Babies On Demand: Cesarean Delivery by Maternal Request

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This powerpoint is a literature review on Cesarean Delivery by Maternal Request (CDMR). It introduces various birthing methods including cesareans and reports on the recent trends of cesarean delivery in the U.S. It then explores CDMR and the trends, issues, and concerns that surround it.

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Babies On Demand: Cesarean Delivery by Maternal Request

  1. 1. Babies on Demand Cesarean Delivery on Maternal Request
  2. 2. Babies on Demand •  What is a Cesarean? –  What are the trends? •  What is Cesarean Delivery on Maternal Request (CDMR)? –  What are the trends? –  What are the concerns? –  What are the reasons women are requesting cesareans? © Anne Geddes •  What next?
  3. 3. Birthing •  Vaginal Birth –  Planned Vaginal Birth: includes vaginal births that require emergency cesareans. © 2009 Nucleus Medical Media, Inc Collard, T., et al. (2008). Cesarean Section. Why women choose it and what nurses need to know. Nursing forWomen’s Health. 12:6. 480-88.
  4. 4. Birthing Interventions • Assisted Vaginal Births (e.g. amniotomy, forceps, vacuum extraction, epidural anesthesia). •  Induction: procedure used to stimulate uterine contractions during pregnancy before labor begins spontaneously. –  Elective: elective inductions are those that are undertaken without definite medical indications © Robin Elise Weiss © iStockPhoto © Robin Elise Weiss © Robin Elise Weiss © iStockPhoto Collard, T., et al. (2008). Cesarean Section. Why women choose it and what nurses need to know. Nursing forWomen’s Health. 12:6. 480-88.
  5. 5. Birthing Interventions •  Cesarean Section: Extraction of the infant, placenta, and membranes through an incision in the maternal abdominal and uterine walls. © 2009 Nucleus Medical Media, Inc Collard, T., et al. (2008). Cesarean Section. Why women choose it and what nurses need to know. Nursing forWomen’s Health. 12:6. 480-88.
  6. 6. Types of Cesareans •  Emergency: procedures initiated after labor has begun due to complications with vaginal delivery Collard, T., et al. (2008). Cesarean Section. Why women choose it and what nurses need to know. Nursing forWomen’s Health. 12:6. 480-88.
  7. 7. Types of Cesareans •  Elective: planned cesarean delivery for a wide range of maternal and fetal indications. •  Medically necessary factors •  Physician-driven factors •  Maternally-driven factors © Nursing for Women’s Health National Institutes of Health State-of-the-Science Conference Statement on Cesarean Delivery on Maternal Request.(2006) NIH Consensus Science Statements. 23 (1) 1-29. Collard, T., et al. (2008). Cesarean Section. Why women choose it and what nurses need to know. Nursing forWomen’s Health. 12:6. 480-88.
  8. 8. Recent Trends of Cesarean Delivery in the U.S. 1996-2007 •  Dramatic increases in cesareans, rising 53% •  Increases across all demographics race, ethnicity, age, and socioeconomic status •  Increases for infants of all gestational ages with preterm infants increasing the greatest •  Increases in all 50 states with rates rising over 70% in six U.S. states Menacker, F., Hamilton, B.E. (2010). Recent trends in cesarean delivery in the United States. NCHS Data Brief. 35. National Center for Health Statistics.1-8.
  9. 9. Recent Trends of Cesarean Delivery in the U.S. 2007
  10. 10. Recent Trends in Cesarean Delivery in the U.S. 35 Cesareans per 100 live births 30 25 20 15 1991 1995 1999 2003 2007 Year Figure 1. Cesarean delivery rates in the United States, 1991-2007. Source: CDC/NCHS. National Vital Statistics System. Menacker, F., Hamilton, B.E. (2010). Recent trends in cesarean delivery in the United States. NCHS Data Brief. 35. National Center for Health Statistics.1-8.
  11. 11. Birthing Methods In the U.S. Primary Elective Pre-Labor Cesarean Delivery as a percentage of all Cesarean Deliveries in the US in 2001 28% Cesarean Births "Primary Elective" Pre-Labor Cesearean Births 72% National Institutes of Health State-of-the-Science Conference Statement on Cesarean Delivery on Maternal Request.(2006) NIH Consensus Science Statements. 23 (1) 1-29.
  12. 12. Why the Rise? •  Multiparious Women –  More repeat cesarean –  Less VBAC procedures •  Advancement in Technology –  More multiple Births due to fertility treatment –  More older women giving birth –  More inductions •  Physician Driven Factors –  Physician Practice Patterns –  Physician Convenience –  Legal Pressures •  Maternally Driven Factors –  Cesarean Delivery on Maternal Request (CDMR) Menacker, F., Hamilton, B.E. (2010). Recent trends in cesarean delivery in the United States. NCHS Data Brief. 35. National Center for Health Statistics.1-8.
  13. 13. Should Rising Cesarean Rates Be a Concern? •  In 2007, 1.4 million women had cesarean birth –  Number of cesarean births has increased 71% since 1996 •  Cesarean Sections are major abdominal surgery –  Associated with higher rates of •  Surgical complications •  Maternal re-hospitalization •  Complications requiring neonatal ICU admission –  Associated with higher costs •  Nearly double that of vaginal birth National Institutes of Health State-of-the-Science Conference Statement on Cesarean Delivery on Maternal Request.(2006) NIH Consensus Science Statements. 23 (1) 1-29. Collard, T., et al. (2008). Cesarean Section. Why women choose it and what nurses need to know. Nursing forWomen’s Health. 12:6. 480-88. Menacker, F., Hamilton, B.E. (2010). Recent trends in cesarean delivery in the United States. NCHS Data Brief. 35. National Center for Health Statistics.1-8.
  14. 14. Projected Trends in Cesarean Delivery in the U.S. 40 Cesareans per 100 live births R² = 0.74127 35 30 25 20 15 1991 1995 1999 2003 2007 2011 2015 Year Figure 1. Cesarean delivery rates in the United States, 1991-2007. Source: CDC/NCHS. National Vital Statistics System. Menacker, F., Hamilton, B.E. (2010). Recent trends in cesarean delivery in the United States. NCHS Data Brief. 35. National Center for Health Statistics.1-8.
  15. 15. What is Cesarean Delivery on Maternal Request (CDMR)? •  CDMR: a cesarean delivery for a singleton pregnancy on maternal request at term in the absence of any medical or obstetric indications. •  Why is CDMR difficult to define? –  Not easily identifiable •  What descriptions are included in CDMR? –  Cesarean delivery with no labor or medical indication –  Cesarean delivery with “no indicated risk” –  Cesarean section by choice (CSBS). National Institutes of Health State-of-the-Science Conference Statement on Cesarean Delivery on Maternal Request.(2006) NIH Consensus Science Statements. 23 (1) 1-29. Collard, T., et al. (2008). Cesarean Section. Why women choose it and what nurses need to know. Nursing forWomen’s Health. 12:6. 480-88.
  16. 16. Recent Trends of Cesarean Delivery on Maternal Request (CDMR) in the U.S. •  2006 estimates of CDMR are between 4% and 18% of all cesareans but the validity of these estimates are questionable. © Anne Geddes National Institutes of Health State-of-the-Science Conference Statement on Cesarean Delivery on Maternal Request.(2006) NIH Consensus Science Statements. 23 (1) 1-29.
  17. 17. Birthing Methods in the U.S. Birthing Method Prevalence Per 100 Live Births in U.S. 2001 5% 2% Non-Cesarean Births 17% Cesarean Births Cesarean with "no indicated risk" Cesarean with no labor or 76% medical indication National Institutes of Health State-of-the-Science Conference Statement on Cesarean Delivery on Maternal Request.(2006) NIH Consensus Science Statements. 23 (1) 1-29.
  18. 18. Should Cesarean Delivery on Maternal request (CDMR) Be a Concern? Significant Maternal Outcomes •  Maternal length of hospital stay •  Hemorrhage © East arolina University © VCU Medical Center National Institutes of Health State-of-the-Science Conference Statement on Cesarean Delivery on Maternal Request.(2006) NIH Consensus Science Statements. 23 (1) 1-29.
  19. 19. Should Cesarean Delivery on Maternal request (CDMR) Be a Concern? Significant Neonatal Outcomes •  Respiratory morbidity © www.childrens.com National Institutes of Health State-of-the-Science Conference Statement on Cesarean Delivery on Maternal Request.(2006) NIH Consensus Science Statements. 23 (1) 1-29.
  20. 20. Projected Trends in Cesarean Delivery in the U.S. Projected Trends of Cesarean Section with "No Indicated Risk" and "No Labor or Medical Indication" 10 9 R² = 1 8 7 6 5.5 Linear(No Indicated Risk) 5 R² = 0.78593 4 Linear(No labor or 3 3.3 Linear(No Labor or Medical 2 2.6 Indication)Indication) Medical 1.9 1 0 1991 1993 1995 1997 1999 2001 2003 2005 2007 2009 2011 2013 2015 2017 National Institutes of Health State-of-the-Science Conference Statement on Cesarean Delivery on Maternal Request.(2006) NIH Consensus Science Statements. 23 (1) 1-29.
  21. 21. World Health Organization (WHO) On CDMR •  Recommends a cesarean rate of 15% in developed nations. •  “Unnecessary cesarean section is a classic example of the mismatch between evidence and practice in obstetrics.” •  The increasing cesarean rate does not automatically lead to better outcomes and could be associated with harm. •  Cesarean section with no medical indication is associated with with increased risk of maternal mortality and morbidity. •  Cesarean section for breech presentation is associated with improved perinatal outcomes. •  Mothers who choose cesareans need to make the decision informed of the increased risks. Lumbiganon, Pisake, et al. (2010).Method of delivery and pregnancy outcomes in Asia: the WHO Global Survey on maternal and perinatal health 2007-08. The Lancet.375. 490-499. Villar, J. et al. (2006). Cesarean delivery rates and pregnancy outcomes in the WHO Global Survey for monitoring maternal and perinatal health in Latin America.The Lancet. 367. 1819-29.
  22. 22. Federation of Obstetrics & Gynecology (FIGO) on CDMR •  CDMR is not ethically justified. •  Factors: medical, legal, psychological, social, and financial. •  Surgical intervention with potential risks to mother and child. •  It uses more resources than vaginal delivery. •  Physician duty not to harm and to allocate resources wisely. •  No hard evidence on risks/benefits of CDMR •  Vaginal delivery is safest for mother and child. •  “Natural concern at introducing an artificial method of delivery in place of the natural process with out medical justification.” Christlaw, J.E. (2006). Cesarean section by choice: Constructing a reproductive rights framework for the debate. International Journal or Gynecology and Obstetrics. 94. 262-268.
  23. 23. American College of Obstetrics and Gynecology (ACOG) on CDMR •  Currently a lack of conclusive data for benefits/ risks. •  “Burden of proof ” lies on CDMR advocates. •  Ethical justification for CDMR depends on how it will effect the overall health of the woman and her fetus. •  Not ethically necessary to include CDMR in discussions of birthing options for every patient. Surgery and patient choice: The ethics of decision making. (2003) ACOG Committee Opinion 289. International Journal of Gynecology & Obstetrics. 84. 188-93.
  24. 24. Recent Trends of Cesarean Delivery on Maternal Request (CDMR) •  Cesarean delivery with “no risk indicated” –  Rose from 3.3% of live births in 1991 to 5.5% in 2001 •  Cesarean delivery with no labor or medical indication –  Rose from 1.9% of live births in 2001 to 2.6% in 2003 •  Cesarean delivery by choice –  Italy: Rose from 4.5% in 1996 to 9% in 2000 –  Sweden: Rose 8.9% in 1994 to 15.8% in 1995 –  Taiwan: Rose from 2% in 1997 to 3.5% in 2001 •  Rates may be lower because costs of cesareans are reimbursed at the lower vaginal delivery cost. National Institutes of Health State-of-the-Science Conference Statement on Cesarean Delivery on Maternal Request.(2006) NIH Consensus Science Statements. 23 (1) 1-29.
  25. 25. So, Why are more women requesting Cesareans? Possible Reasons May Include: •  Fear of… –  Birth experience •  Pain •  Terror Management (i.e. previous adverse birth experience) –  Potential maternal consequences •  pelvic organ prolapse •  Urinary and anal incontinence •  Sexual side-effects •  needing an emergency C-section –  Potential fetal consequences •  Health of baby (i.e. birth defects; complications from birth) •  Potential death of baby during birth •  Control and Convenience –  Scheduling Fenwick, J., et al. (2009). Pre- and postpartum levels of childbirth fear and the relationship to birth outcomes in a cohort of Australian women. Journal of Clinical Nursing. 18, 667-77. Kjærgaard, H., et al. (2008). Fear of childbirth in obstetrically low-risk nulliparous women in Sweden and Denmark. Journal of Reproductive and Infant Psychology. 26:4, 340-350.
  26. 26. So, Why are more women requesting Cesareans? Possible Reasons May Include: •  Fear of… –  Birth experience •  Pain •  Terror Management (i.e. previous adverse birth experience) –  Potential maternal consequences •  pelvic organ prolapse •  Urinary and anal incontinence •  Sexual side-effects •  needing an emergency C-section –  Potential fetal consequences •  Health of baby (i.e. birth defects; complications from birth) •  Potential death of baby during birth •  Control and Convenience –  Scheduling Fenwick, J., et al. (2009). Pre- and postpartum levels of childbirth fear and the relationship to birth outcomes in a cohort of Australian women. Journal of Clinical Nursing. 18, 667-77. Kjærgaard, H., et al. (2008). Fear of childbirth in obstetrically low-risk nulliparous women in Sweden and Denmark. Journal of Reproductive and Infant Psychology. 26:4, 340-350.
  27. 27. Suggestions for moving forward Include a check box for “maternal CDMR data is vague request” on birth certificates. - practices in the collection of data by institutions and the government Lack of standardized definition of CDMR and use of proxies in the literature. CDMR findings are indirect - limiting availability of data
  28. 28. Suggestions for moving forward After proper data collection is established: - Research trends of CDMR - Possible relationships of CDMR and other variables -Possible reasons why women are requesting CDMR - Design interventions to address concerns that become apparent.
  29. 29. Suggestions for Develop moving forward interventions to address psychological Fear of pain during birth experience needs of mothers and CDMR as a terror management Implement health technique. interventions to increase knowledge and Fear surrounding the birth experience dispel uninformed fear of birth. and possible maternal and neonatal physical consequences. Education on the risks and benefits associated with any All mothers who request CDMR cesarean section should be informed.
  30. 30. THANK YOU Pregnancy and Labor Resources www.marchofdimes.com www.ican-online.org www.childbirthconnection.org

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