Download C-Section

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
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
No benefit
Rate of asphixia
Minimum cesarean section rate is optimal
1 Eckerlund
Unnecesary C- section ?
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
Unnecesary C- section ?
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
Unnecesary C- section ?
Healthy People 2000; DHHS publication Nº. (PHS) 91-50212.
Latin America
Grafic I: Incidence of ceasarean secton in Latin American
W.H.O.
Chile
Brazil
México
Argentina
Uruguay
El Salvador
Paraguay
Bolivia
0
5
Unnecesary C- section ?
10
15
20
25
30
35
40
Belizán JM, et al, BMJ 1999;319:1397 -402
Grafic I: Incidence of ceasarean secton in Latin American
W.H.O.
Chile
Brazil
México
Argentina
Uruguay
El Salvador
Paraguay
Bolivia
0
5
Unnecesary C- section ?
10
15
20
25
30
35
40
Belizán JM, et al, BMJ 1999;319:1397 -402
“Rates and implications of caesarean sections
in Latin America: ecological study”
Belizán JM, et al, BMJ 1999;319:1397 -402

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
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.
Fear of malpractice litigation
3.
Increased use of epidural anesthesia ?
4.
Increased use of electronic fetal monitoring
5.
The convenience of physicians
Unnecesary C- section ?
Sachs BP et al., NEJM 1999;340:54 – 57
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
5.
Pelvic floor damage
6.
Maternal mortality
7.
Cultural factors
8.
Autonomy - C-section on demand?
Unnecesary C- section ?
“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
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 C-S reduce fetal death rate?

5 times more frequent than SIDS

Termination of pregnancy when fetal risks in útero
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 útero
are larger than the risks of the newborn: 1/500

Most of fetal deaths occur in non-malformed
fetuses

Women’s preference: C-section of the risk is
> 1:4000 1
Cotzias C, et al., BMJ, 319,31 july 1999
1
Unnecesary C- section ?
Thornton E, et al., J Obstet Gynecol 1989;9:283-8
Factors involved in decision
1.
Fetal mortality and morbidity
2.
Newborn health
3.
VBAC
4.
Cost
5.
Pelvic floor damage
6.
Maternal mortality
7.
Cultural factors
8.
Autonomy - C-section on demand?
Unnecesary C- section ?
“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
Unnecesary C- section ?
Factors involved in decision
1.
Fetal mortality and morbidity
2.
Newborn health
3.
VBAC
4.
Cost
5.
Pelvic floor damage
6.
Maternal mortality
7.
Cultural factors
8.
Autonomy - C-section on demand?
Unnecesary C- section ?
Frequency of cesarean section, primary cesarean and vaginal
birth post-c-section between 1989 - 2001
VBAC
30
25
All c-sections
20
% 15
Primary c-section
10
5
0
89
91
93
95
97
99
2001
Año
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.
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 wellbeing, are driving the goal of fewer
cesarean sections ? 1
1 Clark
Unnecesary C- section ?
S., et al., Am J Obstet Gynecol 2000;182:599-602
Factors involved in decision
1.
Fetal mortality and morbidity
2.
Newborn health
3.
VBAC
4.
Cost
5.
Pelvic floor damage
6.
Maternal mortality
7.
Cultural factors
8.
Autonomy - C-section on demand?
Unnecesary C- section ?
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.
Unnecesary C- section ?
Costs of deliveries
Beth Israel Deaconess Medical Center, Boston, USA

Elective repeated cesarean delivery $ 7.700

Normal vaginal delivery

Intrapartum Cesarean:
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:

Complication
•
Mother: + $ 4.000
•
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

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
Unnecesary C- section ?
Malkin J, et al., Birth 2001;28:208-9
Factors involved in decision
1.
Fetal mortality and morbidity
2.
Newborn health
3.
VBAC
4.
Cost
5.
Pelvic floor damage
6.
Maternal mortality
7.
Cultural factors
8.
Autonomy - C-section on demand?
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
etiologic role of parturition-related nerve damage in
development of pelvic floor disfunction...”1
1
Unnecesary C- section ?
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
Unnecesary C- section ?
Factors involved in decision
1.
Fetal mortality and morbidity
2.
Newborn health
3.
VBAC
4.
Cost
5.
Pelvic floor damage
6.
Maternal mortality
7.
Cultural factors
8.
Autonomy - C-section on demand?
Unnecesary C- section ?
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 ?
Factors involved in decision
1.
Fetal mortality and morbidity
2.
Newborn health
3.
VBAC
4.
Cost
5.
Pelvic floor damage
6.
Maternal mortality
7.
Cultural factors
8.
Autonomy - C-section on demand?
Unnecesary C- section ?
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
Women’s body are perceived as sexual than
maternal
Genitals are perceived for sexual activity than
for childbearing
Nuttall C., et al., BMJ 2000;320:1072
Unnecesary C- section ?
Factors involved in decision
1.
Fetal mortality and morbidity
2.
Newborn health
3.
VBAC
4.
Cost
5.
Pelvic floor damage
6.
Maternal mortality
7.
Cultural factors
8.
Autonomy - C-section on demand?
Unnecesary C- section ?
Cesarean section on demand

31% of female obstetricians would prefer a
cesarean delivery for themselves 1
1
Unnecesary C- section ?
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
Unnecesary C- section ?
1
Al-Muffti et al. Eur J Obstet Gynecol Reprod Biol 1997:73:1-4
2
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 woman’s right
to refuse a cesarean delivery

Nobody is interested in respecting woman’s
desire to refuse vaginal delivery
Wagner M et al., Lancet 2000;356:1677-80
Unnecesary C- section ?
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
Unnecesary C- section ?
Autonomy and informed consent
“...performing cesarean section for non medical
reasons is ethically not justified....”
Committee for the Ethical Aspects of Human Reproduction
and Women’s 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
Unnecesary C- section ?
Natural (phylosophy of terms)

To approve or excuse a behavior. Unnatural

Ecologist’s 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
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)

Artificial is better than natural. Which is the
meaning of arts? (Savater)

Human Life is precisely to be different from
nature
Unnecesary C- section ?
What do we need
1.
RCT: intention of labor vs elective c-section
2.
To accept that is a cultural phenomena
3.
Need of a medical and non medical
approach
4.
Informed Consent
Unnecesary C- section ?
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
women’s informed consent regarding the
aspects of birth.
Unnecesary C- section ?
To think

The nature of birth is related with the female’s
function as a reproductive agent. Is the same
for the women’s condition?

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,
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...”
William Benson Harer
Unnecesary C- section ?
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
Unnecesary C- section ?
Thank you.
-Dr. Mario SebastianiAsociación Argentina de Ginecología y Obstetricia Psicosomática
Servicio de Obstetricia. Hospital Italiano de Buenos Aires. Argentina