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Preventing the First Cesarean
George R. Saade, MD Professor, Departments of Ob-Gyn and Cell Biology Jeanne Sealy Smith Distinguished Chair in Ob-Gyn
Chief of Obstetrics and Maternal Fetal Medicine The University of Texas Medical Branch
Disclosure
This speaker has no conflicts of interest to disclose relative to the contents of this presentation.
Objectives
At the end of this presentation, participants should be able to:
Review the evidence on cesarean delivery rates and contributing factors.
Discuss the recent SMFM and ACOG recommendations regarding prevention of the first cesarean.
Follow management guidelines to decrease primary cesarean.
Data from National Vital Statistics
Cesarean Delivery Rates in US
Total CD rate
Primary CD rate
VBAC rate
U.S. total cesarean delivery rates by state, 2010.
Martin et al. Births: final data for 2009 NVSR 2011
www.cdc.gov/nchs/; www.healthypeople.gov
Behind the Numbers
HP2010 VBAC
HP 2010 1-CD
VBAC Total CD
Primary CD
The Healthy People Challenge
Decision analysis model
If primary and repeat cesareans continue to rise at current rates:
2020:
CS rate of 56.2%
Additional 6,236 previas per year
Additional 4,504 accretas per year
Additional 130 maternal deaths per year
Solheim et al., J Mat-Fet and Neonat Med 2011;24:1341-6
Downstream Consequences of Rising CD Rates
www.cdc.gov/nchs/; www.healthypeople.gov
Behind the Numbers The Healthy People Challenge
HP2010 VBAC
HP 2010 1-CD
VBAC Total CD
Primary CD
www.cdc.gov/nchs/; www.healthypeople.gov
Behind the Numbers
HP2020 VBAC
HP2020 1-CD
The Healthy People Challenge
HP2010 VBAC
HP 2010 1-CD
VBAC Total CD
Primary CD
The most effective
approach to reducing overall
cesarean delivery rates is to prevent the first cesarean
Mar
ch 2
01
4
Obstet
Gynecol 2
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4;
12
3:6
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1
Indications Contributing to the Increasing 1° Cesarean Delivery Rate
Barber EL et al; Obstet Gynecol 2011;118:29–38
Labor arrest 34%
Macrosomia 4%
Malpresentation 17%
Maternal-Fetal 5%
Maternal Request
3%
Multiple Gestation
7%
Nonreassuring fetal tracing
23%
Other obstetric indications
4%
Preeclampsia 3%
Potentially Modifiable Obstetric Indications for First CD
Failed induction
Arrest of labor
Multiple gestation
Preeclampsia
Prior shoulder dystocia
Prior myomectomy
Prior 3/4 degree lacerations
Marginal/low lying placenta Obstet Gynecol 2012;120:1181-93
Detailed in subsequent slides
Potentially Modifiable Fetal Indications for First CD
Malpresentation
ECV
Nonreassuring FHT
Education, confirmatory tests
Suspected macrosomia
5000/4500 cutoffs, monitor weight gain
Malformations
Education Obstet Gynecol 2012;120:1181-93
Detailed in subsequent slides
Potentially Modifiable Maternal Indications for First CD
Obesity
Education, monitor weight gain, preconception weight loss
Infection
Treatment to minimize transmission
CV disease
Inadequate pelvis
Request
Obstet Gynecol 2012;120:1181-93
Education
Induction of Labor
Rate of Induction
Martin JA et al National Vital Statistics Reports 2005
Elective Inductions at Term
Clark SL et al AJOG 2009
•27 hospitals in 14 states, 2007
•14,955 term births •19% of term births
were elective inductions
•Rate of elective induction varied (8-40%)
To avoid first CD related to induction:
Focus on elective labor inductions
Avoid
Recognize association of CD with cervical status
Accept that there is no clinically useful prediction model presently available
Allow the induction sufficient time to progress
Key points 1:
Labor induction for medical indications only
If no indication, should be 39+wks and cervix should be favorable (Bishop score >8)
Obstet Gynecol 2012;120:1181-93
Definitions: Failed Induction
Obstet Gynecol 2012;120:1181-93
Progress of Labor
Friedman. Obstet Gynecol 1956;8:691-703.
Progress of Labor
Rethinking Friedman: Contemporary Patterns of Spontaneous Labor
EMR from 19 US hospitals
62,415 women at term, spontaneous labor, vaginal delivery, normal outcomes
Constructed labor curves using the same methods as Friedman
Zhang, Obstet Gynecol, 2010
2 Zhang, Obstet Gynecol, 2010
Average Labor Curves Singleton term gestation, spontaneous onset of labor, vaginal delivery and normal neonatal outcomes
2 Zhang, Obstet Gynecol, 2010
Average Labor Curves Singleton term gestation, spontaneous onset of labor, vaginal delivery and normal neonatal outcomes
No deceleration phase
2 Zhang, Obstet Gynecol, 2010
Average Labor Curves Singleton term gestation, spontaneous onset of labor, vaginal delivery and normal neonatal outcomes
Multips: inflection at 6 cm (not 4cm)
2 Zhang, Obstet Gynecol, 2010
?
Average Labor Curves Singleton term gestation, spontaneous onset of labor, vaginal delivery and normal neonatal outcomes
Multips: inflection at 6 cm (not 4cm)
Nullips: no clear
inflection point
2 Zhang, Obstet Gynecol, 2010
Average Labor Curves Singleton term gestation, spontaneous onset of labor, vaginal delivery and normal neonatal outcomes
Zhang, Obstet Gynecol, 2010
Zhang, Obstet Gynecol, 2010
Zhang, Obstet Gynecol, 2010
95% similar Nullip
& Multip
Zhang, Obstet Gynecol, 2010
95% similar N&M
Multip. labor
speeds up
Zhang, Obstet Gynecol, 2010
95% similar N&M
Multip. labor
speeds up
All 95% <2h/cm
Obstet Gynecol 2012;120:1181-93
Median & 95th %iles duration of first stage in nulliparas with spontaneous labor
Median & 95th %iles of second stage duration with and without epidural
Obstet Gynecol 2012;120:1181-93
Definitions: Arrest Disorders
Obstet Gynecol 2012;120:1181-93
Spontaneous Labor Algorithm
Obstet Gynecol 2012;120:1181-93
Induced Labor Algorithm
Obstet Gynecol 2012;120:1181-93
Continuous Fetal Heart Rate Monitoring: Time for Reevaluation
Background
1960s Continuous EFM introduced into obstetrical practice
Complicated pregnancies
1978: ~66% US women monitored EFM
2002: >85% US women (3.4M) EFM
Hon et al, 1958
Banta & Thacker, 1979
Martin et al, 2003
0
5
10
15
20
25
30
35
1970 1975 1980 1985 1990 1995 2000 2005
Cesarean
Intrapartum monitoring
66% 85% % US women cEFM in labor
Cesarean delivery rate
%
Continuous Intrapartum Electronic
Fetal Heart Rate Monitoring
C-Section Rates
Source: CDC , Hospital Episode Statistics (UK), Medline, Notzon et al
USA USA
UK
Sweden
UK
Sweden
USA USA
UK
SWEDEN
Fetal Monitoring begins
Trends in CS and CP Rates
0
5
10
15
20
25
1970 1975 1980 1985 1990 1995 2000
Cesarean Section Rate
Cerebral Palsy Rate
Clark SL, et al. Am J Obstet Gynecol 2003;188:628-33.
Efficacy: Cochrane Review
12 clinical trials (n=37,000), 2 of high quality
No “non monitoring” studies
Most very old
cEFM compared to intermittent auscultation
Alfirevic et al. Cochrane 2006 (3) #CD006066
number (trials) RR 95%CI
Perinatal death 33,513 (11 trials) 0.85 0.59-1.23
Neonatal seizures 32,386 (9 trials) 0.50 0.31-0.80
Cerebral palsy 13,252 (2 trials) 1.74 0.97-3.11
Cesarean delivery 18,761 (10 trials) 1.66 1.30-2.13
Operative VD 18,151 (9 trials) 1.16 1.01-1.32
EFM During Labor Neonatal Seizure
No reduction in cerebral palsy
Dramatic increase in cesarean delivery
0
5
10
15
20
25
30
35
1970 1975 1980 1985 1990 1995 2000 2005
Cesarean
Intrapartum monitoring
US Preventive Task Force Grade: D
• No evidence of benefit
• Evidence of harm
66% 85% % US women
cEFM in labor
Continuous Intrapartum Electronic
Fetal Heart Rate Monitoring
Cesarean delivery rate
%
Most FHR abnormalities do not
result in fetal acidosis!
R. W. Beard, et al. The significance of the changes in the continuous foetal heart rate
in the first stage of labour. J Obstet Gynaecol Br Commonw 78:865-881, 1971.
Intrapartum Fetal Heart Rate Monitoring and Cerebral Palsy
Nelson et al. N Eng J Med 1996;334:613-8
Multiple Late Decelerations and/or Decreased Variability in
Prediction of Cerebral Palsy in Singleton Children with Birth
Weights > 2500 g, According to Risk Group
Intrapartum FHR Evaluation Interobserver Variability
Chauhan et al. Am J Obstet Gynecol 2008;199:623.e1-623.e5.
Intrapartum FHR Evaluation Intraobserver Agreement
Westerhuis et al. BJOG 2009;116:545-51
Kappa Values = Moderate 0.4-0.75
Let us just go back to IA
NICE Clinical Guideline 55 (2007)
ACNM. J Midwifery Women's Health 2010;55:397-403
ACNM. J Midwifery Women's Health 2010;55:397-403
Let us fix variability in interpretation and subjectivity
Sponsored by:
NICHD
ACOG
SMFM
Obstetrics & Gynecology: September 2008 - Volume 112 - Issue 3 - pp 661-666 The 2008 National Institute of Child Health and Human Development Workshop Report on
Electronic Fetal Monitoring: Update on Definitions, Interpretation, and Research Guidelines
Macones, GA; Hankins, GDV; Spong, CY; Hauth, J; Moore, T
Continued reevaluation
Additional tests
Non surgical interventions
Meaning & Management
Category II: Indeterminate
SMFM Preventing the First Cesarean Obstet Gynecol 2012;120:1181-93
SMFM Preventing the First Cesarean Obstet Gynecol 2012;120:1181-93
SMFM Preventing the First Cesarean Obstet Gynecol 2012;120:1181-93
SMFM Preventing the First Cesarean Obstet Gynecol 2012;120:1181-93
NICE Clinical Guideline 55 (2007)
Problem with EFM
Problem with EFM
It is a screening test that involves interpretation
Problem with EFM
It is a screening test that involves interpretation
Prediction of Acidemia: Computerized Assessment Czabanski et al. Expert Systems with Applications 2012;39:11846-60
Prediction of Acidemia: Computerized Assessment Czabanski et al. Expert Systems with Applications 2012;39:11846-60
Likelihood Ratio (LR)
Condition + Condition -
Test + 1 800
Test - 0 200
sensitivity/(1-specificity) = 1/0.8 = 1.25 LR+ =
LR- = (1-sensitivity)/specificity = 0/0.2 = NC
NNT = 801 For outcome rate of 1 per 1000 assuming all prevented by CD
Prediction of Acidemia: Computerized Assessment Czabanski et al. Expert Systems with Applications 2012;39:11846-60
Likelihood Ratio (LR)
Condition + Condition -
Test + 8 2000
Test - 2 8000
sensitivity/(1-specificity) = 0.8/0.2 = 4 LR+ =
LR- = (1-sensitivity)/specificity = 0.2/0.8 = 0.25
NNT = 2008/8 = 251 For outcome rate of 1 per 1000 assuming all prevented by CD
Likelihood Ratio (LR)
Condition + Condition -
Test + 16 2000
Test - 4 8000
sensitivity/(1-specificity) = 0.8/0.2 = 4 LR+ =
LR- = (1-sensitivity)/specificity = 0.2/0.8 = 0.25
NNT = 2016/16 = 126 For outcome rate of 2 per 1000 assuming all prevented by CD
Likelihood Ratio (LR)
Condition + Condition -
Test + 32 2000
Test - 8 8000
sensitivity/(1-specificity) = 0.8/0.2 = 4 LR+ =
LR- = (1-sensitivity)/specificity = 0.2/0.8 = 0.25
NNT = 2032/32 = 63.5 For outcome rate of 4 per 1000 assuming all prevented by CD
Prediction of Acidemia: Computerized Assessment Czabanski et al. Expert Systems with Applications 2012;39:11846-60
Prediction of Acidemia: Computerized Assessment Czabanski et al. Expert Systems with Applications 2012;39:11846-60
Sensitivity of GLT Esakoff et al. Am J Obstet Gynecol 2005;193:1040-4
Sensitivity of GLT Esakoff et al. Am J Obstet Gynecol 2005;193:1040-4
We Need to Minimize Human Interpretation
PeriCALM® Tracings™
Using Pattern Recognition Software to Evaluate Intrapartum Fetal Heart Rate Tracings Saade et al. Am J Obstet Gynecol 2014;210:S290
ST Analysis -
STAN System
Automated Fetal ECG
Analysis
Example of STAN recording: Category II tracing with ST events
Log function that automatically
identifies significant ST changes,
information about the type and
degree of abnormality
30 heartbeats = T/QRS ratio = X
ST Event-
significant
change
NICHD’s MFMU Network centers 2011-16
• 14 Clinical sites
• Data center
• NICHD
• ~140,000 deliveries/yr
• Re-competition: 5 yrs
• Columbia
• Case Western
• Duke
• Northwestern
• Ohio State
• Stanford
• U Alabama
• U Colorado
• U North Carolina
• U Texas-Houston
• U Texas SW-Dallas
• U Utah
• UTMB Galveston
• Women and Infants
Neonatal Outcomes
Quality Measures
Obstet Gynecol 2012;120:1181-93
Saade Quality Measures
Rate of cesarean for failure to progress before 6 cm
Rate of cesarean for non-reassuring fetal status with 1 min Apgar >7
Change in Primary Cesarean 2009-2012
Induction of Labor In Singletons
CDC/NCHS, National Vital Statistics System
Recommended