
Macrosomia 14.6% 28.6%Apgar@1
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CS rates in privately insured vs publically fundedpatients Closer relationship between doctor/patient therefore
may be harder to withhold a cesarean
Older population in private hospitals
Racial disparities favor private situation Higher rates of cesarean deliveries before
midnight
Different practice styles
Non-random distribution of patients with private doctorsExplaining sources of payment differences in US Cesarean Rates: Why do
privately insured mothers receive more cesareans than mothers who are notprivately insured? Grant D. Health Care Management Science , 2005.
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Increased rate of induction National Center for Health Statistics 2003
Percent of IOL among all U.S. births: 1989 -- 8%
2003 -- 21.6 %
1.31 OR for CS if IOL vs. spontaneous labor Bryant et al; Ped and perinatal epidem. 2009
International analysis in 9 countries looking atclassification of CS, >47,000 births evaluated 38% of all CS in induced nulliparous womenBrennan et al. Comparative analysis of international cesarean delivery rates
using 10-group classification identifies significant variation inspontaneous labor. AJOG 2009
Induction of Labor
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Among patients admitted1-2 cm dilatedOverall Foley (7) Cytotec(1) Cervidil(8) NoRipeningVaginal 49 2 1 6 40
CS 1st
Stage13 2 0 2 9
CS 2nd
Stage2 3 0 0 2
74% Vaginal 28%Vaginal
100%Vaginal
75%Vaginal
78%Vaginal
Among 1st stage c-sections: 5/13 were at 1-3 cmand average birth weight was 2915 grams with alllatent phase CS done for FTP
Sample of data from one hospital inPQCNCs 39 Weeks Project
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1992-2001 at a single hospital in the UK No change in demographics of patients,
birthweight, documented malposition
Increased preference for vacuum over forceps
in 2nd stage: O.2 VE/1 Forceps (1992)1.9 VE/1 Forceps (2001)
Increase failure of operative vaginal delivery
attempts Decreased number of attempts over all
Changing trends in operative deliveryperformed at full dilation over a 10 yrperiod. J Ob GYN 2010 May, Loudon
Provider Training
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Increased reimbursement for CS v vaginal birthlikely not a big factor:
Increasing reimbursement by $1000 for CSassociated with little more than 1% increase inCS rates in model
Physician Financial Incentives and CesareanDelivery: New conclusions from thehealthcare cost & utilization project. DarrenGrant. Journal of Health Economics 2009.
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1985: 5%
1996: 28.3%
2006: 8.5%
NIH 2010 consensus conference: Concernsover liability have a major impact on thewillingness of physicians & healthcare
institutions to offer TOL.
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Hospitals capable of emergency cesarean withresources immediately available
TOLAC not contraindicated with twins,unknown scar if likely LTCS, two prior CS, lowvertical scar
ECV, induction (no cytotec) reasonableoptions
Most women with one prior LTCS should becounseled about VBAC and offer TOLAC
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http://www.bsc.gwu.edu/mfmu/vagbirth.html Increased likelihood of success
Prior vaginal birth Spontaneous labor
Decreased likelihood of success Recurrent indication for initial CS (Dystocia) Increased age Non-white ethnicity EGA > 40 Preeclampsia Short interpregnancy interval Increased neonatal birth weight
Increased risk of uterine rupture Single layer closure with prior surgery Interpregnancy inteval < 18 months Varying data on uterine wall thickness measured at 37-38
weeksnot ready for prime time
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Neonatal Respiratory Morbidity RatesNeonatal Length of Stay
LeastSuccessTOL
CS withLabor
CS withoutLabor
FailedVBAC
Most
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Index pregnancy
Peripartum hysterectomy Primary CS v vaginal delivery:
OR 6.48 Repeat CS v vaginal delivery:
OR 3.69 Peripartum hysterectomy and
cesarean delivery: a population-
based study. Stivanello. Act ObGyn Scan 2010 March
Endometritis 7-10% rates
Wound Infections 5-15%
Post Partum Hemorrhage dueto atony, requiring transfusion
Bateman, Anethesia and Analgesia,May 2010
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NSVD Op. Vag CS no Labor CS w/laborTTN 2.5% 3% 6-7% 5%
RDS 1% 1% 5% 3%
IVH 0.2% 0.1% 0.6% 0.4%
Injury 2% 12% 0.8% 2%
Why higher risk of IVH with CS with NO labor?Those at higher risk for IVH get a CS?CS not as atraumatic as we think?
Why higher risk of neonatal injury with operativedelivery?
Initially declined but over 8 years, rate increasedAssumed to be due to operator experience
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Abnormalplacentation
by prior CS
Abnormalplacentation
with previa
# ofprior CS Clark1985(n=29)MFMU2006(N=91)
None 5% 3.3%
One 24% 11.0%
Two 47% 40%
Three 40% 61%
Four orMore
67% 67%
# of priorCS % of 143None 0.2
One 0.3
Two 0.6
Three 2.3
Four 2.3
Five ormore
6.7
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Maternal Mortality Elective repeat C/S 13.4/100,000
TOL 3.8/100,000
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NTSV(Nulliparous, term, singleton, vertex)
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Nulliparous, > 37 weeks, Singleton, Vertex
OBIndications
for CS
CS byMaternalRequest
NTSV
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Patient education regarding normal course oflabor
Await spontaneous labor
Avoid inductions with unfavorable cervix
Effective cervical ripening using same technique Induce >41 weeks
Admit patients in active labor, not prodromal
Standardize effective pitocin protocol
Labor support
Be patient with prodromal labors
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