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The First Cut is the Deepest

Preventing primary cesarean
by Hilary Gerber on 10 September 2014

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Transcript of The First Cut is the Deepest

Preventing Primary Cesarean Section
The First Cut is the Deepest
Hilary Gerber, D.O.
VBAC Summit - August 2012

The big picture
Primary? Wait, I thought this was a VBAC Summit!
What exactly is a "risk factor" for cesarean?
Anemia
Cardiac disease
Acute or chronic lung disease
Diabetes
Genital herpes
Polyhydramnios / oligohydramnios
Hemoglobinopathy
Chronic hypertension
Labor and delivery
Medical
Pregnancy associated hypertension
Preclampsia
Incompetent cervix
Previous infant > 4000 g
Previous preterm or small for gestational age infant
Renal disease
Rh sensitization
Uterine bleeding
Know your...
Denominator
Exclusion criteria

Febrile
Meconium moderate/heavy
Premature rupture of membrane
Abruptio placenta
Placenta previa
Other excessive bleeding
Seizures during labor
Precipitous labor
Prolonged labor
Dysfunctional labor
Breech / malpresentation
Cephalopelvic disproportion
Cord prolapse
Anesthetic complication
Fetal distress
http://cesareanart.wordpress.com
Guise JM, Eden K, Emeis C et al. Vaginal birth after cesarean: new insights. Evid Rep Technol Assess (Full Rep ) 2010 March;(191):1-397.
How do we approach cesarean section?
Mode of delivery
Quality outcome
Intervention
Short term consequences
CMAJ. 2007 February 13; 176(4): 455–460
Abnormal placentation
Ectopic pregnancy
Hemorrhage
Hysterectomy
Latex allergy
Endometriosis
Adenomyosis
Increased hospital readmission
Stillbirth
Long term risks
Fetal risks
Increased NICU admission
Separation of the mother and neonate
Iatrogenic prematurity
Laceration
Respiratory problems
Increased special educational needs
The provider effect
Lavender T. Caesarean section for non-medical reasons at term. Cochrane Database Of Systematic Reviews [serial online]. February 8, 2012
Lavender T. Caesarean section for non-medical reasons at term. Cochrane Database Of Systematic Reviews [serial online]. February 8, 2012
Cesarean delivery rate
Primary cesarean rate
VBAC
Repeat cesarean delivery
Declercq E, Menacker F, Macdorman M. Rise in "no indicated risk" primary caesareans in the United States, 1991-2001: cross sectional analysis. BMJ 2005 January 8;330(7482):71-2.
Reime B, Klein MC, Kelly A et al. Do maternity care provider groups have different attitudes towards birth? BJOG 2004 December;111(12):1388-93.
The empowered patient
Induction
Higher risk of cesarean
ACOG Practice Bulletin: "...nulliparous women undergoing induction of labor with unfavorable cervices should be counseled about a two-fold increased risk of cesarean delivery"
Higher risk of subjective cesarean indications
ACOG: "...labor progression differs significantly for women with an elective induction of labor compared to women who have spontaneous labor"
What about if the EFW is high?
ACOG Practice Bulletin No. 22: Fetal macrosomia. 2000 Nov.
ACOG: "Current evidence from cohort studies
does not support
a policy of early induction of labor in term patients with suspected fetal macrosomia. Three recent reports show that induction of labor
at least doubles the risk of cesarean delivery without reducing shoulder dystocia or newborn morbidity
."
ACOG Practice Bulletin No. 107: Induction of Labor. Obstet Gynecol 2009 August;114(2 Pt 1):386-97.
How big is big?
ACOG Level B recommendation:
ACOG Practice Bulletin No. 22: Fetal macrosomia. 2000 Nov.
Cesareanrates.com
ACOG Practice Bulletin No. 107: Induction of Labor. Obstet Gynecol 2009 August;114(2 Pt 1):386-97.
Hueston WJ. Site-to-site variation in the factors affecting cesarean section rates. Arch Fam Med 1995 April;4(4):346-51.
Hueston WJ. Site-to-site variation in the factors affecting cesarean section rates. Arch Fam Med 1995 April;4(4):346-51.
Doula
Provider
Hospital
Induction
momstinfoilhat.wordpress.com
Cesareanrates.com
Childbirthconnection.org
Lamaze
Your best birth
ICAN
Resources
ACOG Practice Bulletin No. 107: Induction of Labor. Obstet Gynecol 2009 August;114(2 Pt 1):386-97.
Luthy DA, Malmgren JA, Zingheim RW, Leininger CJ. Physician contribution to a cesarean delivery risk model. Am J Obstet Gynecol 2003 June;188(6):1579-85.
Community
Or other site
Berghella V, Baxter JK, Chauhan SP. Evidence-based labor and delivery management. Am J Obstet Gynecol 2008 November;199(5):445-54.
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