Cesarean Delivery on Maternal Request - PowerPoint PPT Presentation

1 / 41
About This Presentation
Title:

Cesarean Delivery on Maternal Request

Description:

2Percentage of all live births by cesarean delivery ... Birth is an inherently normal process ... Birth Certificate ... – PowerPoint PPT presentation

Number of Views:1095
Avg rating:3.0/5.0
Slides: 42
Provided by: barbara373
Category:

less

Transcript and Presenter's Notes

Title: Cesarean Delivery on Maternal Request


1
Cesarean Delivery on Maternal Request
  • Presented by
  • Barbara Hughes, CNM, MS, MBA, FACNM
  • Colorado Perinatal Care Council
  • July 31, 2009

2
(No Transcript)
3
Background and Process
  • Increasing Rate of Cesarean Delivery
  • NIH Role
  • CDMR What is it?
  • Identifying the Key Questions
  • What did the evidence say?
  • What were the recommendations?
  • Whats YOUR Opinion?

4
Definition of Cesarean Delivery on Maternal
Request (CDMR)
  • Primary cesarean delivery
  • Singleton pregnancy
  • At term
  • On maternal request
  • No maternal or neonatal indications

5
Conference Sponsors
  • National Institute of Child Health and Human
    Development, NIH (NICHD)
  • Office of Medical Applications of Research, NIH
    (OMAR)
  • Co-Sponsors
  • National Institute of Diabetes and Digestive and
    Kidney Diseases, NIH
  • National Institute of Nursing Research, NIH
  • Office of Research on Womens Health
  • Also supported by
  • The Agency for Healthcare Research and Quality
    (AHRQ)

6
State-of-the-Science Conference
  • NIH consensus and state-of-the-science statements
    are prepared by independent panels of health
    professionals and public representatives on the
    basis of
  • (1) the results of a systematic literature review
    prepared under contract with the Agency for
    Healthcare Research and Quality (AHRQ),
  • (2) presentations by investigators working in
    areas relevant to the conference questions during
    a 2-day public session,
  • (3) questions and statements from conference
    attendees during open discussion periods that are
    part of the public session, and
  • (4) closed deliberations by the panel during the
    remainder of the second day and morning of the
    third. This statement is an independent report of
    the panel and is not a policy statement of the
    NIH or the Federal Government.

7
Who was on the Panel???
  • OB/GYN Physicians
  • MFM
  • Urogynecologist
  • Urologist
  • Anesthesiologist
  • Epidemiologist
  • Bio-statistician
  • Neonatologist
  • Psychiatrist
  • Dean of Law School
  • Nurse-Midwife
  • Patient Representative

8
The Assignment...
  • National Institute of Child Health and Human
    Development (NICHD) and the Office of Medical
    Applications of Research (OMAR) of the National
    Institutes of Health (NIH) convened a
    State-of-the-Science Conference from March 27 to
    29, 2006, to assess the available scientific
    evidence relevant to four key questions

9
What are the Key Questions (KQs)?
  • KQ1 What is the trend and incidence of cesarean
    delivery over time in the US and in other
    developed countries?
  • KQ2 What is the effect of approach to delivery
    (i.e. cesarean delivery on maternal request
    compared to planned vaginal delivery), on
    maternal and infant short-term and long-term
    outcomes?
  • KQ3 What are the factors affecting the magnitude
    of the benefits and harms in KQ2?
  • KQ4 What future research directions need to be
    considered to get evidence for making appropriate
    decisions regarding CDMR versus planned vaginal
    delivery?

10
  • Key Question 1
  • What Is The Trend and Incidence of Cesarean
    Delivery Over Time in the United States and in
    Other Countries?

11
Total and primary cesarean rate and (VBAC)
United States, 1989-2004 (29.1 in 2004)
VBAC1
Per 100
Total cesarean2
Primary cesarean3
1997
2001
1999
20044
1995
1989
1991
1993
2003
Year
1Number of vaginal births after previous
cesarean per 100 live births to women with a
previous cesarean delivery 2Percentage of all
live births by cesarean delivery 3Number of
primary cesarean deliveries per 100 live births
to women who have not had a previous cesarean
4Based on preliminary data NOTE Due to changes
in data collection from implementation of the
2003 revision of the U.S. Standard Certificate of
Live Birth, there may be small discontinuities in
rates of primary cesarean delivery and VBAC in
2003 and 2004. See Technical Notes.
12
What is the IDEAL Rate of CD?
  • Healthy People 2010 15
  • Upon what basis was this rate determined?
  • Does the cesarean section rate influence maternal
    and child health?

13
The Evidence
  • Evidence-based Practice Center (EPC) Report
  • RTI InternationalUniversity of North Carolina at
    Chapel Hill Evidence-based Practice Center
    (RTI-UNC EPC)
  • NUMEROUS additional articles
  • Speakers
  • Audience Participants

14
?
?
Planned Vaginal Delivery
Planned Cesarean Delivery
15
  • Key Question 2
  • What Are the Short-Term (Under One Year) and
    Long-Term Benefits and Harms to Mother and Baby
    Associated With Cesarean by Request Versus
    Attempted Vaginal Delivery?

16
Quality and Relevance of the Evidence
  • For the evidence obtained from the EPC report,
    the panel utilized an evidence quality grading
    scale provided within the document
  • Level Istrong,
  • Level IImoderate,
  • Level IIIweak
  • Level IVabsent

17
What did we have to work with?
  • No Level I evidence was found!
  • 3 outcomes had Level II evidence
  • (Mom) Hemorrhage, LOS
  • (Baby) Respiratory morbidity
  • The remaining outcomes were Level III or IV
  • Interpretation of many outcome variables was
    confounded by a lack of appropriate comparison
    groups, a lack of consistency in outcome
    definitions, and the frequent use of composite
    outcomes proxies.

18
Maternal Outcomes With Moderate-Quality Evidence
(2)
  • Hemorrhage. The frequency of postpartum
    hemorrhage associated with planned CD is less
    than that reported with the combination of PVD
    and unplanned CD.
  • Maternal length of hospital stay is higher for
    CD, planned or otherwise, than for vaginal
    delivery. But...

19
Benefits Harms Summary
  • With the exception of 3 outcome variables with
    moderate-quality evidence (maternal hemorrhage,
    maternal length of stay, and neonatal respiratory
    morbidity)... all of the remaining outcome
    assessments considered by the panel were based on
    weak evidence.
  • This significantly limits the reliability of
    judgments regarding whether an outcome measure
    favors either CDMR or PVD.

20
(No Transcript)
21
  • Key Question 3
  • What Factors Influence Benefits and Harms?

22
What factors influence benefits harms?
  • Patient specific factors
  • Age
  • Childbearing plans/family size
  • Obesity
  • Accuracy of gestational age assessment
  • Psychological factors

23
What factors influence benefits harms?
  • Cultural Societal Issues
  • Cultural beliefs and practices
  • Personal philosophy of birth
  • Increasing societal acceptance
  • Media

24
What factors influence benefits harms?
  • Provider Type and Professional Resources
  • Obstetrical providers...
  • OB/GYN Physicians
  • MFM Physicians
  • Family Medicine Physicians
  • Certified Nurse-Midwives

25
What factors influence benefits harms?
  • Provider Type and Professional Resources
  • Providers View of CDMR...
  • Training
  • Practice environment
  • Experience
  • Personal philosophy
  • Medicolegal issues

26
What factors influence benefits harms?
  • Provider Type and Professional Resources
  • Geographical location
  • Level of perinatal services
  • Availability of anesthesia
  • Hospital resources (OR Staff)
  • Unpredictability of timing
  • Complex issues
  • Potential for biased recommendations

27
What factors influence benefits harms?
  • Ethical Issues
  • Provider/Patient relationship
  • Ethical principles
  • Autonomy
  • Beneficence
  • First, DO NO HARM
  • If a woman requests information...
  • Shared decision making process
  • When a provider cannot support a request for
    CDMR, ...it is appropriate to refer the woman to
    another provider.

28
Summary of factors that influence benefits and
harms...
  • Birth is an inherently normal process
  • The majority of women would like to achieve a
    spontaneous vaginal delivery and should supported
    in their efforts to achieve that goal
  • The available evidence and data comparing risks
    and benefits of PVD and CDMR are sparse and
    provide few clear conclusions

29
  • Key Question 4
  • What future research directions need to be
    considered to get evidence for making appropriate
    decisions regarding cesarean delivery on request
    or attempted vaginal delivery?

30
Future research directions
  • Surveys of women, providers, insurers and
    healthcare facilities regarding CDMR
  • Create mechanisms to identify CDMR
  • CPT Code
  • Birth Certificate
  • Increase research devoted to strategies to
    predict and influence the likelihood of
    successful vaginal birth, especially in the first
    pregnancy

31
Future research directions
  • Study of large, prospective cohorts, including
    long-term follow-up of mothers and children
  • Study of critical outcomes
  • Case-control studies
  • Randomized Trials?

32
Future research directions
  • Future studies should determine whether there are
    modifiable factors in the management of labor
    that can decrease maternal and neonatal
    complications.
  • Furthermore, an attempt should be made to
    identify subgroups of women at higher risk for
    complications that would benefit most from
    planned CDMR.

33
Studies comparing CDMR PVD should consider the
following key outcomes...
  • Maternal
  • Maternal death
  • Placental abnormalities including previa acreta
  • Pelvic floor disorders
  • Psychological factors

34
Studies comparing CDMR PVD should consider the
following key outcomes...
  • Neonatal
  • Neonatal death
  • Neonatal encephalopathy
  • CP
  • Brachial plexus injury
  • Respiratory outcomes
  • Neurodevelopmental outcomes
  • Other birth injuries

35
Studies comparing CDMR PVD should consider the
following key outcomes...
  • Cost analysis of CDMR

36
Conclusions...
  • The incidence of CD without medical/obstetrical
    indications is rising in the United States, and a
    component of this is due to CDMR. Given the tools
    available, the magnitude of the CDMR component is
    difficult to quantify.
  • There is insufficient evidence to evaluate fully
    the benefits and risks of CDMR as compared to
    PVD, and more research is needed.

37
Conclusions...
  • Until quality evidence becomes available, any
    decision to perform a CDMR should be carefully
    individualized and consistent with ethical
    principles.
  • Given that the risks of placenta previa and
    acreta rise with each CD, CDMR is not recommended
    for women desiring several children.

38
Conclusions...
  • CDMR should not be performed prior to 39 weeks or
    without verification of lung maturity, because of
    the significant danger of neonatal respiratory
    complications.
  • Request for CDMR should not be motivated by
    unavailability of effective pain management.
    Efforts must be made to assure availability of
    pain management services for all women.

39
Conclusions...
  • NIH or another appropriate Federal agency should
    establish and maintain a Web site to provide
    up-to-date information on the benefits and risks
    of all modes of delivery.

40
What is YOUR opinion???
41
(No Transcript)
Write a Comment
User Comments (0)
About PowerShow.com