Prof.Dr.S.Cansun DEMİRProf.Dr.S.Cansun DEMİRTurkish Society of Obstetrics and Turkish Society of Obstetrics and GynecologyGynecologyÇukurova University Faculty of MedicineÇukurova University Faculty of Medicine

What should we do to decreaseWhat should we do to decreasehigh Cesarean Section high Cesarean Section

rates ?rates ?

LaborLabor Natural and Normal Physiological Natural and Normal Physiological

Process Process Dystocia : % 23.6Dystocia : % 23.6

Functional Dystocia: % 11.1 Failure in Dilatation and Descensus Arrest Dilatation and Descensus Ineffective Expulsion

Mechanical Dystocia: %12.5 Cephalo-pelvic Disproportion Fetal Macrosomia Pelvic Anatomic Problems Fetal Malpresentation

American Journal of Obstetrics & Gynecology. 195(1):121-128, July 2006.

W.H.O.: W.H.O.: 11

15 %15 % Maximum desirable rate of cesarean Maximum desirable rate of cesarean

sectionsection No benefit for mother and the fetus for No benefit for mother and the fetus for

medical reasonsmedical reasons

11 World Health Organisation. Appropriate technology for birth. World Health Organisation. Appropriate technology for birth. Lancet Lancet 1985;436 7.1985;436 7.

Published ratesPublished rates

Some authors have proposed an “ideal rate” of all Some authors have proposed an “ideal rate” of all cesarean deliveries (such as 15 percent) for a population.cesarean deliveries (such as 15 percent) for a population.

There is no consistency in this ideal rate, and artificial There is no consistency in this ideal rate, and artificial declarations of an ideal rate should be discouraged. declarations of an ideal rate should be discouraged.

Goals for achieving an optimal cesarean delivery rate Goals for achieving an optimal cesarean delivery rate should be based on maximizing the best possible should be based on maximizing the best possible maternal and neonatal outcomes,taking into account maternal and neonatal outcomes,taking into account available medical and health resources and maternal available medical and health resources and maternal preferences.preferences.

Thus, optimal cesarean delivery rates will vary over time Thus, optimal cesarean delivery rates will vary over time and across different populations according to individual and across different populations according to individual and societal circumstances.and societal circumstances.

Optimum C/S Rate ?Optimum C/S Rate ?

Department of Health and Human Department of Health and Human

ServicesServices 15 % by the year 200015 % by the year 2000

““....the advantages of a safe vaginal delivery over a ....the advantages of a safe vaginal delivery over a

cesarean delivery are clear: a vaginal delivery is cesarean delivery are clear: a vaginal delivery is

associated with lower maternal and neonatal associated with lower maternal and neonatal

morbilidity and it costs less...”morbilidity and it costs less...”11 Healthy People 2000; Healthy People 2000; DHHS DHHS publication Nº. (PHS) 91-50212.publication Nº. (PHS) 91-50212.

Healthy People 2000 Healthy People 2000 11

C/S C/S Rates Rises all over the WorldRates Rises all over the World..

The Total cesarean, Primary cesarean and vaginal birth after cesarean rates in the United States from 1989 to 2006. Source: U.S. National Center for Health Statistics

Country Country Rate Rate

““LOW” RATE OF CESAREANLOW” RATE OF CESAREAN Cambodia Cambodia 1.0% 1.0%

Haiti Haiti 1.7% 1.7%

Nigeria Nigeria 1.7% 1.7%

Uganda Uganda 2.6% 2.6%

Eritrea Eritrea 2.7% 2.7%

Uzbekistan Uzbekistan 3.0% 3.0%

Indonesia Indonesia 4.1% 4.1%

““MODERATE” RATEMODERATE” RATE United Kingdom United Kingdom 21.4% 21.4%

Canada Canada 22.5% 22.5%

Ireland Ireland 23.3% 23.3%

Germany Germany 23.7% 23.7%

Switzerland Switzerland 24.3% 24.3%

United States United States 24.4% 24.4%

Cuba Cuba 28.5% 28.5%

Portugal Portugal 30.2% 30.2%

Chile Chile 30.2% 30.2%

““HIGH” RATEHIGH” RATE ItalyItaly 36.0% 36.0%

BrazilBrazil 36.7% 36.7%

Mexico Mexico 39.1% 39.1%

China China 40.5% 40.5%

TurkeyTurkey 46.0%46.0%

Betran AP, Merialdi M, Lauer JA, et al. Rates of cesarean section: analysis of global, regional and national estimates. Paediatr Perinat Epidemiol. 2007;21:98–113.

1.1. Lower toleranceLower tolerance for taking risks for taking risks

2.2. Fear of malpracticeFear of malpractice - - litigation litigation

3.3. IncreasedIncreased use of epidural anesthesia ?use of epidural anesthesia ?

4.4. Increased use of electronic fetalIncreased use of electronic fetal monitoringmonitoring

5.5. The convenience of physiciansThe convenience of physicians

Sachs BP et al., Sachs BP et al., NEJMNEJM 1999;340:54 – 57 1999;340:54 – 57

Why has the rate of cesarean delivery Why has the rate of cesarean delivery climbed so dramaticallyclimbed so dramatically in the past 25 in the past 25

years?years?

Factors of taking C/SFactors of taking C/S

AbsoluteAbsolute

DystociaDystocia

Fetal DistressFetal Distress

Breech Presentation ???Breech Presentation ???

Previous Section ???Previous Section ???

RelativeRelative

Maternal AgeMaternal Age

Demand of SterilizationDemand of Sterilization

Fear of litigation from Fear of litigation from ComplicationsComplications

Intraparturial EFMIntraparturial EFM

Additional FactorsAdditional Factors

Time of day at deliveryTime of day at delivery

Lack of Experience about operative delivery among Lack of Experience about operative delivery among seniorsseniors

C-section on Mother’s RequestC-section on Mother’s RequestStress Incontinance, Ano-genital sphincter insufficiency Disturbance Stress Incontinance, Ano-genital sphincter insufficiency Disturbance in sexual functionin sexual functionLiterateLiterateHigh social level in statusHigh social level in statusUrban or Metropolitian localizationUrban or Metropolitian localization

0

5

10

15

20

25

30

35

40

45

50

West East Med. B.Sea Marm. Mid.An.

%

C/S RATES IN TURKEY,2009C/S RATES IN TURKEY,2009

0

10

20

30

40

50

60

İstanbul Ankara İzmir Adana Bursa

%

0

5

10

15

20

25

Ağrı Bitlis Hakkari Muş Mardin Şırnak

Ağrı

Bitlis

Hakkari

Muş

Mardin

Şırnak

56

58

60

62

64

66

68

70

72

Çan. Burdur Edirne Uşak Osm. Düzce

%

0

10

20

30

40

50

60

70

Public Private University

PublicPrivateUniversity

In 2005; In 2005; The C/S rate in USA is 30.3% among The C/S rate in USA is 30.3% among

all deliveries. all deliveries. 62% of these cases were Primary 62% of these cases were Primary

Elective C/S . Elective C/S . C/S Rates varies by mother’s request C/S Rates varies by mother’s request

or demand was 4-18%. or demand was 4-18%.

Cesarean on DemandCesarean on Demand

The incidence of cesarean delivery The incidence of cesarean delivery without medical or obstetric indications without medical or obstetric indications is increasing in the World, and a is increasing in the World, and a component of this increase is cesarean component of this increase is cesarean delivery on maternal request.delivery on maternal request.

Given the tools available,the Given the tools available,the magnitude of this component is difficult magnitude of this component is difficult to quantify.to quantify.

What is C/S on Demand?What is C/S on Demand? Definition: Definition:

Cesarean section on Cesarean section on demanddemand

Until quality evidence becomes Until quality evidence becomes available, any decision to perform a available, any decision to perform a cesarean delivery on maternal cesarean delivery on maternal request should be carefully request should be carefully individualized and consistent with individualized and consistent with ethical principles.ethical principles.

Cesarean section on Cesarean section on demanddemand

Given that the risks of placenta Given that the risks of placenta previa and accreta rise with each previa and accreta rise with each cesarean delivery, cesarean delivery cesarean delivery, cesarean delivery on maternal request is not on maternal request is not recommended for women desiring recommended for women desiring several children.several children.

Cesarean section on Cesarean section on demanddemand

31% of female obstetricians would 31% of female obstetricians would

prefer a cesarean delivery for prefer a cesarean delivery for

themselves themselves 11

11 Al-Muffti et al. Al-Muffti et al. Eur J Obstet Gynecol Reprod Biol Eur J Obstet Gynecol Reprod Biol 1997:73:1-41997:73:1-4

Rising C/S rate in Turkey.Rising C/S rate in Turkey.The reasons: 1 The reasons: 1

Physician’s attidutes;Physician’s attidutes;C/S easy access and lower riskC/S easy access and lower risk

Time saving procedure ( 12-16 hours-vs 35-45 Time saving procedure ( 12-16 hours-vs 35-45 minutes); To avoid from intrapartum long-term minutes); To avoid from intrapartum long-term follow-up of parturient in labor ward;and not to take follow-up of parturient in labor ward;and not to take any responsibility of labor complications.any responsibility of labor complications.

Malpractice and fear of litigation pushes them to take Malpractice and fear of litigation pushes them to take more Sections.Elective Caserean Section as an more Sections.Elective Caserean Section as an indication recorded into the statistical data. indication recorded into the statistical data.

Not to able to control the unset of labor during very Not to able to control the unset of labor during very heavy clinical work in the day time,and also the extra heavy clinical work in the day time,and also the extra and out of time.and out of time.

To believe that C/S is minimizing perinatal To believe that C/S is minimizing perinatal neurologic injury and also prevents maternal neurologic injury and also prevents maternal adverse outcomes as pelvic relaxation adverse outcomes as pelvic relaxation syndrom with urinary incontinance.syndrom with urinary incontinance.

The reflexion of physicians preference on the The reflexion of physicians preference on the gravidas as to direct them for Section seems gravidas as to direct them for Section seems to be another important factor.to be another important factor.

Normal delivery needs more labour-intensive Normal delivery needs more labour-intensive work but not satisfactory rate of return .work but not satisfactory rate of return .

Rising C/S rate in Turkey.Rising C/S rate in Turkey.The reasons ..2The reasons ..2

The Social Background and Communal The Social Background and Communal Factors;Factors;IVF-ET cycles and pregnancies.Multiple gestation. IVF-ET cycles and pregnancies.Multiple gestation.

Higher prevalence of maternal obesity and related Higher prevalence of maternal obesity and related obstetric problems as hypertansion, obstetric problems as hypertansion, diabetes,systemic diseases and dystocia.diabetes,systemic diseases and dystocia.

Extensive use of Electro-fetal Monitorization and Extensive use of Electro-fetal Monitorization and prenatal ultrasonography (Fetal Macrosomia-15% prenatal ultrasonography (Fetal Macrosomia-15% false positive) false positive)

Cesarean rates are higher among the gravidas Cesarean rates are higher among the gravidas cared by obstetricians ,when compared by cared by obstetricians ,when compared by midwifery during antenatal period.midwifery during antenatal period.

Rising C/S rate in Turkey.Rising C/S rate in Turkey.The reasonsThe reasons ..3..3

Maternal attidutes;Maternal attidutes;Inadequate antenatal booking and lack of antenatal Inadequate antenatal booking and lack of antenatal clinics results misunderstanding at choosing the mode clinics results misunderstanding at choosing the mode of delivery;of delivery;

Not to show enough respect to the parturient’s Not to show enough respect to the parturient’s confidence during labour in the ward,frequency of confidence during labour in the ward,frequency of painful vaginal exams ,Lack of private seperations and painful vaginal exams ,Lack of private seperations and rooms for labour;rooms for labour;

Negative approach and the quality of correspondance Negative approach and the quality of correspondance during admission to the labor wardduring admission to the labor ward

The patients and also the obstetricians adversely The patients and also the obstetricians adversely affected againts normal delivery because of bad affected againts normal delivery because of bad consequences of obstetric complications which consequences of obstetric complications which recognized by community.recognized by community.

Rising C/S rate in Turkey.Rising C/S rate in Turkey.The reasons The reasons ..4..4

The cesarean section should not be used asThe cesarean section should not be used as an an

indicator indicator ofof quality of obstetrical care quality of obstetrical care

We do not have a good definition of We do not have a good definition of uunnecesary c-nnecesary c-

sectionsection

ConclusionConclusion

Comments – 1Comments – 1

High quality of Maternal Schooling.Prenatal High quality of Maternal Schooling.Prenatal Courses on training how to manage spontanous Courses on training how to manage spontanous delivery and experienced trainers must be on this delivery and experienced trainers must be on this field. field. Encouragement and Education.Encouragement and Education.

Normal labor should be cared and followed by Normal labor should be cared and followed by Obstetricians or Midwifes whose only is focused Obstetricians or Midwifes whose only is focused on this subject.on this subject.Certification and Responsibility.Certification and Responsibility.

Physical Conditions of Labor wards and hospital Physical Conditions of Labor wards and hospital must be modernized and must be modernized and Patient Friendly Patient Friendly StructureStructure could be built. could be built.

Gravida must be treated honestly as she feels herself in Gravida must be treated honestly as she feels herself in confidence at labor. During the delivery the confidence at labor. During the delivery the criterias criterias which declared by WHO should be applied.which declared by WHO should be applied. ( No Routine ( No Routine enema,limited number of vaginal exams for low risk enema,limited number of vaginal exams for low risk pregnants,unnecessary Kristeller Manoeuvre,No pregnants,unnecessary Kristeller Manoeuvre,No restriction to take fluids during labor).restriction to take fluids during labor).

Midwifery System should be progressed and rebuilt as Midwifery System should be progressed and rebuilt as they will be responsible of normal spontanous they will be responsible of normal spontanous deliveries .The Education of Midwifes must be in the deliveries .The Education of Midwifes must be in the responsibility of University and Teaching Hospitals which responsibility of University and Teaching Hospitals which updated and upgraded.updated and upgraded.

Comments – 2Comments – 2

Continuous Professional and Postgraduate Continuous Professional and Postgraduate Education Education for midwifes and labor staff .for midwifes and labor staff .

Obligatory Intrapartum Fetal Monitorization.Obligatory Intrapartum Fetal Monitorization. Physicians and Midwifes must be educated on IFM.Physicians and Midwifes must be educated on IFM.

The responsibility of labor Ward must belongs to The responsibility of labor Ward must belongs to Academic StaffAcademic Staff (Obstetricians and Midwifes ). (Obstetricians and Midwifes ).

Full Physicological SupportFull Physicological Support and Obstetric follow- and Obstetric follow-up .up .

Comments - 3…Comments - 3…

Comments – 4Comments – 4

Facility of Facility of Rapid consultationRapid consultation of parturient with of parturient with obstetrician if necessary because of dystocia obstetrician if necessary because of dystocia and other complications appeared at delivery.and other complications appeared at delivery.

GuidelinesGuidelines about Normal Vaginal Delivery and about Normal Vaginal Delivery and Labor Care must be setup in the labor Wards.Labor Care must be setup in the labor Wards.

Induction of LaborInduction of Labor

Thank you very much for your Thank you very much for your attentionattention