This document discusses normal versus abnormal modes of delivery, specifically focusing on cesarean section rates. It provides statistics on global and Lebanese cesarean section rates, noting that Lebanese rates have risen dramatically in recent decades to over 40% currently. The document explores various factors contributing to increasing cesarean rates, such as financial incentives, malpractice concerns, and lack of labor preparation. It also reviews potential adverse effects of cesarean section on infant health outcomes like respiratory issues, microbiome disturbance, and increased risk of obesity and metabolic disorders. Solutions proposed to reduce unnecessary cesarean sections include implementing national guidelines, improving prenatal education, and promoting vaginal birth after cesarean.

1. Normal and “Abnormal”
mode of Delivery
GABY FALAKHA
PEDIATRICIAN-NEONATOLOGIST
CHN ZGHARTA
NOVEMBER 17TH, 2018
The 3d Annual Haykal Hospital Scientific Congress

2. I HAVE NO DISCLOSURES

3. Objectives
1. Evaluate the prevalence of Cesarean Sections worldwide
and in Lebanon
2. Discuss the underlying factors
3. Review the short and long-term effects of C-section on
the health of newborns.
4. Recommend solutions to reduce the rate of unnecessary
C-Sections

4. 1. PREVALENCE OF C SECTION

5. World Health Organization
 Recommended rate of C section : Not to exceed 15%
(1985)
 A study published in December 2015 in JAMA indicates
that if the CS rate increases to 19%, maternal and
neonatal mortality decline
 A CS rate above this level did not lead to any improvement
in maternal and neonatal mortality rates

6. PLoS ONE 11 (2): e0148343. doi:10.1371/journal.pone.0148343

7. Rising Trends of Cesarean Section Worldwide:
A Systematic Review
Soto-Vega E. et al. Obstet Gynecol Int J 2015, 3(2): 00073

8. Rising Trends of Cesarean Section Worldwide:
A Systematic Review
Soto-Vega E. et al. Obstet Gynecol Int J 2015, 3(2): 00073

9. Rising Trends of Cesarean Section Worldwide:
A Systematic Review
Soto-Vega E. et al. Obstet Gynecol Int J 2015, 3(2): 00073

10. Lebanon
 The Lebanese literature demonstrated that this rate
increased alarmingly since the beginnings of the 1990s, as
it reached:
 33% of total deliveries in 1996
 35% in 2004
 40.8% in 2008
(Abdallah et al, 2004; DeJong et al., 2010; Mroue, 2011)
 Latest figures reported from the MoPH in 2013 showed
that the rate of C Section reached 44-45 % of total
deliveries covered by MoPH.

11. • The study was conducted through GlobeMed’s portfolio
• The majority of centers included in the study were private
hospitals
• Between January 2000 and December 2015 : 29,878
pregnant women were included in the study.

12. Rates of CS and NVD
from 2000 until 2015 in Lebanon
S.M. Zgheib et al. / Women and Birth 30 (2017) e265–e271

13. Maternal age and Rates of CS and NVD
from 2000 until 2015 in Lebanon
S.M. Zgheib et al. / Women and Birth 30 (2017) e265–e271

14. Region of birth and Rates of CS and NVD
from 2000 until 2015 in Lebanon
S.M. Zgheib et al. / Women and Birth 30 (2017) e265–e271

15. Complications and Rates of CS and NVD
from 2000 until 2015 in Lebanon
S.M. Zgheib et al. / Women and Birth 30 (2017) e265–e271

16. Day of birth and Rates of CS and NVD
from 2000 until 2015 in Lebanon
S.M. Zgheib et al. / Women and Birth 30 (2017) e265–e271

17. Prevalence of and risk factors associated with
cesarean section in Lebanon
A retrospective study based on a sample of 29,270 women
S.M. Zgheib et al. / Women and Birth 30 (2017) e265–e271
 Prolonged labor
 Breech presentation
 Fetal distress
 Multiple birth
 Twins
 Premature rupture of
membranes
 Hypertensive
disorders
 Oligohydramnios
 Maternal age of 35
years or more
 Maternal request

18. Moussawi F, Nakkash R, Jamal D, El-Jardali F.
Knowledge to Policy (K2P) Center
Reducing Rates of Unnecessary Cesarean Sections in Lebanon
Beirut, Lebanon; June 2015.
 Absence of national guidelines
 Diversity in medical schools
 Opposition of stakeholders
 Higher benefit
 Lack of coverage for epidurals
 Excessive physicians supply
 Poor prenatal education and
preparation
 Practice of defensive medicine
 Mandatory second opinion
 Group practice
 More implication of midwives
 Increase the doctor fees for NVD
 Cover for epidurals
 Prenatal awareness campaign
Factors Recommendations
Rate of C sections in Lebanon in 2015
44%

19. Moussawi F, Nakkash R, Jamal D, El-Jardali F.
Knowledge to Policy (K2P) Center
Reducing Rates of Unnecessary Cesarean Sections in Lebanon
Beirut, Lebanon; June 2015.
 Absence of national guidelines
 Diversity in medical schools
 Opposition of stakeholders
 Higher benefit
 Lack of coverage for epidurals
 Excessive physicians supply
 Poor prenatal education and
preparation
 Practice of defensive medicine
 Mandatory second opinion
 Group practice
 More implication of midwives
 Increase the doctor fees for NVD
 Cover for epidurals
 Prenatal awareness campaign
Factors Recommendations

20. A private hospital statistics
2017 2018 (January to September)
Parity NVD C-
section
% C-section NVD C-section % C-section
P0 66 209 59% 57 247 77%
P1 63 190 60% 31 119 74%
P2 53 98 69% 13 39 75%
P3 20 41 66% 3 9 75%
P4 9 18 67% 4 100%
P5 4 100% 2 100%
P6 2 100% 1 100%
Total 211 562 72.7% 104 452 76.9%

21. A private hospital statistics
2017 2018 (January to September)
Parity NVD C-
section
% C-section NVD C-section % C-section
P0 66 209 59% 57 247 77%
P1 63 190 60% 31 119 74%
P2 53 98 69% 13 39 75%
P3 20 41 66% 3 9 75%
P4 9 18 67% 4 100%
P5 4 100% 2 100%
P6 2 100% 1 100%
Total 211 562 72.7% 104 452 76.9%

22. 2. WHY IS THE C SECTION RATE INCREASING?

23. More convenient
1. To Obstetricians
* 20-25 minutes programmed in working hours V/S
unpredictable long night hours
* More profitable
2. To Hospitals
* Prolonged LOS
* More profitable
3. To Mothers?
* Scheduled delivery timing
* No labor pain, no episiotomy

24. More convenient
1. To Obstetricians
2. To Hospitals
3. To Mothers
4. But not to the baby !!!
 Have more breathing problems and NICU admissions
 His microbiome is negatively disturbed
 He has a higher risk of developing Obesity, Asthma,
Metabolic syndrome and Diabetes

25. More convenient
1. To Obstetricians
2. To Hospitals
3. To Mothers
4. But not to the baby
 Have more respiratory problems and NICU admissions
 His microbiome is negatively disturbed
 He has a higher risk of developing Obesity, Asthma,
Metabolic syndrome and Diabetes

26. Financial issues
Class Normal
Vaginal
Cesarean
section
First class (Obstetrician) 680 USD 920 USD
First class (Hospital) 1550 USD 3200 USD
CNSS (Obstetrician) 450,000 LL 680,000 LL
CNSS (Hospital) 785,000 LL 1790,000 LL
MOPH (Obstetrician) 375,000 LL 500,000 LL
MOPH (Hospital) 735,000 LL 1,790,000 LL

27. Epidural anesthesia
 Not covered by MoPH
 Costs 200-250 USD

28. Malpractice suits
 Obstetrics is a high-risk specialty in terms of malpractice
allegations.
 Obstetricians have the third-highest lawsuit rate among
physician specialties, third only to plastic surgeons and
neurosurgeons
 Almost every obstetrician will be sued before age 65.

29. A typical Lebanese anomaly
 Choosing a “cool” date
 12/12/12
 11/12/13
 18/08/18

30.  1 in 3 women with diabetes is of reproductive age
 1 in 7 births is affected by gestational diabetes
 The incidence of GD in the gulf region reaches in some parts
40%
Gestational
Diabetes
Macrosomia C section

31. No preparation for the pregnant mom
 Prenatal classes
 Relaxation methods
 Breathing techniques
 Physical activity and muscle strengthening

32. Once a C section, always a C section!
 Vaginal Birth after CS (VBAC) that is rising in developing
countries and contributing to the reduction of repeated CS
rate constitutes only 0.2% of deliveries in Lebanon.
 This low rate indicates that women who undergo primary CS
are more likely to go through repeated CS in Lebanon (WHO,
2010)

33. Non-reassuring fetal heart rate
 Almost all hospital births include continuous monitoring of
the fetal heart beat.
 These monitors are highly unreliable, which means that a
majority of babies identified to have “non-reassuring”
heart rate patterns by continuous electronic monitoring
may not be compromised at birth.
Graham et al. Obstet Gynecol. 2014 Sep;124(3):507-13.

34. Cesarean Delivery on Maternal Request:
A Western North Carolina Perspective
S Romero et al. Matern Child Health J (2012) 16:725–734
Patients’ opinion about cesarean versus vaginal delivery

35. Cesarean Delivery on Maternal Request:
A Western North Carolina Perspective
S Romero et al. Matern Child Health J (2012) 16:725–734
Patients’ opinion about cesarean versus vaginal delivery

36. 3. WHAT ARE THE ADVERSE EFFECTS OF C SECTION?

37. Elective C section and the late preterm
 Pregnancy dating has an error margin of 2-3 weeks
 Most elective C-sections are performed around 36 weeks of GA
 The late preterm newborn (34-37 weeks GA) is prone to the
following risks:
1. Hypothermia
2. Respiratory distress and TTN (3 x more than at 39 weeks)
Stutchfield P, Br Med J 331(7518):662; 2005
3. Hyperbilirubinemia and Hypoglycemia
4. The suck-swallow reflex and intestinal motility are also
impaired in late preterm infants

38. Negative effects of C section on the Baby
 Higher Neonatal Intensive Care Unit admission (Hannah et
al., 2000; Stutchfield et al., 2005)
 Other systematic reviews showed that unnecessary CS are
highly associated with childhood overweight and obesity (Li et
al, 2013; Huh et al., 2012; Barros et al., 2012) respiratory complications
like pulmonary hypertension and asthma besides brain
damage in some occasions (Main et al., 2012; Zanardo et al., 2004;
MacDorman, 2008).
 CS were also associated with a decrease of breastfeeding
rates (Rowe-Murray & Fisher, 2002; Zanardo et al., 2010; Merten et al., 2007;
Labbok & Taylor, 2008).

39. Fluid in the lungs of the fetus
 Lungs are full of fluid in fetal life (38 ml/Kg)
 Resorbed shortly after birth
 In NVD with natural labor 40% of the alveolar fluid is
resorbed before birth due to the action of stress
hormones
 In elective C section there is no labor and no stress
hormones, therefore the baby frequently ends up in the
NICU
Lucky Jain, Physiology of fetal lung fluid clearance and the effect of labor Semin Perinatol 30, 2006

40. Breastfeeding after cesarean delivery:
a systematic review and meta-analysis of
world literature
 The systematic review included 53 studies (554,568
subjects, 33 countries); 25 authors contributed additional
data (245,455 subjects), and 48 studies (553,306 subjects,
31 countries) were included in the meta-analysis.
 Rates of early breastfeeding were lower after CD compared
with after VD (pooled OR: 0.57; P < 0.00001)
Prior E. Am J Clin Nutr. 2012 May;95(5):1113-35

41. Birth by cesarean section
in relation to adult offspring overweight
and biomarkers of cardio-metabolic risk
Methods:
 The Danish Fetal Origins Cohort enrolled 965 pregnant women
in 1988–1989.
 In 2008, a follow-up study of the offspring was completed.
Results:
 Birth by C-section was associated with increased odds of
overweight or obesity at 20 years (OR=2.17 ) after adjustment
for potential confounders.
 Birth by C-section was also associated with higher serum
concentrations of total cholesterol (8.5%), LDL cholesterol
(12.6%), leptin (73.1%) and Apolipoprotein B (0.08 g/l)
S. Hansen et al. International Journal of Obesity 42, 15–19 (2018)

42. Long-term risks and benefits associated with
cesarean delivery for mother, baby, and
subsequent pregnancies
 One RCT and 79 cohort studies were included, involving
29,928,274 participants.
 Children delivered by cesarean delivery had increased risk
of asthma (OR 1.21, 1.11 to 1.32; n = 887,960; 13 studies)
and obesity (OR 1.59, 1.33 to 1.90; n = 64,113; 6 studies).
Oonagh E. Keag et al. PLOS Medicine | https://doi.org/10.1371/journal.pmed.1002494 January 23, 2018

43. Caesarean Section is associated with reduced perinatal
cytokine response, increased risk of bacterial
colonization in the airway, and infantile wheezing
 Children delivered by CS were associated with
increased risk of wheezing (aHR 1.63; 95% CI: 1.01–
2.62) and decreased compliance of the respiratory
system at 12 months (p = 0.045).
 CS was associated with reduced TLR1–2- triggered TNF-
α and IL-6 responses at birth.
 By 12 months of age, children delivered by CS had
significantly less airway bacterial clearance.
SUI-Ling LIAO et al. Scientific Reports | 7: 9053 | DOI:10.1038

44. The Elevated Rate of Cesarean Section and Its Contribution to
Non-Communicable Chronic Diseases in Latin America:
The Growing Involvement of the Microbiota
 Conclusion : The establishment of the gut microbiota is
delayed in infants born by C-section during the postnatal
period, during a critical developmental window for the
maturation of the newborn’s immune system.
 This delay may favor the subsequent development of
inflammatory and metabolic disorders during childhood
Magne F et al. Front. Pediatr. 5:192. doi: 10.3389/fped.2017.00192

49. 4. ARE THERE ANY SOLUTIONS?

50. Moussawi F, Nakkash R, Jamal D, El-Jardali F.
Knowledge to Policy (K2P) Center
Reducing Rates of Unnecessary Cesarean Sections in Lebanon
Beirut, Lebanon; June 2015.
 Dominance of private sector
 Absence of national guidelines
 Diversity in medical schools
 Opposition of stakeholders
 Higher benefit
 Competition between insurance
companies
 Lack of coverage for epidurals
 Excessive physicians supply
 Poor prenatal education and
preparation
 Practice of defensive medicine
 Mandatory second opinion
 Group practice
 More implication of midwives
 Increase the doctor fees for NVD
 Cover for epidurals
 Prenatal awareness campaign
Factors Recommendations

51. Partial restoration of the microbiota
of cesarean-born infants via
vaginal microbial transfer
 Samples from 18 infants and their mothers, including 7 born
vaginally and 11 delivered by scheduled C-section, of which 4
were exposed to the maternal vaginal fluids at birth.
 Briefly, the microbial restoration procedure consists of
incubating a sterile gauze in the vagina of mothers that are
negative for Group B streptococcus (GBS) during the hour
preceding the C-section.
 Within the first two minutes of birth, babies were swabbed
with the gauze, starting with the mouth, then the face, and
finally the rest of the body
Maria Dominiguez-Bello et al. Nat Med. 2016 March ; 22(3): 250–253.

52. Partial restoration of the microbiota
of cesarean-born infants via
vaginal microbial transfer
Maria Dominiguez-Bello et al. Nat Med. 2016 March ; 22(3): 250–253.

53. Fucosylated HMOs attenuate the Effects of
Caesarean Birth on Infant Gut Microbiota
 The fucosylated HMOs have shown to promote early
growth of beneficial microbiota in infant’s gut which play
an important role in the maturation of the infants’
immune system.
 Infants born by C-section and formula fed could benefit
from supplementation with fucosylated HMOs such as 2′FL
Fucosylated oligosaccharides in mother’s milk alleviate the effects of caesarean birth on infant gut microbiota.
Sci Rep. 2018 Sep;8:13757

54. Cesarean section and risks of childhood allergic
disorder, attenuated by breastfeeding
Shuyuan et al. Nature Scientific Reports | 7: 9762 | DOI:10.1038/s41598-017-10206-3
12,639 children

55. The Dutch experience
 C section rate 14% in 2000-2001
 Increased to 16.7% in 2010
 Fetal and early neonatal morbidity decreased in the same time
period from 0.53% to 0.21%
 30 % of all deliveries were done at home assisted by the
midwife
 There are no epidurals at homes
 All expenses at home are for free
 Non-indicated C sections at hospital are self-payed by the
patient
Zhao Y, et al. (2016) Modest Rise in Caesarean Section from 2000-2010: The Dutch Experience.
PLoS ONE 11(5): e0155565.

56. Take home message
1. The rate of C section in Lebanon has reached unacceptable
levels
2. Improving women's knowledge can lead to a positive maternal
attitude towards vaginal delivery.
3. Increase the quality of vaginal delivery services ( and possibly
fees) and cover for epidurals by official 3d party payers
4. Prevent the first cesarean delivery in Nulliparous Term
Singleton Vertex.
5. Encourage breast-feeding
6. It’s all about the gut colonization of the newborn

57. Thank you for your attention
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