This document discusses ways to reduce cesarean section rates. It outlines the benefits and risks of cesarean sections and vaginal births. Reasons for the rise in cesarean rates include patient request, fear of litigation, older maternal age, and overuse for issues like failure to progress. Interventions to decrease rates include standardized indications, encouraging vaginal birth after cesarean, continuous labor support, correct diagnosis of labor, and restricting electronic fetal monitoring use. However, some interventions like selective cesareans may have no influence on overall rates.

1. HOW TO REDUCE CS RATES?
Aboubakr Elnashar
Benha university Hospital, Egypt
Aboubakr Elnashar

2. CONTENTS
1. BENEFITS OF CS
2. RISKS OF CS
3. BALANCING RISKS AND BENEFITS
4. RISKS OF CS AND VAGINAL DELIVERY
5. CSR
6. REASONS FOR THE INCREASE IN CSR
7. INTERVENTIONS TO DECREASE CSR
8. INTERVENTIONS HAVE NO INFLUENCE ON
CSR
Aboubakr Elnashar

3. 1. BENEFITS OF CS
1. Mother:
 Relative safety
 Accommodating the concerns and wishes
 Avoiding damage to the pelvic floor
2. Fetus:
Reduced risk
3. Obstetrician:
Convenience to in terms of timing& duration of delivery
Aboubakr Elnashar

4. 2. RISKS OF CS
I. Immediate
 Anesthetic complications: shock, cardiac arrest,
acute renal failure, assisted ventilation
 Blood loss
 Bowel or bladder injury
 Amniotic or air embolism
 Scalpel damage to the baby: 1-2%
(Smith 1997)
Aboubakr Elnashar

5. II. Post operative risks
 infection, or in-hospital wound disruption
 Hge that requires hysterectomy or transfusion,
 Venous thromboembolism
 Hematomae
 was increased 3-fold for CS as compared with VD
(2.7% vs 0.9%, respectively).
Aboubakr Elnashar

6. III. Risks in subsequent pregnancy
 Placenta previa &/or accreta
 placenta previa: increases with each subsequent CS,
1% with 1 prior CS
3% with 3 prior CS.
 Placenta accreta: 10-fold increase over the last
decades
after 3 CS: placenta previa will be complicated by
placenta accreta in 40%.
 Rupture of a uterine scar
 Recurrent CS
increases the likelihood of most CS related
complications, including
Aboubakr Elnashar

7. VI. Remote risks:
Infertility
{adhesions}
Bowel obstruction
V. Neonatal complications
{combination of complications}
Neonatal RDS/Wet lung
Neonatal intensive care unit admission
Perinatal death.
Aboubakr Elnashar

8. 3. BALANCING RISKS AND BENEFITS
 When CS is necessary:
lifesaving for mother and baby.
For placenta previa or uterine rupture:
CS is firmly established as the safest route of
delivery.
 Over half of CS: unnecessary
(A consumer advocacy group and The Public Health Citizen's Research
Group)
For low risk pregnancies:
CS has greater risk of maternal morbidity and
mortality than VD
Aboubakr Elnashar

9. 4. RISKS OF CS AND VAGINAL DELIVERY
(ACOG , 2014)
Aboubakr Elnashar

10. Aboubakr Elnashar

11. Aboubakr Elnashar

12. C.S Vs vaginal delivery:
1. Risk to the mother's health: greater
2. Maternal recovery: slow
3. Costs: heavy economic& social price.
4. Mortality rate: 2-4 times of vaginal births.
5.No decline in cerebral palsy or shoulder dystocia
Aboubakr Elnashar

13. 5. CSR
Rapid increase from 1996 through 2011 without
clear evidence of concomitant decreases in maternal
or neonatal morbidity or mortality: raises significant
concern that CS is overused.
USA: 23%: 1991
32%: 2007
Canada: 18%: 1991
31%: 2008
Australia:14%: 1995
29%: 2005
Italy: In Campania: 60% 2008 births
In Rome:44%- 85% in some private clinics.
Brazil: up to 80%
Aboubakr Elnashar

14. CSR in Arab countries
(Khawaja et al, 2009)
Aboubakr Elnashar

15. Variation across
Arab countries:
ranging from a low of 15% to a high of nearly 55%
Nulliparous term singleton vertex
Hospitals: 10-fold variation
Clinical practice patterns affect CSR.
Aboubakr Elnashar

16.  In Egypt
 MOH hospital:
 Normal Vaginal Deliveries (30) = 42.8%
 Cesarean sections (40)= 57.2%
 90% previous CS
 0% instrumental delivery
 Private Hospitals:
≥90%
Aboubakr Elnashar

17. Aboubakr Elnashar

18. 60% of all CS are primary cesarean
Indications for primary CS, in order of frequency
1. Labor dystocia: 34%
2. Abnormal or indeterminate (formerly,
Non reassuring) fetal heart rate tracing: 23%
1+2 = 57%
3. Fetal malpresentation: 17%
4. Multiple gestation: 7%
5. Suspected fetal macrosomia: 4%
Aboubakr Elnashar

19. Aboubakr Elnashar

20. 6. REASONS FOR THE INCREASE IN CSR
 Elective CS:
 Previous CS: VBAC has decreased
from a high of 28% in 1996 to 8% in 2007 USA,
1989:
 PET: CSR for PET have increased, whereas IOL
have declined.
 Breech: Most are now delivered by CS.
{fetal injury
infrequency with which a breech presentation meets
criteria for a labor trial, almost guarantee that most
will be delivered by CS. Breech (already 12% of all
C/S) Aboubakr Elnashar

21. Multiple pregnancy: increased
{increased frequency of infertility & the effect of its
therapy}.
Elderly PG: The average maternal age is rising,
and older women, especially nulliparas, are at
increased risk of cesarean delivery. an increased
CS rate.
Rates of labor induction continue to rise, and induced labor, especially among
nulliparas, increases the cesarean delivery rate
Aboubakr Elnashar

22.  Obesity: has risen dramatically, and obesity
increases the cesarean delivery risk
 Maternal medical conditions: more women with
chronic health problems (diabetes heart disease)
are successfully carrying a baby.
Aboubakr Elnashar

23. Nonmedical factors.
 Patient:
 Patient request
 Concern for: vaginal birth
Pain
Pelvic floor injury
Fetal injury
 Women are having fewer children: greater
percentage of births are among nulliparas, who are
at increased risk for CS.
 Socioeconomic status
 Convenience
Aboubakr Elnashar

24.  Obstetrican:
 Individual philosophy
 Malpractice litigation related to fetal injury during
spontaneous or operative vaginal delivery: Fear of
litigation & cost of litigation.
 The threat of malpractice: altered the training of new
obstetricians: little exposure to managing birth
complications
 Financial gain: A linear correlation between fee & CS
 Convenience
 The effect of Obstetric catastrophe:– CSR increased
after VB with poor outcome from 21% to 29%
(Turrentino 1999).
Aboubakr Elnashar

25. Selective CS:
 Overuse of CS for failure to progress (dystocia)
 Increased interventions before active labor
established.
 The frequency of instrumental delivery: forceps and
vacuum has decreased
 Increased use of electronic fetal monitoring :
When physicians observe disturbing patterns on the monitor
they tend to respond conservatively with a "better safe than
sorry" attitude which results in CS.
CS performed primarily for “fetal distress” comprises only a
minority of all such procedures. In many more cases,
concern for an abnormal or “nonreassuring” FHR tracing
lowers the threshold for CS.
Aboubakr Elnashar

26. Reasons
are
Complex
Medicalization
Fear of
Litigations
Maternal
request
Demographics/
Ethnicity
Increasing
Maternal
Age
Smaller
Family size
Doctors’
decision
Privatisation
of Care
Aboubakr Elnashar

27. 7. INTERVENTIONS TO DECREASE CSR
 CSR can be lowered without any adverse effect on
neonatal outcome
The Obstetrician:
 single most important factor that will reduce CSR is
physician motivation to make a change.
 Should be provided with EB clinical practice
guidelines for CS
 Acuity-adjusted physician-specific CSR
 Supplementary fees for performing VBAC.
 Second opinion for performing all except
emergency CS.
Aboubakr Elnashar

28. Organizational, Hospital actions
 Changing the local culture and attitudes of
doctors regarding the interventions to reduce
CSR across
 indications
 across community
 academic settings.
 CSR was reduced by 13% when
audit and feedback were used
 CSR was reduced by 27% when:
 audit and feedback
 second opinions and
 culture change.
Aboubakr Elnashar

29. Aboubakr Elnashar

30. Aboubakr Elnashar

31. Elective:
1. Standardize indications for CS& inductions
Many indications for CS, especially prior to labour,
can& should be questioned:
Macrosomia
Maternal age
Parity
CPD
Breech .
Shoe size, maternal height& estimations of fetal
size (US or clinical examination) do not accurately
predict CPD: should not be used to predict "failure to
progress" during labour.
(Grade B) (National Guideline Clearinghouse, 2005)
Aboubakr Elnashar

32. Herpes simplex virus
CS is not recommended for women with a history of herpes
simplex virus infection but no active genital disease during
labor.
Aboubakr Elnashar

33. Aboubakr Elnashar

34. Aboubakr Elnashar

35. Women with an uncomplicated pregnancy should
be offered induction of labour beyond 41 w
because this reduces the risk of perinatal
mortality and the likelihood of CS
(NICE Clinical Guideline 2004) (grade A )
The routine use of early US to calculate
gestational age significantly reduces the
incidence of post-term pregnancy
(grade A) Cochrane Review, 2010
Aboubakr Elnashar

36. Aboubakr Elnashar

37. External cephalic version:
 uncomplicated singleton breech pregnancy at 36
w should be offered ECV.
 Exceptions
in labour
uterine scar or abnormality
fetal compromise
ruptured membranes
vaginal bleeding
medical conditions .
(Grade A).
Aboubakr Elnashar

38. Aboubakr Elnashar

39. Aboubakr Elnashar

40. 2. VBAC
 should be offered and encouraged for all
patients unless there is a separate complicating
risk factor that justifies CS.
 safer for both mother and infant, in most cases,
than is routine elective CS, which is major
surgery.
 Patient acceptance of VBAC is important
{it would be unethical to insist on a VBAC trial in a
patient adamantly opposed to such a trial}.
(II-2A)
Aboubakr Elnashar

41.  Selection criteria :
 One low-transverse CS
 Clinically adequate pelvis
 No other uterine scars or previous rupture
 Availability of anesthesia and personnel for
emergency CS
 Continuous electronic fetal monitoring.
(II-2A)
Aboubakr Elnashar

42.  Contraindications
1. Patients at high risk for uterine rupture.
2. Prior classical or T-shaped incision or other
transfundal uterine surgery
3. Contracted pelvis
4. Medical or obstetric complication that precludes
vaginal delivery
5. Inability to perform emergency CS
{unavailable surgeon, anesthesia, sufficient staff, or
facility}
(II-2A)
Aboubakr Elnashar

43. 3. Maternal request
 Clinician:
Not on its own an indication for CS
Specific reasons for the request should be
explored, discussed, and recorded
(GPP )
has the right to decline a request for CS in the
absence of an identifiable reason.
The woman’s decision should be respected and
she should be offered referral for a second opinion.
Aboubakr Elnashar

44.  Public:
 Health awareness
 Education
 Media involvement
 Patient:
 Benefits and risks of CS compared with vaginal
birth should be discussed and recorded.
 A fear of childbirth: counseling (cognitive behavioral
therapy) {:reduced fear of pain in labour and shorter
labour}.
Aboubakr Elnashar

45. Aboubakr Elnashar

46. Selective:
1. Continuous labor and delivery support
presence of continuous one-on-one support during
labor and delivery:
improved patient satisfaction
significant reduction in CSR
Aboubakr Elnashar

47. 2. Correct diagnosis of labour
The diagnosis of labor is made within 1 hr of presentation.
Spontaneous contractions at least 2/15 min &
at least 2 of the following:
 Complete effacement of cervix
 Cervical dilation 3 cm or greater
 SROM
 (NGC,2004)
3. Routine amniotomy should be discouraged
Aboubakr Elnashar

48. 4. A partogram with a 4-hour action line should
be used to monitor progress of labour of
women in spontaneous labour with an
uncomplicated singleton pregnancy at term
(grade A).
5. Consultant obstetricians should be involved in
the decision making for CS
(Grade C)
6. Use of electronic fetal monitoring should be
restricted to high risk pregnancy and better
understanding of the fetal monitor & what
actually constitutes fetal distress
(grade B ) National Guideline Clearinghouse April 2005
Aboubakr Elnashar

49. Aboubakr Elnashar

50. Aboubakr Elnashar

51. Aboubakr Elnashar

52. Aboubakr Elnashar

53. 8. INTERVENTIONS HAVE NO INFLUENCE ON CSR
(Grade A) National Guideline Clearinghouse April 2005
Aboubakr Elnashar

54. 263 lectures
1. My scientific
page on face
book: 3604
members
2. Slide share:
1228 followers
Aboubakr Elnashar