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
Cesarean section «good or harm». Increasing cesarean section rates! The dilemma of health care in obstetrics today
% Cesarean sections as a percentage of 25 all deliveries 1975 2010, % 20 15 10 Denmark Norway Sweden Finland Iceland 5 0 1975 1980 1985 1990 1995 2000 2005 2010 Source: 01/11/2013 THL, Nordic perinatal statistics 3
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.
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?
Mean maternal age for primiparas 1975-2008, years Source: THL, Nordic perinatal statistics 30 29 28 27 26 25 24 23 22 21 20 1975 1980 1985 1990 1995 2000 2005 2010 Danmark Finland Island Norge Sverige 6
Older maternal age Later marriage Second marriage Better contraceptive options Further education Career advancement
Maternal age 35 years or more 1975-2008, % 25 Source: THL, Nordic perinatal statistics 20 15 10 5 0 1975 1980 1985 1990 1995 2000 2005 2010 Danmark Finland Island Norge Sverige 8
Older women Acquire: 1. Medical conditions 2. Surgical conditions 3. Lifestyle factors (obesity)
Increased perinatal mortality Ectopic pregnancy Spontaneous abortion Cesarean delivery Increased maternal age > 35 years Fetal chromosomal abnormalities Preeclampsia Congenital anomalies Gestational diabetes Placenta previa
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
Too posh to push Are middel-class mums too posh to push? Ref: Bragg et al. BMJ 2010;341:c5065doi:10.1136/bmj.c5065 Age Number of CS Rate of CS OR Adjusted OR* Under 20 5304 13% 0.74 0.73 (0.70-0.76) 20-24 20709 17% 1 1 25-29 36691 22% 1.33 1.24 (1.21-1.27) 30-35 44915 27% 1.77 1.57 (1.52-1.62) Over 35 40107 33% 2.4 2.14 (2.05-2.24) Total 147726 24%
Cesarean section in low-risk population (primipara and para one 1999-2006) Norway. Ref Herstad et al. AOGS 2012;91:816-823 25 Elective CS Emergency CS 20 15 10 5 0 <20 20-24 25-29 30-34 35-39 >40
Kolås et al AOGS 2007;86:840-848 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 1996-2004 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 (1.19-1.24) 1.34 (1.27-1.42) <0.001 1 (9.2%) 1.26 (1.21-1.30) 1.50 (1.38-1.63) <0.001 1 (43.0%) 1.14 (0.99-1.31) 1.25 (0.92-1.69) 0.037 1 (27.2%) 1.37 (1.12-1.67) 1.55 (1.01-2.38) 0.001 1 (24.1%) 1.10 (1.03-1.18) 1.12 (0.96-1.30) 0.007 1 (65.4%) 1.06 (1.02-1.09) 1.04 (0.95-1.13) 0.003 1 (90.1%) 1.04 (0.96-1.13) 0.98 (0.76-1.27) 0.552
Percentage of primipara in Norway delivered by C-section (term, singleton, cephalic) Waldenstrøm et al. BJOG 2012 80 >40 years 35-39 years All primipara 70 60 50 40 30 20 10 0 1975 1980 1985 1990 1995 2000 2005
Forget too posh to push Health professionals resorts to the: too old too sich too fat and asking for it
Kvinneklinikken Haukeland universitetssykehus, Bergen
Number of deliveries 6000 5000 Kvinneklinikken/fødeavd Storken 4000 3000 2000 1000 0 1985 1990 1995 2000 2005 2010
1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 Proportion of operative deliveries, Haukeland University Hospital 80 70 60 50 40 30 20 10 0 Cesarean section Forceps Vacuum Vaginal breech
1967 1970 1973 1976 1979 1982 1985 1988 1991 1994 1997 2000 2003 2006 2009 Per cent Proportion of cesarean section Kvinneklinikken Total birth population 20 15 10 5 0
Antall keisersnitt 700 600 500 400 300 Akutt CS Elektiv CS 200 100 0 2006 2007 2008 2009 2010 2011 2012
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
1980 1984 1988 1992 1996 2000 2004 2008 1980 1984 1988 1992 1996 2000 2004 2008 Proportion of operative vaginal deliveries Kvinneklinikken, Forceps Total birth population, Forceps Total birth population, Vacuum Kvinneklinikken, Vacuum 10 9 8 7 6 5 4 3 2 1 0 10 9 8 7 6 5 4 3 2 1 0
14 12 10 8 6 4 2 0 1980 1982 1984 Proportion of vaginal operative deliveries (vacuum and forceps) Total birth population 1986 1988 1990 1992 1994 1996 1998 2000 2002 Kvinneklinikken 2004 2006 2008 2010 2012
Praktisk obstetrikk kurs Årlig kurs: nasjonalt og lokalt Fødselsmekanik Vaginal forløsningsteknikk (tang, vakuum) Vaginal forløsning tvillinger Vaginal forløsning seteleie Keisersnitt
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)
Strategi- samtalepoliklinikk Rådgivningssenter for mor og barn Kontakt: jordmor og lege Samtale indhold: informasjon og gjennomgang Skriftlig avtale for fødsel
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
Resultater 200 kvinner (2010-11) 359 konsultasjoner 22% førstegangsfødende 9.4% operativ vaginal forløsning 14.4% akutt keisersnitt 12.8% elektiv keisersnitt
Fosterovervåking Lytting (stetoskop/doppler) Ekstern CTG STAN registrering
Kontinuerlig kvalitetssikring Morgenmøte: (alle leger) Daglig gjennomgang STAN registering læringseffekt holdningsskapendeeffekt Ukentlig møte leger-jordmødre
Kontinuerlig kvalitetssikring Morgenmøte: Holdningsskapendeeffekt Fokus på indikasjon for keisersnitt Vurder induksjon Keisersnitt inntil utslettet mormunn Utslettet mormunn: operativ vaginal forløsning
Cesarean section Standard population groups Gestational age 37 weeks, singleton P0, spontaneous P0, induced P>0, no-cs, spontaneous P>0, no-cs, induced 30 25 20 15 10 5 0 1991 1993 1995 1997 1999 2001 2003 2005 2007 2009 2011 2013
Delivery after cesarean section Gestational age 37 weeks, singleton P>0, Cesarean section P>0, operative delivery 50 45 40 35 30 25 20 15 10 5 0 1991 1993 1995 1997 1999 2001 2003 2005 2007 2009 2011 2013
Proportion of cesarean section < 37 weeks, singleton 40 35 30 25 20 15 10 5 0 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012
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
Strategi- tidligere kejsersnit 1. gangs kejsersnit: vaginal fødsel 2. gangs kejsersnit: tilbud om vaginal fødsel
Middle class women are NOT too posh to push Cesarean delivery are NOT safer than vaginal birth Women are NOT too scared to push
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.
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