Preventing the First Cesarean · Fetal Heart Rate Monitoring Cesarean delivery rate % Most FHR abnormalities do not ... Using Pattern Recognition Software to Evaluate ... Rate of

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

http://www.cdc.gov/nchs/

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


Behind the Numbers The Healthy People Challenge

HP2010 VBAC

HP 2010 1-CD

VBAC Total CD

Primary CD



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

http://www.acog.org/

Mar

ch 2

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Obstet

Gynecol 2

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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)


Definitions: Failed Induction


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



No deceleration phase



Multips: inflection at 6 cm (not 4cm)


?


Multips: inflection at 6 cm (not 4cm)

Nullips: no clear

inflection point






95% similar Nullip

& Multip


95% similar N&M

Multip. labor

speeds up


95% similar N&M

Multip. labor

speeds up

All 95% <2h/cm


Median & 95th %iles duration of first stage in nulliparas with spontaneous labor

Median & 95th %iles of second stage duration with and without epidural


Definitions: Arrest Disorders


Spontaneous Labor Algorithm


Induced Labor Algorithm


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

http://www.imdb.com/media/rm1041734656/tt0177971

Continued reevaluation

Additional tests

Non surgical interventions

Meaning & Management

Category II: Indeterminate

http://www.acog.org/

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


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




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



Test + 16 2000

Test - 4 8000



NNT = 2016/16 = 126 For outcome rate of 2 per 1000 assuming all prevented by CD



Test + 32 2000

Test - 8 8000



NNT = 2032/32 = 63.5 For outcome rate of 4 per 1000 assuming all prevented by CD



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


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

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Preventing the First Cesarean · Fetal Heart Rate Monitoring Cesarean delivery rate % Most FHR abnormalities do not ... Using Pattern Recognition Software to Evaluate ... Rate of