safe prevention of primary cesarean section

8/18/2019 Safe Prevention of Primary Cesarean Section

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Safe

Prevention

of the

Primar

Melinda Weiss, DO PGY3

April 1, 2016


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Primar Objectives

Describe the trend o cesarean section !"#$ inthe %nited #tates

&a'e the 'ost co''on ca(ses o "#

)denti* ris+ actors or "#

eco-ni.e the di/erence beteen old and ne

labor descriptions

Describe the reco''ended interventions todecrease "#


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ac+-ro(nd

1620114 rapid increase in "# rate

20114 153 o'en delivered via "#

&o evidence o conco'itant decrease in'aternal or neonatal 'orbidit* or 'ortalit*


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alancin- ris+s and benets

#aest ro(te in placenta previa or (teriner(pt(re

7or lo ris+ pre-nancies, "# has -reater ris+ o'aternal 'orbidit* and 'ortalit* than 8D

Di9c(lt to isolate 'orbidit* ca(sed specicall*b* ro(te o deliver*

": o breech to (nder-o "# or 8D

3'o 5(4 (rinar* b(t not ecal incontinence in 8D

(t this di/erence no lon-er si-nicant at 2*r 5(


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"o'pared to 8D, "# has a ;;;;; old ris+ osevere 'aternal 'orbidities, dened as4

he'orrha-e re


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>on- ter' ris+s ith "#

#(bse


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What is o(r state "# rateB


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"# ates

8ariation across4

#tates4 230?

Cospitals4 E16E?

>oris+ o'en4 2E36EF?

ole o 'aternal charactersitics !a-e, ei-ht, andethnicit*$ do &O: (ll* acco(nt or te'poralincrease in "# or re-ional variation

#(--ests that other potentiall* 'odiable actors,ie patient preerences, practice variation acrosss*ste's and practitioners li+el* contrib(tes to risin-rate


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What are the 'ost co''on indications or "#B

>abor d*stocia

&7C:

Malpresentation

M(ltiple -estation

#(spected 'acroso'ia

2011 data


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What are the 'ost co''on indications or "#B

>abor d*stocia

&7C:

Malpresentation

M(ltiple -estation

#(spected 'acroso'ia

2011 data

@F0?


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#oHhat is abnor'al laborB

>abor denitions

Old4 Active phase !c'$

&(llip4 1E2c'5hr

M(ltip4 1EFc'5hr

%pdated4 Active phase !6c'$ Ihen-

&(llip4 0EF0Ec'5hr

M(ltip4 0EF1E3c'5hr

7ro' 6c'4 o'en dilate the sa'eJ ater 6c','(ltips dilate aster


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Abnor'al laborB

Prolon-ed latent phase

&(llip4 @20 ho(rs

M(ltip4 @1 ho(rs

)s prolon-ed latent phase indication or deliver*B

&opeE


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)nd(ction

%se cervical ripenin-

)n latent phase, i 7C: is reass(rin- and 'aternal and etal stat(sesare stable, do not intervene loer "# rate

>atent phase is >O&G= in )O> co'pared to spontaneo(s

3 st(dies have shon )O> patients in latent labor 121K ho(rs ithpitocin and OM ill deliver va-inall* i ind(ction is contin(ed

OM and pitocin sho(ld be considered prere


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=/ect o ind(ction o labor

)nd(ction rate increased EF?23E1? !10200K$

"o'parin- )O> to spontaneo(s labor )O>associated ith increase "#

WO&G

"o'parin- )O> to epectant 'ana-e'ent

no di/erence or decreased "# rate

"ervical ripenin-


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&e denition or rst sta-e arrest

7ro' A"OG P 10 )nd(ction o >abor

LAlloin- at least 121K ho(rs o latent labor

beore dia-nosin- a ailed ind(ction 'a*red(ce the ris+ o cesarean deliver*E


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#econd sta-e neonatal o(tco'es

)n n(llips, adverse neonatal o(tco'es -enerall* have not been associatedith the d(ration o the second sta-e o labor

)n a secondar* anal*sis o a '(lticenter rando'i.ed st(d* !,126 o'en$ noneo the olloin- neonatal o(tco'es as o(nd to be related to the d(ration o thesecond sta-e !so'e cases @F ho(rs$

F'in(te Ap-ar score o less than

('bilical arter* pC less than E0

int(bation in the deliver* roo'

need or ad'ission to &)"%

neonatal sepsis

#econdar* anal*sis o 1,K62 o'en enrolled in an earl* vers(s dela*edp(shin- trial

lon-er d(ration o active p(shin- &O: not associated ith adverse neonatalo(tco'es !even in @3ho(rs p(shin-$

etrospective cohort st(d* o 1F,F n(lliparo(s o'en o(nd no adversee/ects in second sta-e @ ho(rs

>ess data in '(ltiparo(s o'en


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#econd sta-e 'aternal o(tco'es

Ci-her rates o4

inection

3rd and th de-ree lacerations

Postpart(' he'orha-e

7or each ho(r o second sta-e, chance o 8Ddecreases @3 ho(rs, onl* 15 n(lliparo(s o'en and 153

'(ltiparo(s o'en deliver va-inall*


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#econd sta-e interventionsB

>on-er epectant 'ana-e'ent

Operative va-inal deliver*

Overall rate has decreased in past 1F *ears &o di/erence in serio(s 'orbidit* !neonatal death

or intracerebral he'orrha-e$ beteen operativedeliveries and "#

3? o o'en ith operative deliver* -o on to "#

Man(al rotation o etal occip(t

7orceps

&o increase in cord prolapse !31 o'en$


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#econd sta-e reco''endations


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"onQictin- dataB

AROG April 201

"(rrentl* available evidence does not s(pportsaet* o lon-er second sta-e

3 reports here data ere inappropriatel*adj(sted or 'ode o deliver*


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&7C: interventions Most tracin-s are "at ))

Accelerations !spontaneo(s or elicited$ areassociated ith nor'al ('bilical cord arterial pC!@E20$

&o c(rrent data s(pportin- interventions ordecelerations ith Lat*pical eat(res !s(ch assho(lders, slo ret(rn to baseline, or variabilit* onl*ithin the deceleration$H the* have not been

associated ith etal acide'ia

Lec(rrent variablesHare not the'selvespatholo-icE Coever, i re


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Other ca(ses Malpresentation !reech$ 4 3E? o pre-nancies, KF? o

persistent breech are delivered via "# ="8(nder(tili.ed

#(spected 'acroso'ia4 "# onl* o/ered i F,000- non

diabetic, ,F00- diabetic

=cessive 'aternal ei-ht -ain4 donSt do it

:ins4 "# rate F3?F? !1F200K$, even verte

presentin- tins F6K?

C#84 s(ppress 3 ee+s beore deliver*


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eerences

Obstetric care consens(s4 #ae prevention o thepri'ar* cesarean deliver*E A"OG, #M7ME 201E

Preventin- the 7irst "esarean Deliver*4 #(''ar*o a Roint =(nice Tenned* #hriver &ational )nstit(teo "hild Cealth and C('an Develop'ent, #ociet*or Maternal7etal Medicine, and A'erican "olle-eo Obstetricians and G*necolo-ists Wor+shop, 2012

A"OG P 104 )nd(ction o >aborE ea9r'ed 201FE

>eveno, TE, et alE #econdsta-e labor4 ho lon- istoo lon-B AROG 21!$ KKE April 1, 2016E

safe prevention of primary cesarean section

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