Hvordan undgå det første keisersnit? Cesarean section «good or harm»

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1 Hvordan undgå det første keisersnit? Cesarean section «good or harm» Susanne Albrechtsen Head of department Department of Obstetrics and Gynecology, Haukeland University Hospital, Bergen, Norway

2 Cesarean section «good or harm». Increasing cesarean section rates! The dilemma of health care in obstetrics today

3 % Cesarean sections as a percentage of 25 all deliveries , % Denmark Norway Sweden Finland Iceland Source: 01/11/2013 THL, Nordic perinatal statistics 3

4 Victoria Beckham Victoria Beckham started the "Too Posh to Push" craze by delivering all three of her sons, and most recently her daughter, via C-section.

5 Too posh to push Are middle-class mums too posh to push? «Too NICE to push» has c-section become safer than natural birth? «too posh to push» or too scared to push?

6 Mean maternal age for primiparas , years Source: THL, Nordic perinatal statistics Danmark Finland Island Norge Sverige 6

7 Older maternal age Later marriage Second marriage Better contraceptive options Further education Career advancement

8 Maternal age 35 years or more , % 25 Source: THL, Nordic perinatal statistics Danmark Finland Island Norge Sverige 8

9 Older women Acquire: 1. Medical conditions 2. Surgical conditions 3. Lifestyle factors (obesity)

10 Increased perinatal mortality Ectopic pregnancy Spontaneous abortion Cesarean delivery Increased maternal age > 35 years Fetal chromosomal abnormalities Preeclampsia Congenital anomalies Gestational diabetes Placenta previa

11 Older women High rates of operative delivery: 1. Dysfunctional labor -failure to progress/uterine dysfunction 2. Medical complications 3. Induction of labor 4. Fetal malposition 5. Lower treshold for CS! 6. If VBAC more CS - failed trial of labor - uterine rupture

12 Too posh to push Are middel-class mums too posh to push? Ref: Bragg et al. BMJ 2010;341:c5065doi: /bmj.c5065 Age Number of CS Rate of CS OR Adjusted OR* Under % ( ) % % ( ) % ( ) Over % ( ) Total %

13 Cesarean section in low-risk population (primipara and para one ) Norway. Ref Herstad et al. AOGS 2012;91: Elective CS Emergency CS < >40

14 Kolås et al AOGS 2007;86: RR of CS delivery (adjusted maternal age, year of birth) All deliveries Low-risk Pre-gestational diabetes Gestational diabetes SGA Breech presentation Placenta previa Educational level RR (95% CI) High Medium Low High Medium Low High Medium Low High Medium Low High Medium Low High Medium Low High Medium Low p-value for trend p-value for trend p-value for trend p-value for trend p-value for trend p-value for trend p-value for trend 1 (15.4%) 1.21 ( ) 1.34 ( ) < (9.2%) 1.26 ( ) 1.50 ( ) < (43.0%) 1.14 ( ) 1.25 ( ) (27.2%) 1.37 ( ) 1.55 ( ) (24.1%) 1.10 ( ) 1.12 ( ) (65.4%) 1.06 ( ) 1.04 ( ) (90.1%) 1.04 ( ) 0.98 ( ) 0.552

15 Percentage of primipara in Norway delivered by C-section (term, singleton, cephalic) Waldenstrøm et al. BJOG >40 years years All primipara

16 Forget too posh to push Health professionals resorts to the: too old too sich too fat and asking for it

17 Kvinneklinikken Haukeland universitetssykehus, Bergen

18 Number of deliveries Kvinneklinikken/fødeavd Storken

19 Proportion of operative deliveries, Haukeland University Hospital Cesarean section Forceps Vacuum Vaginal breech

20 Per cent Proportion of cesarean section Kvinneklinikken Total birth population

21 Antall keisersnitt Akutt CS Elektiv CS

22 Praktisk obstetrikk er et teoretisk fag The safe and effective management of labour and delivery requires a clear understanding on the part of the birth attendant of the anatomy, physiology and biochemistry of human parturition and of its central participants the mother and infant. Munro Kerr s Operative Obstetrics 2007

23 Proportion of operative vaginal deliveries Kvinneklinikken, Forceps Total birth population, Forceps Total birth population, Vacuum Kvinneklinikken, Vacuum

24 Proportion of vaginal operative deliveries (vacuum and forceps) Total birth population Kvinneklinikken

25 Praktisk obstetrikk kurs Årlig kurs: nasjonalt og lokalt Fødselsmekanik Vaginal forløsningsteknikk (tang, vakuum) Vaginal forløsning tvillinger Vaginal forløsning seteleie Keisersnitt

26 Factors associated with wish for cesarean section on maternal request Fear of childbirth prevalence 5-40% Age Previuos cesarean section Previous birth injury Sexual abuse Previous stillbirth or injured infant related to pregnancy or delivery Psychiatric illness Other reasons (practical reasons)

27 Strategi- samtalepoliklinikk Rådgivningssenter for mor og barn Kontakt: jordmor og lege Samtale indhold: informasjon og gjennomgang Skriftlig avtale for fødsel

28 Counselling Patient-specific issues: Comorbid medical conditions Body mass index Future reproductive plans Prior childbirth experiences Outcome of previous surgical procedures Patients personal philosophy about childbirth

29 Resultater 200 kvinner ( ) 359 konsultasjoner 22% førstegangsfødende 9.4% operativ vaginal forløsning 14.4% akutt keisersnitt 12.8% elektiv keisersnitt

30 Fosterovervåking Lytting (stetoskop/doppler) Ekstern CTG STAN registrering

31 Kontinuerlig kvalitetssikring Morgenmøte: (alle leger) Daglig gjennomgang STAN registering læringseffekt holdningsskapendeeffekt Ukentlig møte leger-jordmødre

32 Kontinuerlig kvalitetssikring Morgenmøte: Holdningsskapendeeffekt Fokus på indikasjon for keisersnitt Vurder induksjon Keisersnitt inntil utslettet mormunn Utslettet mormunn: operativ vaginal forløsning

33 Cesarean section Standard population groups Gestational age 37 weeks, singleton P0, spontaneous P0, induced P>0, no-cs, spontaneous P>0, no-cs, induced

34 Delivery after cesarean section Gestational age 37 weeks, singleton P>0, Cesarean section P>0, operative delivery

35 Proportion of cesarean section < 37 weeks, singleton

36 Operativ vaginal forløsning Lav keisersnittsandel - ikke noe kvalitetsmål. Det er ikke slik at keisersnitt er den eneste vei til trygg fødselshjelp. Men det kan være den tryggeste vei Et mål: Tilstrebe minst mulig intervensjon, uten omkostning for mor og barn

37 Strategi- tidligere kejsersnit 1. gangs kejsersnit: vaginal fødsel 2. gangs kejsersnit: tilbud om vaginal fødsel

38 Middle class women are NOT too posh to push Cesarean delivery are NOT safer than vaginal birth Women are NOT too scared to push

39 Vaginal delivery remains the choice Disparities in the rates of cesarean section are an important issue because they are linked to (pervasive racial-ethnic) and socioeconomic disparities in maternity care.

40 Oppsummering Opprettholde praktiske obstetriske ferdigheter Operativ vaginal forløsning må læres, slik all operativ aktivitet må læres. Krever innsats Holdningsskapende diskusjoner Enighet Kontinuerlig fokus: Trender kan endres. Det krever innsats vilje og arbeid