Cesarean Delivery on Maternal Request by mikeholy

VIEWS: 16 PAGES: 41

									  Cesarean Delivery
  on
  Maternal Request
Presented by:
Barbara Hughes, CNM, MS, MBA, FACNM
Colorado Perinatal Care Council
July 31, 2009
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?
 What’s YOUR Opinion?
Definition of Cesarean Delivery
on Maternal Request (CDMR)

   Primary cesarean delivery
   Singleton pregnancy
   At term
   On maternal request
   No maternal or neonatal
  indications
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 Women’s Health
Also supported by:
  The Agency for Healthcare Research and
  Quality (AHRQ)
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.
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
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:
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?
Key Question 1

What Is The Trend and Incidence of
 Cesarean Delivery Over Time in the
 United States and in Other Countries?
Total and primary cesarean rate and (VBAC):
United States, 1989-2004 (29.1% in 2004)

          35
          30
          25                                                     VBAC1
Per 100




          20                                              Total cesarean2
          15
                                                         Primary cesarean3
          10
          5                                                                                         1999
                     1989            1991            1993            1995           1997                            2001            2003 20044

          0
                                                                            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.”
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?
The Evidence

 Evidence-based Practice Center
 (EPC) Report:
   RTI International—University of North Carolina
   at Chapel Hill Evidence-based Practice Center
   (RTI-UNC EPC)
 NUMEROUS additional articles
 Speakers
 Audience Participants
                   ? ?
Planned Vaginal Delivery   Planned Cesarean Delivery
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?
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 I—strong,
 Level II—moderate,
 Level III—weak
 Level IV—absent
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.
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...
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.
                        Planned Delivery Route            Actual Delivery Route
                                                              Spontaneous
                                                             Vaginal Delivery
                                                             Vacuum Assisted
                  Planned                                    Vaginal Delivery
                  Vaginal
                  Delivery                                   Forceps Assisted
                                                             Vaginal Delivery

                                                          Cesearean After Labor
Singleton
Pregnancy                        Planned Cesarean for
                                                          Unlabored Cesarean for
                                  Maternal Indications:
                                                           Maternal Indications
                                 -Previa, Preeclampsia


            Planned              Planned Cesarean for
                                                          Unlabored Cesarean for
            Cesarean               Fetal Indications:
                                                            Neonatal Indication
             Delivery            -Breech, birth defects



                                Planned Cesarean for      Unlabored Cesarean on
                                  Maternal Request          Maternal Request

                    Planned Delivery Route                Actual Delivery Route
Key Question 3

What Factors Influence Benefits and
 Harms?
What factors influence benefits &
harms?
 Patient specific factors
   Age
   Childbearing plans/family size
   Obesity
   Accuracy of gestational age assessment
   Psychological factors
What factors influence benefits &
harms?
 Cultural & Societal Issues
   Cultural beliefs and practices
   Personal philosophy of birth
   Increasing societal acceptance
   Media
What factors influence benefits &
harms?
Provider Type and Professional
 Resources
 Obstetrical providers...
   OB/GYN Physicians
   MFM Physicians
   Family Medicine Physicians
   Certified Nurse-Midwives
What factors influence benefits &
harms?
Provider Type and Professional
 Resources
 Provider’s View of CDMR...
   Training
   Practice environment
   Experience
   Personal philosophy
   Medicolegal issues
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
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.”
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
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?
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
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?
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.
Studies comparing CDMR & PVD
should consider the following key
outcomes...
 Maternal
   Maternal death
   Placental
   abnormalities
   including previa &
   acreta
   Pelvic floor
   disorders
   Psychological
   factors
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
Studies comparing CDMR & PVD
should consider the following key
outcomes...
 Cost analysis of CDMR
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.
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.
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.
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.
What is
YOUR
opinion???

								
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