Normal and abnormal delivery 2018
- 1. Normal and “Abnormal” mode of Delivery GABY FALAKHA PEDIATRICIAN-NEONATOLOGIST CHN ZGHARTA NOVEMBER 17TH, 2018 The 3d Annual Haykal Hospital Scientific Congress
- 2. I HAVE NO DISCLOSURES
- 3. Objectives 1. Evaluate the prevalence of Cesarean Sections worldwide and in Lebanon 2. Discuss the underlying factors 3. Review the short and long-term effects of C-section on the health of newborns. 4. Recommend solutions to reduce the rate of unnecessary C-Sections
- 4. 1. PREVALENCE OF C SECTION
- 5. World Health Organization Recommended rate of C section : Not to exceed 15% (1985) A study published in December 2015 in JAMA indicates that if the CS rate increases to 19%, maternal and neonatal mortality decline A CS rate above this level did not lead to any improvement in maternal and neonatal mortality rates
- 6. PLoS ONE 11 (2): e0148343. doi:10.1371/journal.pone.0148343
- 7. Rising Trends of Cesarean Section Worldwide: A Systematic Review Soto-Vega E. et al. Obstet Gynecol Int J 2015, 3(2): 00073
- 8. Rising Trends of Cesarean Section Worldwide: A Systematic Review Soto-Vega E. et al. Obstet Gynecol Int J 2015, 3(2): 00073
- 9. Rising Trends of Cesarean Section Worldwide: A Systematic Review Soto-Vega E. et al. Obstet Gynecol Int J 2015, 3(2): 00073
- 10. Lebanon The Lebanese literature demonstrated that this rate increased alarmingly since the beginnings of the 1990s, as it reached: 33% of total deliveries in 1996 35% in 2004 40.8% in 2008 (Abdallah et al, 2004; DeJong et al., 2010; Mroue, 2011) Latest figures reported from the MoPH in 2013 showed that the rate of C Section reached 44-45 % of total deliveries covered by MoPH.
- 11. • The study was conducted through GlobeMed’s portfolio • The majority of centers included in the study were private hospitals • Between January 2000 and December 2015 : 29,878 pregnant women were included in the study.
- 12. Rates of CS and NVD from 2000 until 2015 in Lebanon S.M. Zgheib et al. / Women and Birth 30 (2017) e265–e271
- 13. Maternal age and Rates of CS and NVD from 2000 until 2015 in Lebanon S.M. Zgheib et al. / Women and Birth 30 (2017) e265–e271
- 14. Region of birth and Rates of CS and NVD from 2000 until 2015 in Lebanon S.M. Zgheib et al. / Women and Birth 30 (2017) e265–e271
- 15. Complications and Rates of CS and NVD from 2000 until 2015 in Lebanon S.M. Zgheib et al. / Women and Birth 30 (2017) e265–e271
- 16. Day of birth and Rates of CS and NVD from 2000 until 2015 in Lebanon S.M. Zgheib et al. / Women and Birth 30 (2017) e265–e271
- 17. Prevalence of and risk factors associated with cesarean section in Lebanon A retrospective study based on a sample of 29,270 women S.M. Zgheib et al. / Women and Birth 30 (2017) e265–e271 Prolonged labor Breech presentation Fetal distress Multiple birth Twins Premature rupture of membranes Hypertensive disorders Oligohydramnios Maternal age of 35 years or more Maternal request
- 18. Moussawi F, Nakkash R, Jamal D, El-Jardali F. Knowledge to Policy (K2P) Center Reducing Rates of Unnecessary Cesarean Sections in Lebanon Beirut, Lebanon; June 2015. Absence of national guidelines Diversity in medical schools Opposition of stakeholders Higher benefit Lack of coverage for epidurals Excessive physicians supply Poor prenatal education and preparation Practice of defensive medicine Mandatory second opinion Group practice More implication of midwives Increase the doctor fees for NVD Cover for epidurals Prenatal awareness campaign Factors Recommendations Rate of C sections in Lebanon in 2015 44%
- 19. Moussawi F, Nakkash R, Jamal D, El-Jardali F. Knowledge to Policy (K2P) Center Reducing Rates of Unnecessary Cesarean Sections in Lebanon Beirut, Lebanon; June 2015. Absence of national guidelines Diversity in medical schools Opposition of stakeholders Higher benefit Lack of coverage for epidurals Excessive physicians supply Poor prenatal education and preparation Practice of defensive medicine Mandatory second opinion Group practice More implication of midwives Increase the doctor fees for NVD Cover for epidurals Prenatal awareness campaign Factors Recommendations
- 20. A private hospital statistics 2017 2018 (January to September) Parity NVD C- section % C-section NVD C-section % C-section P0 66 209 59% 57 247 77% P1 63 190 60% 31 119 74% P2 53 98 69% 13 39 75% P3 20 41 66% 3 9 75% P4 9 18 67% 4 100% P5 4 100% 2 100% P6 2 100% 1 100% Total 211 562 72.7% 104 452 76.9%
- 21. A private hospital statistics 2017 2018 (January to September) Parity NVD C- section % C-section NVD C-section % C-section P0 66 209 59% 57 247 77% P1 63 190 60% 31 119 74% P2 53 98 69% 13 39 75% P3 20 41 66% 3 9 75% P4 9 18 67% 4 100% P5 4 100% 2 100% P6 2 100% 1 100% Total 211 562 72.7% 104 452 76.9%
- 22. 2. WHY IS THE C SECTION RATE INCREASING?
- 23. More convenient 1. To Obstetricians * 20-25 minutes programmed in working hours V/S unpredictable long night hours * More profitable 2. To Hospitals * Prolonged LOS * More profitable 3. To Mothers? * Scheduled delivery timing * No labor pain, no episiotomy
- 24. More convenient 1. To Obstetricians 2. To Hospitals 3. To Mothers 4. But not to the baby !!! Have more breathing problems and NICU admissions His microbiome is negatively disturbed He has a higher risk of developing Obesity, Asthma, Metabolic syndrome and Diabetes
- 25. More convenient 1. To Obstetricians 2. To Hospitals 3. To Mothers 4. But not to the baby Have more respiratory problems and NICU admissions His microbiome is negatively disturbed He has a higher risk of developing Obesity, Asthma, Metabolic syndrome and Diabetes
- 26. Financial issues Class Normal Vaginal Cesarean section First class (Obstetrician) 680 USD 920 USD First class (Hospital) 1550 USD 3200 USD CNSS (Obstetrician) 450,000 LL 680,000 LL CNSS (Hospital) 785,000 LL 1790,000 LL MOPH (Obstetrician) 375,000 LL 500,000 LL MOPH (Hospital) 735,000 LL 1,790,000 LL
- 27. Epidural anesthesia Not covered by MoPH Costs 200-250 USD
- 28. Malpractice suits Obstetrics is a high-risk specialty in terms of malpractice allegations. Obstetricians have the third-highest lawsuit rate among physician specialties, third only to plastic surgeons and neurosurgeons Almost every obstetrician will be sued before age 65.
- 29. A typical Lebanese anomaly Choosing a “cool” date 12/12/12 11/12/13 18/08/18
- 30. 1 in 3 women with diabetes is of reproductive age 1 in 7 births is affected by gestational diabetes The incidence of GD in the gulf region reaches in some parts 40% Gestational Diabetes Macrosomia C section
- 31. No preparation for the pregnant mom Prenatal classes Relaxation methods Breathing techniques Physical activity and muscle strengthening
- 32. Once a C section, always a C section! Vaginal Birth after CS (VBAC) that is rising in developing countries and contributing to the reduction of repeated CS rate constitutes only 0.2% of deliveries in Lebanon. This low rate indicates that women who undergo primary CS are more likely to go through repeated CS in Lebanon (WHO, 2010)
- 33. Non-reassuring fetal heart rate Almost all hospital births include continuous monitoring of the fetal heart beat. These monitors are highly unreliable, which means that a majority of babies identified to have “non-reassuring” heart rate patterns by continuous electronic monitoring may not be compromised at birth. Graham et al. Obstet Gynecol. 2014 Sep;124(3):507-13.
- 34. Cesarean Delivery on Maternal Request: A Western North Carolina Perspective S Romero et al. Matern Child Health J (2012) 16:725–734 Patients’ opinion about cesarean versus vaginal delivery
- 35. Cesarean Delivery on Maternal Request: A Western North Carolina Perspective S Romero et al. Matern Child Health J (2012) 16:725–734 Patients’ opinion about cesarean versus vaginal delivery
- 36. 3. WHAT ARE THE ADVERSE EFFECTS OF C SECTION?
- 37. Elective C section and the late preterm Pregnancy dating has an error margin of 2-3 weeks Most elective C-sections are performed around 36 weeks of GA The late preterm newborn (34-37 weeks GA) is prone to the following risks: 1. Hypothermia 2. Respiratory distress and TTN (3 x more than at 39 weeks) Stutchfield P, Br Med J 331(7518):662; 2005 3. Hyperbilirubinemia and Hypoglycemia 4. The suck-swallow reflex and intestinal motility are also impaired in late preterm infants
- 38. Negative effects of C section on the Baby Higher Neonatal Intensive Care Unit admission (Hannah et al., 2000; Stutchfield et al., 2005) Other systematic reviews showed that unnecessary CS are highly associated with childhood overweight and obesity (Li et al, 2013; Huh et al., 2012; Barros et al., 2012) respiratory complications like pulmonary hypertension and asthma besides brain damage in some occasions (Main et al., 2012; Zanardo et al., 2004; MacDorman, 2008). CS were also associated with a decrease of breastfeeding rates (Rowe-Murray & Fisher, 2002; Zanardo et al., 2010; Merten et al., 2007; Labbok & Taylor, 2008).
- 39. Fluid in the lungs of the fetus Lungs are full of fluid in fetal life (38 ml/Kg) Resorbed shortly after birth In NVD with natural labor 40% of the alveolar fluid is resorbed before birth due to the action of stress hormones In elective C section there is no labor and no stress hormones, therefore the baby frequently ends up in the NICU Lucky Jain, Physiology of fetal lung fluid clearance and the effect of labor Semin Perinatol 30, 2006
- 40. Breastfeeding after cesarean delivery: a systematic review and meta-analysis of world literature The systematic review included 53 studies (554,568 subjects, 33 countries); 25 authors contributed additional data (245,455 subjects), and 48 studies (553,306 subjects, 31 countries) were included in the meta-analysis. Rates of early breastfeeding were lower after CD compared with after VD (pooled OR: 0.57; P < 0.00001) Prior E. Am J Clin Nutr. 2012 May;95(5):1113-35
- 41. Birth by cesarean section in relation to adult offspring overweight and biomarkers of cardio-metabolic risk Methods: The Danish Fetal Origins Cohort enrolled 965 pregnant women in 1988–1989. In 2008, a follow-up study of the offspring was completed. Results: Birth by C-section was associated with increased odds of overweight or obesity at 20 years (OR=2.17 ) after adjustment for potential confounders. Birth by C-section was also associated with higher serum concentrations of total cholesterol (8.5%), LDL cholesterol (12.6%), leptin (73.1%) and Apolipoprotein B (0.08 g/l) S. Hansen et al. International Journal of Obesity 42, 15–19 (2018)
- 42. Long-term risks and benefits associated with cesarean delivery for mother, baby, and subsequent pregnancies One RCT and 79 cohort studies were included, involving 29,928,274 participants. Children delivered by cesarean delivery had increased risk of asthma (OR 1.21, 1.11 to 1.32; n = 887,960; 13 studies) and obesity (OR 1.59, 1.33 to 1.90; n = 64,113; 6 studies). Oonagh E. Keag et al. PLOS Medicine | https://doi.org/10.1371/journal.pmed.1002494 January 23, 2018
- 43. Caesarean Section is associated with reduced perinatal cytokine response, increased risk of bacterial colonization in the airway, and infantile wheezing Children delivered by CS were associated with increased risk of wheezing (aHR 1.63; 95% CI: 1.01– 2.62) and decreased compliance of the respiratory system at 12 months (p = 0.045). CS was associated with reduced TLR1–2- triggered TNF- α and IL-6 responses at birth. By 12 months of age, children delivered by CS had significantly less airway bacterial clearance. SUI-Ling LIAO et al. Scientific Reports | 7: 9053 | DOI:10.1038
- 44. The Elevated Rate of Cesarean Section and Its Contribution to Non-Communicable Chronic Diseases in Latin America: The Growing Involvement of the Microbiota Conclusion : The establishment of the gut microbiota is delayed in infants born by C-section during the postnatal period, during a critical developmental window for the maturation of the newborn’s immune system. This delay may favor the subsequent development of inflammatory and metabolic disorders during childhood Magne F et al. Front. Pediatr. 5:192. doi: 10.3389/fped.2017.00192
- 49. 4. ARE THERE ANY SOLUTIONS?
- 50. Moussawi F, Nakkash R, Jamal D, El-Jardali F. Knowledge to Policy (K2P) Center Reducing Rates of Unnecessary Cesarean Sections in Lebanon Beirut, Lebanon; June 2015. Dominance of private sector Absence of national guidelines Diversity in medical schools Opposition of stakeholders Higher benefit Competition between insurance companies Lack of coverage for epidurals Excessive physicians supply Poor prenatal education and preparation Practice of defensive medicine Mandatory second opinion Group practice More implication of midwives Increase the doctor fees for NVD Cover for epidurals Prenatal awareness campaign Factors Recommendations
- 51. Partial restoration of the microbiota of cesarean-born infants via vaginal microbial transfer Samples from 18 infants and their mothers, including 7 born vaginally and 11 delivered by scheduled C-section, of which 4 were exposed to the maternal vaginal fluids at birth. Briefly, the microbial restoration procedure consists of incubating a sterile gauze in the vagina of mothers that are negative for Group B streptococcus (GBS) during the hour preceding the C-section. Within the first two minutes of birth, babies were swabbed with the gauze, starting with the mouth, then the face, and finally the rest of the body Maria Dominiguez-Bello et al. Nat Med. 2016 March ; 22(3): 250–253.
- 52. Partial restoration of the microbiota of cesarean-born infants via vaginal microbial transfer Maria Dominiguez-Bello et al. Nat Med. 2016 March ; 22(3): 250–253.
- 53. Fucosylated HMOs attenuate the Effects of Caesarean Birth on Infant Gut Microbiota The fucosylated HMOs have shown to promote early growth of beneficial microbiota in infant’s gut which play an important role in the maturation of the infants’ immune system. Infants born by C-section and formula fed could benefit from supplementation with fucosylated HMOs such as 2′FL Fucosylated oligosaccharides in mother’s milk alleviate the effects of caesarean birth on infant gut microbiota. Sci Rep. 2018 Sep;8:13757
- 54. Cesarean section and risks of childhood allergic disorder, attenuated by breastfeeding Shuyuan et al. Nature Scientific Reports | 7: 9762 | DOI:10.1038/s41598-017-10206-3 12,639 children
- 55. The Dutch experience C section rate 14% in 2000-2001 Increased to 16.7% in 2010 Fetal and early neonatal morbidity decreased in the same time period from 0.53% to 0.21% 30 % of all deliveries were done at home assisted by the midwife There are no epidurals at homes All expenses at home are for free Non-indicated C sections at hospital are self-payed by the patient Zhao Y, et al. (2016) Modest Rise in Caesarean Section from 2000-2010: The Dutch Experience. PLoS ONE 11(5): e0155565.
- 56. Take home message 1. The rate of C section in Lebanon has reached unacceptable levels 2. Improving women's knowledge can lead to a positive maternal attitude towards vaginal delivery. 3. Increase the quality of vaginal delivery services ( and possibly fees) and cover for epidurals by official 3d party payers 4. Prevent the first cesarean delivery in Nulliparous Term Singleton Vertex. 5. Encourage breast-feeding 6. It’s all about the gut colonization of the newborn
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