Waiting for the Natural Exit: C-Section Reduction/media/files/providence...Natural Exit: C-Section...

10/24/2016

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Waiting for the Natural Exit:

C-Section

ReductionM D’ARCY-EVANS, PHD, CNM

Our Goal

To ensure that every child is born as healthy as

possible while causing the least possible damage

to the mother

FACTS

The cesarean rate rose nearly 60% from 1996 to 2009

Can be life saving

In now USA 33%

No decrease in

maternal morbidity

and mortality rate

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� Pregnancy-related deaths in the U.S. have risen from 7.2 per

100,000 live births in 1987 to 17.8 in 2009 and 2011, (CDC)

� Women in the U.S. face a 1-in-1,800 risk for maternal death, the

worst among the developed nations surveyed in Save the

Children's 16th annual State of the World's Mothers report

� U.S. women are more likely to die during childbirth than women in

any other developed country, leading the U.S. to be ranked 33rd

among 179 countries on the health and well-being of women and children.

Causes?

� Stagnation in the quality of medical/nursing care

� Change in population demographics masking

improvements

� Is the increase in cesarean delivery causally, or

associatively related to maternal death

Clark,S.L., Belfort,M.A., Dildy,G.A., Herbst, M.A., Meyers, J.A. & Hankins, G.D. (2007). Maternal death in the 21st century:causes,

prevention, and relationship to cesarean delivery. American Journal of Obstetrics & Gynecology.

Why Reduce C-Section Rates??

Potential Maternal Risks:

Hemorrhage Increased risk placenta previa or accretaUterine rupturePuerperal InfectionAnesthetic complications Surgical complications Pain - Narcotic use

Repeat surgery subsequent pregnancy

increased risk of ectopic pregnancy

(9.5/1000 compared with 5.7/1000)

Gravid hysterectomyVenous thromoembolism

Limit family size

Longer hospital stay

Cost

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Potential Maternal Risks:

Hemorrhage Increased risk placenta previa or accretaUterine rupturePuerperal InfectionAnesthetic complicationsSurgical complications Pain - Narcotic use

Repeat surgery subsequent pregnancy

Increased risk of ectopic pregnancy

(9.5/1000 compared with 5.7/1000)

Gravid hysterectomyVenous thromoembolism

Limit family size

Longer hospital stay

Cost

Rate of Accreta

1 in 4,027 pregnancies in the 1970s

1 in 2,510 pregnancies in the 19801 in 533 from 1982-2002

Photo Credit:http://fetalsono.com/teachfiles/PlacAcc.lasso

Placenta accreta is a general term used to

describe the clinical condition when part of the

placenta, or the entire placenta, invades and is

inseparable from the uterine wall

Women at greatest risk of placenta

accreta are those who have

myometrial damage caused by a

previous cesarean delivery

http://www.acog.org/Resources%20And%20Publications/Committee%20Opinions/

Committee%20on%20Obstetric%20Practice/Placenta%20Accreta.aspx


Potential Maternal Risks: Placenta Accreta

� Incidence increased and seems to parallel the increasing cesarean

delivery rate

� Rate of Accreta

� 1 in 4,027 pregnancies in the 1970s

� 1 in 2,510 pregnancies in the 1980

� 1 in 533 from 1982-2002

� Risk increases with each cesarean delivery

http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Placenta-Accreta

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� Placenta does not completely separate from the uterus

�Massive obstetric hemorrhage

�average blood loss at delivery in women with placenta accreta is 3,000–5,000 ml

�40% require more than 10 units of packed red blood cells

� Risk of DIC

� Hysterectomy� Renal damage�Maternal mortality with placenta accreta has been reported to be as

high as 7%

http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Placenta-Accreta

Morbidity associated with cesarean delivery in the United States: is placenta accreta an

increasingly important contributor?

� 2000-2011 Nationwide Inpatient Sample data

� identify cesarean deliveries and records with 12 potential cesarean

delivery complications, including placenta accreta

� rate of placenta accreta increased by 30.8% among women with a

repeat cesarean deliveries

� placenta accreta became an increasingly important contributor to repeat cesarean delivery morbidity

Creanga, A.A., Bateman, B.T., Butwick, A.J., Raleigh,L. Maeda, A., Kukline, E. & Callaghan, W.M. (2015) Morbidity associated with

cesarean delivery in the United Stes: is placenta accreta an increasingly important contributor? Am J Obstet Gynecol. 2015

Sep;213(3):384.e1-11


Benefits to Baby of spontaneous labor and delivery

Labor increases fetal catecholaminesand prostaglandins causing increased secretion of lung surfactant

Physical compression of thorax removes lung fluid

Reduced exposure to drugs

Potential Risks of elective C/S:

Iatrogenic prematurityNICU - Longer hospital stay RDSAnesthetic complicationsFetal lacerationIncreased Allergic diseasesHypoglycemiaHypothermiaTransient tachypeaPersistent pulmonary hypertensionChanges in skin and gut bacterial colonization

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Fecal Microflora in Healthy Infants Born by Different Methods of Delivery:

Permanent Changes in Intestinal Flora After Cesarean Delivery

Grölund, Minna-Maija*†; Lehtonen, Olli-Pekka†; Eerola, Erkki‡; Kero, Pentti

Journal of Pediatric Gastroenterology & Nutrition: January 1999 - Volume 28 - Issue 1 - pp 19-25

Conclusions: This study shows for the first time that the primary

gut flora in infants born by cesarean delivery may be disturbed

for up to 6 months after the birth. The clinical relevance of these

changes in unknown, and even longer follow-up is needed to establish how long-lasting these alterations of the primary gut

flora can be.

In Pediatrics, Bisgaard and colleagues examined the correlation between C-sections and immunological disorders in two million Danish children born over a period of 35 years between 1973 and 2012.

� Children born by C-section have been more frequently hospitalized than those born vaginally due to asthma, juvenile rheumatoid arthritis, inflammatory bowel disorder, immune system defects, leukaemia, and other tissue disorders during their lives.

� More specifically, the risk of developing asthma is 20 per cent higher if you are born by C-section. The researchers conclude that there is an approximately 40 per cent greater risk of developing immune defects and a 10 per cent greater risk of developing juvenile rheumatoid arthritis.

http://sciencenordic.com/giant-study-links-c-sections-chronic-disorders

Cesarean section is the most common in-patient operating

room procedure in U.S.

hospitals.

One in three women will have a cesarean birth

❤❤❤❤❤❤❤❤❥❥❥❥❤❤❤❤❤❤❤❤❥❥❥❥❤❤❤❤❤❤❤❤❥❥❥❥

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Cesarean birth

� Now the most frequently performed inpatient operation

� In the USA more than 1.2 million cesareans are performed

each year

� In 1965 the national US cesarean rate was 4.5%

� This rate has increased 7 fold

� In 2009 it peaked at 32.9

� In 2014 it is 32.2%

2014

� Number of vaginal deliveries: 2,699,951

� Number of Cesarean deliveries: 1,284,551

� Percent of all deliveries by Cesarean: 32.2%

� http://www.cdc.gov/nchs/fastats/delivery.htm

Increased rate of cesarean deliver is not validated by tangible improvements in perinatal outcomes

Both short term and long-term maternal morbidity has risen significantly

giving birth is

one of the most profound

emotional experiences in a woman’s life

Reuwer, P., Bruinse, H., & Franx, A. (2015) Proactive Support of Labor: The Challenge of Normal Childbirth, p.1. Cambridge University Press

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Contributing Factors

� Society’s acceptance of surgery for childbirth

�Common surgery – forget its major abdominal surgery

� Women’s trust in their care provider

� Maternal request

� Too strong a reliance on technology

� Electronic Fetal Monitoring (EFM) – the most common obstetric procedure

Cesarean Delivery on Maternal Request

ACOG Committee Opinion (#559, 4/13 – reaffirmed)

� Is defined as a primary prelabor cesarean delivery on maternal request in the absence of any maternal or fetal indications.

� No accurate means to determine rate estimated to be 2.5% of all births in the United States

Martin JA, Hamilton BE, Ventura SJ, Osterman MJ, Wilson EC, Mathews TJ. Births: final data for 2010. Natl Vital Stat Rep 2012;61(1). Available at: http://www.cdc.gov/nchs/data/nvsr/nvsr61/nvsr61_01.pdf. Retrieved November 1, 2012. ⇦ NIH State-of-the-Science Conference Statement on cesarean delivery on maternal request. NIH Consens State Sci Statements 2006;23:1–29. Available at: http://consensus.nih.gov/2006/cesareanstatement.pdf. Retrieved November 7, 2012. ⇦

Cesarean Delivery on Maternal Request

Obstetrician–Gynecologists’ Knowledge, Perception,

and Practice Patterns

� 2006, 1031 questionnaires mailed to US OBGYNs – 68% return rate

� 50% believe women should be able to request an elective C/S

� Approx 50% acknowledge having performed at least one c/s for non medical reasons based on maternal request

� 58% noted increased inquiries into maternal request c/s

�Media

�Convenience

Bettes, B.A., Coleman, V.H., Zinberg, S., spong, C.Y., Portnoy, B., DeVoto, E., & Schulkin, J. (2007) Obstetrics and Gynecology. Vol

109, Ni.1, Jan. p.57-66

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Cesarean Delivery on Maternal

Request

� Need to track frequency

� Prevalence world wide 1-18 %

� Appears to be increasing correlating with population

affluence

http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Cesarean-Delivery-on-

Maternal-Request


Request

� Reason

� Fear/anxiety Critical life experiences

� Reproductive plans rape

� Personal values FGM

� Poor obstetric outcomes Culture


Maternal-Request


Request Is it ethical?

Ethical Framework

1. Patient autonomy

2. Avoiding harm - nonmaleficence

3. Cost-effectiveness - in conjunction with an understanding of what

matters most to the patient.

4. Effects on health care system of increasing choice

� ‘How the choices of some can affect opportunities for others

raises important questions of justice’

http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Ethics/Elective-Surgery-and-Patient-Choice

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� ACOG’s recommendation in cases in which cesarean

delivery on maternal request is planned:

� A gestational age of 39 weeks.

� Request should not be motivated by the unavailability of

effective pain management.

� Not recommended for women desiring several children, given that the risks of placenta previa, placenta accreta,

and gravid hysterectomy increase with each cesarean

delivery.


Maternal-Request

Committee on Obstetric Practice offers

the following recommendations

‘In the absence of maternal or fetal indications

for cesarean delivery,

a plan for vaginal delivery

is safe and appropriate and should be

recommended.’


Maternal-Request


� Too strong a reliance on technology

� Electronic Fetal Monitoring (EFM) – the most common obstetric

procedure

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EFM

� limited evidence to support it is better than intermittent auscultation in

low risk women

� Subjective interpretation – category 2 tracings – false positive rate high

� ? Contributing to increased c/s rate

Semin Perinatol. 2016 Aug;40(5):307-17. doi: 10.1053/j.semperi.2016.03.008. Epub 2016 Apr 29.

What we have learned about intrapartum fetal monitoring trials in the MFMU Network.

Bloom SL1, Belfort M2, Saade G3; Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal

Medicine Units Network.

Cochrane review

“no evidence of benefit for the use of the admission CTG for low-risk

women on admission in labor.

Furthermore, the probability is that admission CTG increases the caesarean section rate by approximately 20%.

The findings of this review support recommendations that the admission CTG not be used for women who are low risk on admission in

labor.

Women should be informed that admission CTG is likely associated with

an increase in the incidence of caesarean section without evidence of

benefit”.

Devane D, Lalor JG, Daly S, McGuire W, Smith V (2012) Cardiotocography versus intermittent auscultation of fetal heart on admission

to labour ward for assessment of fetal wellbeing (Review) The Cochrane Collaboration.

https://www.ranzcog.edu.au/index.php

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Intrapartum fetal surveillance in the absence of recognized risk factors

Admission CTG

Recommendation 4 Grade and supporting

references

Admission CTG increases the rate of continuous electronic fetal

monitoring use, may increase the rate of caesarean section but may identify a small number of previously unidentified at risk

fetuses.

Attending clinicians should decide whether or not to use admission

CTG according to individual women’s circumstances and decisions.

A (Level I) Body of evidence can be trusted to

guide practice

Good Practice Note Grade and supporting references

Women should receive 1:1 midwifery intrapartum care.

Cardiotocography should not be used as a substitute for adequate intrapartum midwifery staffing.

Good Practice Note (Consensus-based)

Women in active labor should receive

continuous close support from an

appropriately trained person. (I-A)

Intrapartum fetal surveillance for healthy term women in spontaneous labor in the

absence of risk factors for adverse

perinatal outcome.

Intermittent auscultation following an

established protocol of surveillance and

response is the recommended method of

fetal surveillance; compared with

electronic fetal monitoring, it has lower

intervention rates without evidence of compromising neonatal outcome. (I-B)

Epidural analgesia and intermittent auscultation. 1.Intermittent auscultation may be used to monitor the fetus when epidural analgesia is used during labor, provided that a protocol is in place for frequent intermittent auscultation assessment

Recommendation 10: Admission Fetal Heart Test

1. Admission fetal heart tracings are not recommended for healthy women at term in labor in the absence of risk factors for adverse perinatal outcome, as there is no evident benefit. (I-A)

Recommendation 11: Intrapartum Fetal Surveillance for Women With Risk Factors for Adverse Perinatal Outcome

Normal electronic fetal monitoring tracings during the first stage of labor. When a normal tracing is identified, it may be appropriate to interrupt the electronic fetal monitoring tracing for up to 30 minutes to facilitate periods of ambulation, bathing, or position change, providing that (1) the maternal-fetal condition is stable and (2) if oxytocin is being administered, the infusion rate is not increased. (III-B)

S6 �SEPTEMBER JOGC SEPTEMBRE 2007

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Decision support tool-intermittent

auscultation in labor for healthy

Term women without risk factors for

adverse perinatal outcome

SEPTEMBER JOGC SEPTEMBRE 2007� S31


Failure to trust women’s bodies to give birth naturally

Advocate for :

� Spontaneous labor at term

� Continuous support during labor from OB RN

� Informed caring, comfort, support, calmness

� Patience and watchful waiting

�Constant vigilance!

� Promote ambulation, movement, use gravity

WHY IS THE C-SECTION RATE SO HIGH? Fact sheet, Childbirth Connection| AUGUST 2016

Continuous support in

labor leads to:

Decreased incidence of cesarean birth

Women have greater satisfaction in their labors

Benefits for both mother and infant with no known harm

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Continuous support for women during

childbirth (Cochrane Review)

� 22 trials involving 15,288 women

� Women with continuous support

�More likely to have spontaneous vaginal delivery

� Less likely to have intrapartum regional analgesia

� Less likely to report dissatisfaction

�Had shorter labors

� Less likely to have c/s or instrumental vaginal delivery

� Less likely to have a baby with low 5 minute APGAR score

http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003766.pub5/abstract

Doula Care, Birth Outcomes, and Costs

Among Medicaid Beneficiaries

Results.

� Cesarean rate was 22.3% among doula-supported births and

31.5% among Medicaid beneficiaries nationally.

� Preterm birth rates were 6.1% and 7.3%,

� After control for clinical and sociodemographic factors, odds of

cesarean delivery were 40.9% lower for doula-supported births

(adjusted odds ratio = 0.59; P < .001).

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3617571/

Old Adage from 1916

Once a cesarean always a cesarean

This is the case for approximately

90% of women who have had a previous

cesarean in the USA

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Stated objective of the

U.S. Department of Health and Human Services

Health People 2020

Reduce repeat cesarean births among low-risk women

90.8 percent of low-risk females had a repeat cesarean

birth in 2007

Target 10% reduction to 81.7%

U.S. Department of Health and Human Services. Healthy People 2020 Maternal, Infant, and Child Health Objectives. Available at:

http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicid=26. Retrieved October 1, 2016

http://emedicine.medscape.com/article/272187-overview updated Dec.2013

Increase in

primary

Cesarean births

Decrease in

VBACs

TOLAC – trial of labor after cesarean

� Careful counseling

� Review maternal obstetric history

� Maternal wishes

� Avoid induction of labor

� Manage delivery in a hospital setting

� Higher # previous C/S greater risk

� Successful VBAC offer protection for subsequent VBACs

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TOLAC

� 1999 ACOG guideline very restrictive

� 2010 updated

� Recommend that TOLAC occurs at facilities with staff

capable of emergency delivery

� Recognizes patient autonomy

�Pt to be fully informed of potential risks

TOLAC - ACOG 2010 Guidelines

Level A Evidence

� Most women with a prior cesarean delivery with a low

transverse incision are candidates for VBAC and should

be offered TOLAC.

� Epidural anesthesia may be used as part of TOLAC.

� Misoprostol should not be used for patients who have

had a prior cesarean delivery or major uterine surgery.

ACOG practice bulletin; no. 115)

Increased Chance of Success Decreased Chance of Success

Prior vaginal delivery Maternal obesity

Prior VBAC Short maternal stature

Spontaneous labor Macrosomia

Favorable cervix Increased maternal age (>40 y)

Nonrecurring indication (breech presentation, placenta previa, herpes)

Induction of labor

Preterm deliveryRecurring indication (cephalopelvicdisproportion, failed second stage)

Increased interpregnancy weight gain

Latina or African American race/ethnicity

Gestational age ≥41 wk

Preconceptional or gestational diabetes mellitus

Predictors

of VBAC Success or

Failure

Vaginal Birth After Cesarean birth, 2015, Caughey et alhttp://emedicine.medscape.com/article/272187-overview?pa=zct6OYZejm8NX9ud6MSU1XmpHgbf8uyq1AT82VUVnRoQVDqUCqq1I5CI4ZD7%2BA3e8SIvl8zjYv73GUyW5rsbWA%3D%3D

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Increased Rate of Uterine

Rupture

Decreased Rate of Uterine

Rupture

Classic hysterotomy Spontaneous labor

Two or more cesarean

deliveriesPrior vaginal delivery

Single-layer closure Longer interpregnancy interval

Induction of labor Preterm delivery

Use of prostaglandins

Short interpregnancy interval

Infection at prior cesarean delivery

Predictors

of UterineRupture

Vaginal Birth After Cesarean birth, 2015, Caughey et alhttp://emedicine.medscape.com/article/272187-overview?pa=zct6OYZejm8NX9ud6MSU1XmpHgbf8uyq1AT82VUVnRoQVDqUCqq1I5CI4ZD7%2BA3e8SIvl8zjYv73GUyW5rsbWA%3D%3D

‘The most effective approach to reducing overall

morbidities related to cesarean delivery is to

avoid the first cesarean delivery’

Reduce Primary Cesarean Births

Spong, C.Y., Berghella., V., Wenstrom, K. D., Mercer, B. M. & Saade, G. R. (2012) Preventing the First Cesarean Delivery: Summary of a Joint

Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, and American

College of Obstetricians and Gynecologists Workshop. Obstetrics & Gynecology Vol 120(5), p 1181-1193

National Vital Statistics Reports,

Vol. 63, No. 6, November 5, 2014

Low risk defined as

Primary cesareanSingle and Vertex presentation

37 or more completed weeks of pregnancy

14.5% in1996

28.8% in 2009

26.9% in 2013

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Reduce cesarean births among low-risk

(full-term, singleton, and vertex presentation)

women is a stated objective of the

U.S. Department of Health and Human Services

Target 10% reduction to 23.9%

U.S. Department of Health and Human Services. Healthy People 2020 Maternal, Infant, and Child Health Objectives. Available at:

http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicid=26. Retrieved October 1, 2016

Primary Cesarean Birth

Most frequent indications

� labor dystocia/failure to progress

� abnormal or indeterminate fetal heart rate tracing

� fetal malpresentation

�multiple gestation

� suspected fetal macrosomia

ACOG. Safe Prevention of the Primary Cesarean Delivery. Obstetrics & Gynecology

2014;123:3:693-711

Primary Cesarean Delivery in USA

From a study by Boyle et al, 2013

Retrospective cohort study

� 38,484 women in the study

� Overall primary cesarean rate 21.3%

� Primiparous cesarean rate 30.8%

� Multiparous primary cesarean rate 11.5%

Failure to progress #1 indicator

42.6% of primiparous women and 33.5% of multiparous women never progressed beyond 5cm of dilation prior to delivery.

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Study by Zhang, 2010

Patterns of Spontaneous Labor

Definitions effect labor management

In this study active labor did not start until 6cm dilation

� Friedman curve outdated

� Different population

� Maternal age – women older

� Both maternal and fetal weight

� Increased use of epidural/intrathecal

Zhang, Jun et al, 2010. Contemporary Patterns of Spontaneous Labor with Normal Neonatal Outcomes. Onste Gynecol, Dec; 116(6): 1281-1287

Average labor curve by parity – singleton, term, vertix, SVD, normal neonatal outcomes


Patterns of Spont Labor

� Data were from the Consortium on Safe Labor

�62,415 parturients

�single term gestation

�spontaneous labor

�vertex presentation

�SVD

�normal perinatal outcome

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Results

� Labor may take over 6 hours to progress from 4 to 5 cm

� Over 3 hours to progress from 5 to 6 cm of dilation.

� Nulliparas and multiparas appeared to progress at a similar pace before

6 cm.

� However, after 6 cm labor accelerated much faster in multiparas than in

nulliparas.

Zhang, Jun et al, 2010. Contemporary Patterns of Spontaneous Labor with Normal Neonatal Outcomes. Onste Gynecol, Dec; 116(6):

1281-1287



Results

� The 95th percentile of the 2nd stage of labor in nulliparas with and without

epidural analgesia was 3.6 and 2.8 hours, respectively.

Zhang, Jun et al, 2010. Contemporary Patterns of Spontaneous Labor with Normal Neonatal Outcomes. Onste Gynecol, Dec; 116(6):

1281-1287

Extending the length of the 2nd

Stage of Labor

� 78 nulliparous women randomly assigned

� Group 1: 2nd stage 2hrs without epidural 3 hrs with epidural

anesthesia

� Group: 2 2nd stage extended for at least one additional hour

All women had epidural anesthesia.

The incidence of cesarean delivery was

� 19.5% (n 1⁄4 8/41 deliveries) in the extended labor group

� 43.2% (n 1⁄4 16/37 deliveries) in the usual labor group

Gimovsky,A.C. & Berghella, V. 2016. Ranomized controlled trial of prolonged second stage: extending the time limit vs usual guideline.

American Journal of Obstetrics & gynecology. http://dx.doi.org/10.1016/j.ajog.2015.12.042

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Laboring Down

� Physiological management of 2nd stage of labor

�With or without an epidural

� Goal to wait until woman feels an urge to push

�Optimal use of maternal energy

� Improved fetal oxygenation

� Need to stop the directed valsalva bearing-down as soon as the

cervix is fully dilated

ACOG/SMFM guidelines for prevention of

primary cesarean delivery

� Prolonged latent (early)-phase labor should be permitted

� The start of active-phase labor can be defined as cervical dilation of 6 cm, rather than 4 cm

� In the active phase, more time should be permitted for labor to

progress

� Multiparous women should be allowed to push for 2 or more

hours and primiparous women for 3 or more hours; pushing may be allowed to continue for even longer periods in some cases,

as when epidural anesthesia is administered

American College of Obstetricians and Gynecologists, Society for Maternal-Fetal Medicine. Obstetric care consensus no. 1:

safe prevention of the primary cesarean delivery. Obstet Gynecol. 2014 Mar. 123 (3):693-711. [Medline].

ACOG/SMFM guidelines for prevention of primary cesarean delivery� Patients should be encouraged to avoid excessive weight gain during

pregnancy

� Access to nonmedical interventions during labor, such as continuous

support during labor and delivery, should be increased

� External cephalic version should be performed for breech presentation

� Women with twin gestations should, if the first twin is in cephalic

presentation, be permitted a trial of labor

� Techniques to aid vaginal delivery, such as the use of forceps, should be

employed

American College of Obstetricians and Gynecologists, Society for Maternal-Fetal Medicine. Obstetric care consensus no. 1:

safe prevention of the primary cesarean delivery. Obstet Gynecol. 2014 Mar. 123 (3):693-711. [Medline].

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Operative Vaginal Delivery

Supported by ACOG when appropriate to reduce the incidence of

cesarean births

For example

� Maternal exhaustion

� Inability to push effectively

� Pre-exisiting cardiovascular disease

� Arrest of descent or need to rotate

� Non reassuring fetal heart rate patterns in the 2nd of stage of labor

ACOG Practice Bulletin No.154: Operative Vaginal Delivery. Obstetrics and Gynecology. Volume 126(5) November 2015, p.e56-65

Operative Vaginal Delivery

Rate of operative vaginal delivery

1993 Rate 9.01%

2013Rate 3.3%

Can be used safely to avoid cesarean delivery

Routine episiotomy is not recommended

Need to have an experience health care provider

ACOG Practice Bulletin No.154: Operative Vaginal Delivery. Obstetrics and Gynecology. Volume 126(5) November 2015, p.e56-65

Primary Cesarean Section Rates

WA State

� 2006 20.4

� 2009 20.2

� 2012 19.5

Idaho

� 2006 14.5

� 2009 14.9

� 2012 14.7

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Advocate for:

� Constant one on one labor support by experienced OB RN

� Avoid Induction of Labor

� Reconsider use of constant EFM

� Promote ambulation and position changes

� Redefine onset of active labor

� Support ‘laboring down’

� Extend active non-directive pushing in 2nd stage of labor (by at least an

hour)

� Support instrumental vaginal deliveries

� Change society’s and the media’s portrayal of labor

Any Questions

Thank you ☺

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