how to reduce cesarean section rate is a hot topic. This presentation discusses various steps and fields that may lower CS rate.

1. How to reduce cesarean
section Rate?
Mahmoud Abdel-Aleem
Assistant Professor of Obstetrics and Gynecology

2. Acknowledgments

3. Outline
 Why this topic ?
 Introduction.
 How to reduce CS rate?

4. Introduction

5. An old extreme:
 Cesarean birth has been a major source of interest and
concern over the last 15-25 years.
 Academic leaders preached, as did Williams, that ‘‘the
excellence of an obstetrician should be gauged not by the
number of cesareans which he performs, but rather by
those which he does not do.’’
 Davis (Philadelphia) in 1919, he stated ‘‘Anybody who can
use his hands and has a few tools can do a cesarean
section. I take much more pride in getting my borderline
cases through spontaneously than I do opening their
abdomens

6. Our target (which figure?)
 The Myth of the ideal cesarean section rate.
 let everyone practice the best obstetrics they know, and
let the cesarean section rate seek its own level.

7.  Williams maintained a cesarean rate of 0.9% between
1900 and 1921. His legacy kept the cesarean rate low for
decades after his death in 1931.

8. Where to begin?
Primary
Secondary

9. Primary Prevention
 Proper management of labour.
 Proper use of EHRM.
 Better understanding and definition of dystocia.
 Proper conduct of induction of labour.
 More elaborate use of safe operative vaginal delivery.
 More elaborate indications for vaginal delivery
 Breech.
 ECV
 TBT
 Multiple pregnancy.
 First vertex –second ------

10. Secondary prevention.
VBAC

11. I- EHRM

12.  The story of EFM is well known. EFM was adopted into clinical
practice in the 1960s and 1970s before being assessed in
randomized trials.
 Today, EFM is often used as the “poster child” for a medical
technology that was accepted in clinical practice despite
having no documented benefits
 Argument that EFM should be discarded frequently appears in
the obstetrical literature.
 Changing a practice that is currently standard of care is very
difficult.

13.  A reduction in intrapartum stillbirth is still a true
benefit of EFM.
 A Cochrane meta-analysis, compared 13 RCTs of
continuous EFM with intermittent auscultation (IA)
and confirmed higher cesarean section rates but no
improvement in Apgar scores, perinatal mortality or
rates of cerebral palsy in infants born to women in
the continuous EFM.
 50% reduction in the incidence of early neonatal
seizures, but there were no differences between
the EFM and IA groups in the rate of cerebral palsy
when the infants with newborn seizures were
reexamined at 4 years of age.

14. How to improve EHRM ?
1- Promote the use of IA of FHR in low-risk population
for which continuous FHR was not originally designed.
2- Use of backup tests in the setting of category II
tracing These may include FBS with or without fetal
ECG analysis.
3- computerized analysis of FHR tracings.
4- Decrease the false-positive interpretation rate by
increasing the threshold required to perform a CD for
FHR indications.
5- 5-tier not 3-tier system:

16. II. Conduct of labour

17. (1) Active labor must be accurately diagnosed before
the rate of cervical dilation is used to assess labor
progression.
(2) In nulliparous women, 90% of women have a linear
dilation rate of at least 0.5 cm/h.
(3) The time between each centimeter of dilatation is
more variable in early active labor than it is in late
active labor
(5) The partogram includes a dystocia line that
incorporates these 4 principles and additionally
assumes any 4-hour delay in dilation after 5 cm is an
indication for intervention

18. (6) Continuous supportive care.
(7) Avoiding epidural analgesia.
(8) Supporting adequate hydration.
(9) Use of upright positions.
(10) Less use of amniotomy and oxytocin
during labor.

19. “Dysfunctional team-work”

20. III. Patient as a factor

21. The arguments for cesarean section by
maternal request
 Social convenience and planning.
 Peer group pressures.
 Tokophobia.
 Avoiding presumed fetal risk.
 Avoiding maternal risk (pelvic floor
problems).

22. Response of an obstetrician to medically
unindicated CS
Doctor Response Result
A Recommends elective CS
over VD with evidence
available to support this
position.
Cesarean medically
indicated.
B Recommends VD over CS with
evidence available to support
this position.
Refuses non-medically
indicated cesarean section.
C Considers VD and elective CS
are equivalent with evidence
available to support this
position.
Allows maternal choice
D Considers evidence uncertain
in that the available
evidence does not support
any particular mode of
delivery.
May allow maternal choice

23. IV. Modern Obstetric delivery
instruments “Assisted Vacuum and
Forceps delivery”

24. Instrumental delivery

25.  A lost Art.
 As long as the vaginal route is an option for human
delivery obstetrical forceps and vacuum will continue to
be an option to assist women and children to carry on the
delivery process unharmed.

26. How to Improve ?

27. V. Progress of labour_Dystocia

28. Norms
 Norms are Based on findings of Dr/ Emanual Friedman in
1955.
 Dystocia is a vague term denoting slow or abnormal
progression of labor.
 A pioneer work done by Zhang over thousands of patients
shows that labour nowadays takes more time to proceed
 A cervical dilation of 6 cm appears to be a better landmark for
the start of the active phase.
 For both nulliparous and multiparous women, labor may take >6
hours to progress from 4 to 5 cm and >3 hours to progress from
5 to 6 cm of dilation.
 The 95th percentile for duration of the second stage in a
nulliparous woman with conduction anesthesia is closer to 4 hours.

29. Changes in labor patterns
 Laughon, et al (AJOG,May 2012).
 Comparison of Collaborative Perinatal Project (CPP)
39,491 births from 1959-1966 and the Consortium on Safe
Labor (CSL) 98,359 births from 2002-2008
 CPP was prospective study 54,390 births
 CSL was retrospective study 228,668 births

30. Friedman curve
622  500…..1955
Zhang curve
62,415 …..2010

31. The BMI Effect
 More First Stage
 CSL
 Multips enter active labor by 6cm
 Labor proceeds more slowly as BMI increases.
 Need to allow more time during labor management

32. Second stage of labour

33. New designations
 Allow at least 12 hours after rupture of membranes for a
patient to exit the latent phase of labor.
 Arrest of Labor in the Active Phase: patients achieved at least
6cm dilation with membrane rupture and failed to demonstrate
cervical change over 4 or more hours of adequate (> 200 MVUs)
contractions or 6 or more hours of inadequate contractions.
 Second Stage Arrest: patients in the second stage who have
failed to demonstrate fetal descent or rotation for:
 >/= 4 hours in a nullipara with an epidural
 >/= 3 hours in a nullipara without an epidural
 >/= 3 hours in a multipara with an epidural
 >/= 2 hours in a multipara without an epidural

34. VI. VBAC

35.  Actually in 2015, we still apply the 1916 dictum "Once a
cesarean, always a cesarean.
 More than one third of all cesarean births occur as the
direct result of a previous cesarean delivery.
 Apply the dictum “"Once a cesarean, always a scar” with
careful handling of labour.

36.  Repeat CS is now the commonest cause of CS.
 Chance to deliver vaginally after 1-2 CS ~ 70%
 Success of VBAC starts by the already done CS; SO please
 LSCS is to be done in all cases.
 Two layer closure using delayed absorbable sutures is the rule.
 Exert every effort to prevent infection.
 Medical report (discharge summary) is a must.
 In women with previous scar: Induction of labor at 39
weeks, when compared to expectant management, was
associated with a higher chance of VBAC but also of
uterine rupture.

37. VII. Induction of labour

38.  Timing: 41 weeks.
 Use label of “NonIndicated” rather than “Elective.”
 Pre-induction phase: use ripening agents.
 Failed induction: 24 hours of labor have passed
without reaching a cervical dilation of 6 cm.
 Oxytocin can be used in PROM for 12-16 hours to have
an effect.

39. Take care!!!!
Time to progress from 4-10cm
longer in induced labor (5.5 hrs
vs 3.8 hrs median)
After 6 cm, women in induced
and spontaneous labor spend
similar amounts of time
advancing 1 cm in dilation
Both multips & nullips who are
induced can spend (95th%ile) >
17 hrs after 4cm
Induced women may require >
8hrs from 3 to 4cm

40. And many others
 Beech.
 Multiple pregnancy.
 VBAC in 2 CS.
 And
 And
 And
 And ………………………………………….

41. And Lastly !!!!

42. The malpractice crisis
Timing.
 Too early
 Too late.
Anesthesia.
Trauma.

43. Take Home message
 CS epidemic is annoying to the whole medical societies.
 CS isn’t a simple operation as it appears but it has many
“uncommon” but “disastrous” complications. Rising rate=
rising rate of complications.
 Turning the tide on caesarean rates is not easy. Cultural
change takes time; it also requires inspired leadership
and grassroots support.
 Pushing the obstetrician to practice obstetrics in the best
way is mandatory.

44. Bibliography
 Friedman EA. The graphic analysis of labor. Am J Obstet Gynecol 1954;68:1568-75.
 Friedman EA. Primigravid labor: a graphicostatistical analysis. Obstet Gynecol 1955:6:5678-89.
Harper 2012
 Kominiarek, M.A., Zhang, J., VanVeldhuisen, P., et al. Contemporary Labor Patterns: The
Impact of Body Mass Index. American Journal of Obstetrics and Gynecology 2011;205:244.e1-
8.
 Laughon, S.K., Branch, D.W., Beaver, J., et al. Changes in Labor Patterns over 50 years.
American Journal of Obstetrics and Gynecology 2012; 206:419.e1-9.
 Norman, S.M., Methodius, G.T., Odibo, A.O., et al. The Effects Of Obesity On The First Stage
Of Labor. Obstetrics and Gynecology 2012; 120(1):130-135.
 Rouse, Dwight J., et al. Failed Labor Induction: Toward an Objective Diagnosis. Obstetrics and
Gynecology 2011; 117(2pt1):267-272.
 Spong, C.Y., Berghella, V., Wenstrom, K.D., Mercer, B.M., & Saade, G.R. Preventing the First
Cesarean Delivery: Summary of a Joint Eunice Kennedy Shriver National Institute of Child
Health and Human Development, Society for Maternal Fetal-Medicine, and American College of
Obstetricans and Gynecologists Workshop. Obstetrics and Gynecology 2012; 120:5:1181-1193.
 Zhang, Jun, et al. Contemporary Patterns of Spontaneous Labor with Normal Neonatal
Outcomes. Obstetrics and Gynecology 2010; 116(2):1281-1287.
 Zhang, J., Troendle, J., Mikolajczyk, R., et al. The Natural History Of The Normal First Stage
Of Labor. Obstetrics and Gynecology 2010;115(4):705-710.