Title: Cesarean Delivery on Maternal Request
1Cesarean Delivery on Maternal Request
- Presented by
- Barbara Hughes, CNM, MS, MBA, FACNM
- Colorado Perinatal Care Council
- July 31, 2009
2(No Transcript)
3Background 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?
4Definition of Cesarean Delivery on Maternal
Request (CDMR)
- Primary cesarean delivery
- Singleton pregnancy
- At term
- On maternal request
- No maternal or neonatal indications
5Conference 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)
6State-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.
7Who was on the Panel???
- OB/GYN Physicians
- MFM
- Urogynecologist
- Urologist
- Anesthesiologist
- Epidemiologist
- Bio-statistician
- Neonatologist
- Psychiatrist
- Dean of Law School
- Nurse-Midwife
- Patient Representative
8The 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
9What 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?
11Total 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.
12What 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?
13The 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?
16Quality 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
17What 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.
18Maternal 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...
19Benefits 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?
22What factors influence benefits harms?
- Patient specific factors
- Age
- Childbearing plans/family size
- Obesity
- Accuracy of gestational age assessment
- Psychological factors
23What factors influence benefits harms?
- Cultural Societal Issues
- Cultural beliefs and practices
- Personal philosophy of birth
- Increasing societal acceptance
- Media
24What factors influence benefits harms?
- Provider Type and Professional Resources
- Obstetrical providers...
- OB/GYN Physicians
- MFM Physicians
- Family Medicine Physicians
- Certified Nurse-Midwives
25What factors influence benefits harms?
- Provider Type and Professional Resources
- Providers View of CDMR...
- Training
- Practice environment
- Experience
- Personal philosophy
- Medicolegal issues
26What 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
27What 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.
28Summary 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?
30Future 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
31Future 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?
32Future 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.
33Studies comparing CDMR PVD should consider the
following key outcomes...
- Maternal
- Maternal death
- Placental abnormalities including previa acreta
- Pelvic floor disorders
- Psychological factors
34Studies 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
35Studies comparing CDMR PVD should consider the
following key outcomes...
36Conclusions...
- 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.
37Conclusions...
- 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.
38Conclusions...
- 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.
39Conclusions...
- 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.
40What is YOUR opinion???
41(No Transcript)