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8/18/2019 Safe Prevention of Primary Cesarean Section
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Safe
Prevention
of the
Primar
Melinda Weiss, DO PGY3
April 1, 2016
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Primar Objectives
Describe the trend o cesarean section !"#$ inthe %nited #tates
&a'e the 'ost co''on ca(ses o "#
)denti* ris+ actors or "#
eco-ni.e the di/erence beteen old and ne
labor descriptions
Describe the reco''ended interventions todecrease "#
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ac+-ro(nd
1620114 rapid increase in "# rate
20114 153 o'en delivered via "#
&o evidence o conco'itant decrease in'aternal or neonatal 'orbidit* or 'ortalit*
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alancin- ris+s and benets
#aest ro(te in placenta previa or (teriner(pt(re
7or lo ris+ pre-nancies, "# has -reater ris+ o'aternal 'orbidit* and 'ortalit* than 8D
Di9c(lt to isolate 'orbidit* ca(sed specicall*b* ro(te o deliver*
": o breech to (nder-o "# or 8D
3'o 5(4 (rinar* b(t not ecal incontinence in 8D
(t this di/erence no lon-er si-nicant at 2*r 5(
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"o'pared to 8D, "# has a ;;;;; old ris+ osevere 'aternal 'orbidities, dened as4
he'orrha-e re
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>on- ter' ris+s ith "#
#(bse
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What is o(r state "# rateB
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"# ates
8ariation across4
#tates4 230?
Cospitals4 E16E?
>oris+ o'en4 2E36EF?
ole o 'aternal charactersitics !a-e, ei-ht, andethnicit*$ do &O: (ll* acco(nt or te'poralincrease in "# or re-ional variation
#(--ests that other potentiall* 'odiable actors,ie patient preerences, practice variation acrosss*ste's and practitioners li+el* contrib(tes to risin-rate
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What are the 'ost co''on indications or "#B
>abor d*stocia
&7C:
Malpresentation
M(ltiple -estation
#(spected 'acroso'ia
2011 data
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What are the 'ost co''on indications or "#B
>abor d*stocia
&7C:
Malpresentation
M(ltiple -estation
#(spected 'acroso'ia
2011 data
@F0?
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#oHhat is abnor'al laborB
>abor denitions
Old4 Active phase !c'$
&(llip4 1E2c'5hr
M(ltip4 1EFc'5hr
%pdated4 Active phase !6c'$ Ihen-
&(llip4 0EF0Ec'5hr
M(ltip4 0EF1E3c'5hr
7ro' 6c'4 o'en dilate the sa'eJ ater 6c','(ltips dilate aster
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Abnor'al laborB
Prolon-ed latent phase
&(llip4 @20 ho(rs
M(ltip4 @1 ho(rs
)s prolon-ed latent phase indication or deliver*B
&opeE
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)nd(ction
%se cervical ripenin-
)n latent phase, i 7C: is reass(rin- and 'aternal and etal stat(sesare stable, do not intervene loer "# rate
>atent phase is >O&G= in )O> co'pared to spontaneo(s
3 st(dies have shon )O> patients in latent labor 121K ho(rs ithpitocin and OM ill deliver va-inall* i ind(ction is contin(ed
OM and pitocin sho(ld be considered prere
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=/ect o ind(ction o labor
)nd(ction rate increased EF?23E1? !10200K$
"o'parin- )O> to spontaneo(s labor )O>associated ith increase "#
WO&G
"o'parin- )O> to epectant 'ana-e'ent
no di/erence or decreased "# rate
"ervical ripenin-
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&e denition or rst sta-e arrest
7ro' A"OG P 10 )nd(ction o >abor
LAlloin- at least 121K ho(rs o latent labor
beore dia-nosin- a ailed ind(ction 'a*red(ce the ris+ o cesarean deliver*E
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#econd sta-e neonatal o(tco'es
)n n(llips, adverse neonatal o(tco'es -enerall* have not been associatedith the d(ration o the second sta-e o labor
)n a secondar* anal*sis o a '(lticenter rando'i.ed st(d* !,126 o'en$ noneo the olloin- neonatal o(tco'es as o(nd to be related to the d(ration o thesecond sta-e !so'e cases @F ho(rs$
F'in(te Ap-ar score o less than
('bilical arter* pC less than E0
int(bation in the deliver* roo'
need or ad'ission to &)"%
neonatal sepsis
#econdar* anal*sis o 1,K62 o'en enrolled in an earl* vers(s dela*edp(shin- trial
lon-er d(ration o active p(shin- &O: not associated ith adverse neonatalo(tco'es !even in @3ho(rs p(shin-$
etrospective cohort st(d* o 1F,F n(lliparo(s o'en o(nd no adversee/ects in second sta-e @ ho(rs
>ess data in '(ltiparo(s o'en
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#econd sta-e 'aternal o(tco'es
Ci-her rates o4
inection
3rd and th de-ree lacerations
Postpart(' he'orha-e
7or each ho(r o second sta-e, chance o 8Ddecreases @3 ho(rs, onl* 15 n(lliparo(s o'en and 153
'(ltiparo(s o'en deliver va-inall*
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#econd sta-e interventionsB
>on-er epectant 'ana-e'ent
Operative va-inal deliver*
Overall rate has decreased in past 1F *ears &o di/erence in serio(s 'orbidit* !neonatal death
or intracerebral he'orrha-e$ beteen operativedeliveries and "#
3? o o'en ith operative deliver* -o on to "#
Man(al rotation o etal occip(t
7orceps
&o increase in cord prolapse !31 o'en$
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#econd sta-e reco''endations
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"onQictin- dataB
AROG April 201
"(rrentl* available evidence does not s(pportsaet* o lon-er second sta-e
3 reports here data ere inappropriatel*adj(sted or 'ode o deliver*
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&7C: interventions Most tracin-s are "at ))
Accelerations !spontaneo(s or elicited$ areassociated ith nor'al ('bilical cord arterial pC!@E20$
&o c(rrent data s(pportin- interventions ordecelerations ith Lat*pical eat(res !s(ch assho(lders, slo ret(rn to baseline, or variabilit* onl*ithin the deceleration$H the* have not been
associated ith etal acide'ia
Lec(rrent variablesHare not the'selvespatholo-icE Coever, i re
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Other ca(ses Malpresentation !reech$ 4 3E? o pre-nancies, KF? o
persistent breech are delivered via "# ="8(nder(tili.ed
#(spected 'acroso'ia4 "# onl* o/ered i F,000- non
diabetic, ,F00- diabetic
=cessive 'aternal ei-ht -ain4 donSt do it
:ins4 "# rate F3?F? !1F200K$, even verte
presentin- tins F6K?
C#84 s(ppress 3 ee+s beore deliver*
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eerences
Obstetric care consens(s4 #ae prevention o thepri'ar* cesarean deliver*E A"OG, #M7ME 201E
Preventin- the 7irst "esarean Deliver*4 #(''ar*o a Roint =(nice Tenned* #hriver &ational )nstit(teo "hild Cealth and C('an Develop'ent, #ociet*or Maternal7etal Medicine, and A'erican "olle-eo Obstetricians and G*necolo-ists Wor+shop, 2012
A"OG P 104 )nd(ction o >aborE ea9r'ed 201FE
>eveno, TE, et alE #econdsta-e labor4 ho lon- istoo lon-B AROG 21!$ KKE April 1, 2016E