The document discusses strategies for safely reducing the rate of primary cesarean deliveries. It finds that the most common indications for primary c-sections are labor dystocia, abnormal fetal heart rate tracings, fetal malpresentation, multiple gestation, and suspected macrosomia. Safe reduction of c-section rates will require different approaches tailored to each of these indications. Some strategies discussed include revising the definition of labor dystocia, improving interpretation of fetal heart rate monitoring, increasing access to support during labor, attempting external cephalic version for breech babies, and allowing trial of labor for some twin pregnancies. The document emphasizes using evidence-based guidelines and a multifaceted approach at the organizational and regional levels,

1. Safe prevention of the primary
cesarean delivery
ACOG/SMFM OBSTETRIC CARE CONSENSUS, 2014
Aboubakr Elnashar
Benha university , Egypt
Aboubakr Elnashar

2. Balancing risks and benefits
CS can be lifesaving for the fetus, the mother, or
both in certain cases
For placenta previa or uterine rupture:
CS is firmly established as the safest route of
delivery.
For low risk pregnancies:
CS has greater risk of maternal morbidity and
mortality than VD
Aboubakr Elnashar

3. Risk of severe maternal morbidities:
hge that requires hysterectomy or transfusion,
uterine rupture
anesthetic complications: shock, cardiac arrest,
acute renal failure, assisted ventilation
venous thromboembolism
major infection, or in-hospital wound disruption or
hematomae
was increased 3-fold for CS as compared with VD
(2.7% vs 0.9%, respectively).
Aboubakr Elnashar

4. long-term risks associated with CS
placental abnormalities:
placenta previa, in future pregnancies increases
with each subsequent CS, from 1% with 1 prior CS
to almost 3% with 3 prior CS.
after 3 CS, the risk that a placenta previa will be
complicated by placenta accreta is nearly 40%.
Aboubakr Elnashar

5. Neonatal complications
{combination of complications}
neonatal intensive care unit admission
perinatal death.
Aboubakr Elnashar

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8. CSR
Rapid increase in CSR from 1996 through 2011
without clear evidence of concomitant decreases in
maternal or neonatal morbidity or mortality: raises
significant concern that CS is overused.
USA : 23% 1991
32% 2007
Canada: 18% 1991
31% 2008
Australia:14% 1995
29% 2005
Italy: In Campania: 60% 2008 births
In Rome:44%- 85% in some private clinics.
Developing countries i.e. Brazil …it is up to 80%Aboubakr Elnashar

9. The epidemic of CS is a matter deserving
international attention.
Aboubakr Elnashar

10. Khawaja et al, 2009
Aboubakr Elnashar

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12. Indications for primary CS
Variation across
Arab countries: ranging from a low of 15% to a
high of nearly 55%
Nulliparous term singleton vertex
Hospitals: 10-fold variation
clinical practice patterns affect CSR.
Aboubakr Elnashar

13. Maternal characteristics
Age, weight, and ethnicity:
do not account fully for increase in the CSR or its
regional variations.
Other factors: likely contribute to the increasing
CSR.
1.Patient preferences
2. Practice variation among hospitals, systems, and
health care providers
Aboubakr Elnashar

14. Indications for primary CS, in order of frequency
1.Labor dystocia: 34%
2.Abnormal or indeterminate (formerly,
Non reassuring) fetal heart rate tracing: 23%
3. Fetal malpresentation: 17%
4. Multiple gestation: 7%
5. Suspected fetal macrosomia: 4%
Arrest of labor and abnormal or indeterminate fetal
heart rate tracing accounted for more than half of
all primary CS
Aboubakr Elnashar

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16. Safe reduction of the rate of primary
cesarean deliveries (2014)
require different approaches for each of these, as
well as other, indications.
Aboubakr Elnashar

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24. Maternal request
Public:
Health awareness, education, media involvement
Patient:
1.Benefits and risks of CS compared with vaginal
birth should be discussed and recorded.
2. A fear of childbirth: counselling (cognitive
behavioural therapy) {:reduced fear of pain in
labour and shorter labour}.
Aboubakr Elnashar

25.  Clinician:
has the right to decline a request for CS in the
absence of an identifiable reason.
 The woman’s decision should be respected and
she should be offered referral for a second
opinion.
Aboubakr Elnashar

26. Herpes simplex virus
Cesarean delivery is not recommended for women
with a history of herpes simplex virus infection but
no active genital disease during labor.
Continuous labor and delivery support
presence of continuous one-on-one support during
labor and delivery was associated with improved
patient satisfaction and a statistically significant
reduction in the rate of cesarean delivery.
Aboubakr Elnashar

27. Organizational actions
Changing the local culture and attitudes of doctors
regarding the
A. systemic interventions to reduce CSR across
indications and across community and academic
settings.
CSR was reduced by 13% when audit and feedback
were used
CSR was reduced by 27% when audit and feedback
were used as part of a multifaceted intervention,
which involved second opinions and culture change.
Aboubakr Elnashar

28. “B. Specific intervention
Culture of defensive practice
We shouldn't be blamed.
Our approach must be understood.
We doctors are often sued for events and complications that
cannot be classified as malpractice. So we turn to defensive
medicine.
We will keep acting this way as long as medical mistakes are
not de-penalized. We are not martyrs. So if a pregnant woman is
facing an even minimum risk, we suggest she gets a C-section "
Italian gynaecologyst Enrico Zupi, whose clinic in Rome, Mater
Dei, was under media attention for carrying a record of
Caesarian sections (90% over total birth)
Aboubakr Elnashar

29. A necessary component of culture change will be tort
reform because the practice environment is extremely
vulnerable to external medicolegal pressures.
Studies have demonstrated associations between
CSR and malpractice premiums and state-level tort
regulations, such as caps on damages.
‫الضرر‬ ‫اصل ح‬
Aboubakr Elnashar

30. Evidence-based approaches
changes in individual clinician practice patterns,
development of clinical management guidelines
implementation of systemic approaches at the
organizational level and regional level, and tort
reforme to ensure that unnecessary cesarean
deliveries are reduced.
Conduct research to provide a better knowledge base to guide decisions
regarding CS and to encourage policy changes that safely lower the rate of
primary cesarean delivery
Aboubakr Elnashar

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33. Conclusion
The most common indications for primary CS
include, in order of frequency, labor dystocia,
abnormal or indeterminate fetal heart rate tracing,
fetal malpresentation, multiple gestation, and
suspected fetal macrosomia.
Safe reduction of the rate of primary CS will
require different approaches for each of these, as
well as other, indications.
Aboubakr Elnashar

34. 1. Definition of labor dystocia should be revisted
because recent data show that contemporary
labor progresses at a rate substantially slower
than what was historically taught.
2. Improved and standardized FHR interpretation
and management
3. Increasing women’s access to nonmedical
interventions during labor, such as continuous
labor and delivery support
4. External cephalic version for breech
5. Trial of labor for women with twin gestations
when the first twin is in cephalic presentation
Aboubakr Elnashar

35. Thank youAboubakr Elnashar