perspective on “c” birth
DESCRIPTION
Perspective on “C” Birth. 1940 to Present. Fredric D. Frigoletto , Jr., M.D. Massachusetts General Hospital Harvard Medical School. “I have no disclosures to announce”. Fredric D. Frigoletto, Jr., M.D. 1940’s. 50% of U.S. Births at home Maternal Mortality for - PowerPoint PPT PresentationTRANSCRIPT
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Perspective on “C” Birth1940 to Present
Fredric D. Frigoletto, Jr., M.D.Massachusetts General Hospital
Harvard Medical School
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“I have no disclosures to announce”
Fredric D. Frigoletto, Jr., M.D.
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1940’s
50% of U.S. Births at home Maternal Mortality for Primigravid “C” ~ 6% “C” rate ~ 3.5%
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1950’s• “C” rate ~ 5%• 99% of U.S. births @ hospitals• Antibiotics• “C” MMR ~ 1%
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1960’s• Anesthesia (The Verdict)• Epidural• Blood Banks 24/7• Intensive Care• More Antibiotics• EFM
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1970’s• MFM• Neonatology• Fetus as a patient• Marked increase “C” rate• NIH CDC on “C” birth• “C” MMR 4/10,000
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1980’s• International comparisons• AML• Increasing threat of malpractice• “C” delivery MMR ~ 4 times greater
than vaginal deliveryMany confounding factors make it impossible to assign a specific MMR for all women
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1990’s• National push for VBAC• Negative side of VBAC’s• Increasing maternal age, weight, birth weight• IVF and increasing maternal age leads to
increasing multiples• Plummeting use of operative delivery
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2000’s
• Pelvic floor morbidity• “C” delivery rate increased greater than
40% since 1996• “C” delivery on maternal request• Changing attitudes
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What Happened?1950’s More medical management of pregnancy
Changes in management of labor pain EFM – US – Fetus becomes patient
• NICU’s• New discipline of MFM• Improved infant survival
Medico legal impact Plummeting use of forceps Increasing maternal age, weight, and birth weight Cesarean delivery on maternal request
2000’s
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NEJMJanuary 7, 1937
Ten Yr. Study of 703 “C” Cases at BCH
TYPE NO DEATHS MMR (%)PRIMIGRAVID 395 27 6.8REPEAT 308 3 1.0
22880 /703 = 3.07% NEJM 216:1:37
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Method of delivery*Primigravidas Multigravidas
No. % No. %Spontaneous 31 15.5 184 55Low forceps 115 57 108 32Midforceps 44 22 36 11Breech 8 4 3 0.8Version Extraction 1 0.5 2 0.6Cesarean Section 2 1 2 0.6TOTAL 201 100 335 100*Statistics include 5 sets of twins
AJOG 1992;305:65
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Cesarean Births USA1960 to 1980
• Remained at 5 to 6% through the 60’s• From 5.5% in 1970 increased to 15% in
1978• NICHD TASK FORCE ON “C” BIRTH
CREATED• CD Conference
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Maternal Mortality Ratios
0
20
40
60
80
100
120
1970 1974 1978
Cesarean Vaginal
Per 100,000 births
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“C” SectionMassachusetts Hospitals 1992-1993
Total 30,730 = 21.9% (Nat’l Avg)Primigravid* 14,584 = 25.4%Multips** 3,802 = 5.7%
*Range 13.3% TO 52.9%**Range 1.2% TO 11%
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Primigravid “C” SectionNMH Rates by Year
’87 ’88 ’89 ’90 ’91 ’92 ‘93
N 182 209 179 231 263 246 312
% 7.8 8.1 8.1 10.3 11.3 10.1 12.1
MARate
25.4%
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Primigravid “C” SectionNMH Rates by Year
’87 ’88 ’89 ’90 ’91 ’92 ’93
N 182 209 179 231 263 246 312
% 7.8 8.1 8.1 10.3 11.3 10.1 12.1
MARate
25.4%
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Total “C” Rate
0
5
10
15
20
25
30
35
1989 1991 1993 1995 1997 1999 2001 2003 2004
USA DUBLIN USA % inc DUBLIN % inc%
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National Maternity Hospital Dublin10 year comparative table
YEAR #Delivered Primigravid % “C” %Induction1994 6244 41.1 8.8 16.91995 6616 41.5 10.3 16.81996 7173 44.8 10.8 151997 7546 44.2 10.8 18.81998 7814 45.7 12.8 17.11999 7534 46 12.9 14.62000 7722 44.4 14.2 15.62001 7980 44.5 14.4 15.42002 8022 45.5 15.6 23.72003 8255 45.4 16.1 24.62004 8318 44.9 17.0 24.3
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Dublin “C” Rate
Total Primigravid
1994 8.8% 41%
2004 17% 45%
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0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
England&W
ales
North East
ern
North W
estern
East M
idlands
West
Midlan
ds
Eastern
London
South East
South W
est
Wale
s
Northern
Irela
nd
Huge Rise in Caesarean Births
October 26, 2001
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Non OB Factors Contributing to “C” Rates
• Hospital volume• Teaching vs non teaching• Individual practice style• 24 hr obstetric coverage• Payer source • Intrapartum nursing• Litigation
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Hospital Volume
No clear relationship
What limited data exists is not case mix adjusted
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Teaching vs Non Teaching
Cesarean rates are lower in teachingand county hospitals
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Role of the Practitioner• 24 hour in house obstetrical coverage
services have lower cesarean birth rates
• Individual practice style
• Intrapartum nursing
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THE GREENBAY CESAREAN SECTION STUDY7335 Singleton Deliveries
1986 - 1988
11 Obstetricians
Rates 5.6% - 19.7%
Not Attributable to Risk, S-E, or Service Status
Higher rates improved neonatal outcome
AJOG 1990;162:1593
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The Physician Factor in C/S RatesGoyert, Bottoms NEJM 320-706-89
Individual practice style is an importantdeterminant of the wide variations ofrates of C/S among OBS
Nullip C/S Rate 17.2Range 9.6 to 31.8
Low Risk pts/11 OBS
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Distribution of Cervical Examinations at the time of Cesarean Delivery for Dystocia
0
5
10
15
20
25
Finger tip1 2 3 4 5 6 7 8 9 Rim
10
Percent
733 patients @ term 30 hospitals
Gifford DS, el al. Obstet Gynecol 95:589, 2000
Cervical Examination (cm)
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Intrapartum Nursing
• There is variation in Nurses’ cesarean rates• One study showed range from 4.9% to 19%• Relationship to proportion of Direct vs.
Indirect care; role of continuous presence of trained individual
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Payer Source
Women with private insurance are more likely to have “C”
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461,000 Deliveries in California, 198624.4% Sectioned
PRIVATE
NON KAISER
HMO
MEDICAL
KAISER
SELF PAY
INDIGENT
5
10
15
20
25
30PERCENT
“C”
Am J Pub Health 1990;80:213
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Fear of Litigation
• Data to support threat of litigation as factor is qualitative
• Threat influences obstetric behavior• Large number of Cases from Term
Pregnancies are for: “ Failure to Perform Timely “C”
• Confusion regarding percentage of health care dollar that goes for malpractice insurance
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States in 1996 with lowest cesarean rates
• Colorado• Wisconsin• Utah• Idaho
15.1%15.6%15.9%16.0%
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States in 1996 with highest cesarean rates
• Mississippi• Louisiana• Arkansas• New Jersey
26.6%26.4%25.3%24.0%
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OB Factors Impacting“C” Delivery Rates
• Maternal Age• Maternal Weight• Fetal Weight• Dx of Dystocia• AML• Epidural
• EFM• Induction• Breech• Preterm delivery• Multiple gestation• VBAC
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Maternal Age
• Not entirely known: BUT a. Premium Baby Attitude b. Overweight/Obesity c. Diabetes, pre-eclampsia, hypertension
Increasing age is associated with increased risk of “C”
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Cesarean Rate by AgeAll Races (2003) USA
%<20 19.120-24 22.625-29 26.430-34 31.435-39 36.840-54 42.5
ACOG 2006 Pocket Guide
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Weight
• Pre-pregnancy weight• Weight gain• Birth Weight
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Prevalence of Overweight and Obesity Among US Women Aged 20-39 Years, 1999-2002, By Racial/Ethnic Group
Hedley et al., JAMA 291: 2847, 2004
01020304050607080
Overweightand Obese
(BMI >=25)
Obese(BMI >=30)
Per
cent
of W
omen
Non-HispanicWhite
Non-HispanicBlack
Mexican-Am erican
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0
1
2
3
4
5
6
Gestational diabetes Preeclampsia Eclampsia
Adj
uste
d O
dds
Rat
io
Normal (BM I 20.0-24.9)
Overweight (BM I25.0-29.9)
Obese (BM I >=30.0)
Adjusted* Odds Ratios for Pregnancy Complications by Maternal BMI
Baeten et al., Am J Public Health 91;436, 2001
* Adjusted for maternal age, smoking, education, marital status, trimester prenatal care began, payer, and weight gain during pregnancy; BMI <20.0 ( lean) reference group
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19961991
Obesity Trends* Among U.S. AdultsBRFSS, 1991, 1996, 2004
2004
No Data <10% 10%–14 15%–19% 20%–24% > 25%
*BMI > 30
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Effect of Changes in MAParity and BW Dist on 1º “C”
0
10
20
30
40
50
60
<15 15-19 20-24 25-29 30-34 35-39 >40
Maternal age, y
Cesarean
Deliveries
%
<2500
2500-3499
3500-3999
>4000
Baby weight, g
Primary cesarean deliveries by maternal age and birth weight among primiparous women in Washington State from 1987 through 1990.
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Diagnosis of Dystocia
Most common indication for“C” birth in nulliparous patient
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Percentage of Population and of C/SAccording to Obstetric-Condition Group
5%
4%
84%
4%3%
Multiple
Breech
Preterm
No Trial of Labor
Term Labor
Percent of Population8%
18%
8%
14%
52%
Percent of Cesareans
Cont OB/GYN January 00
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Delivery Characteristics in RCT’s of AML compared with NMH
NMH Boston Chicago
AML UC AML UCSpontaneous Delivery
81 78 74 64 58
Forceps Delivery
14 11 14 25 28
“C” Delivery
5 11 12 11 14
Labor > 12 hrs
2 9 26 5 19
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“C” Risk with Elective Induction,Term, Nulliparous
Spontaneous LaborElective InductionMedically Indicated
7.8%17.5%*17.7%*
RATE
*Significant OB/GYN 1999; 94
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Induction of Labor
Year %2003 20.62002 20.52001 20.52000 19.51995 15.91990 9.3 ACOG Pocket Guide 2006
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National Maternity HospitalDublin
Year INDUCTIONS%
CESAREANS%
1994 16.9 8.8
2004 24.3 17.0
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Multiple Births (USA)
Twins 1980
68,339
2003
128,665
From 1980 to 1998, the rate for triplets (and more) rose from: 37/100,000 to 193/100,000 live births.
ACOG Pocket Guide 2006
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TWINSUS 1980 to 2003
0
20
40
60
80
100
120
140
'80 '85 '90 95 '00 '01 '02 '03
Thousands
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TWINSUS 1980 to 2003
'80 '85 '90 95 '00 '01 '02 '03
East 68 77 93 96 118 121 125 128
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Number and Rate of Cesarean Sections by Plurality 1993-2003
Year Number Rate Number Rate Number Rate Total Rate 1993 807, 127 20.9 54,860 55.2 861,987 21.8 99304 6.4
1994 775,464 20.3 55,053 54.7 830, 517 21.2 100605 6.6
1995 750,663 19.9 56,059 55.6 806,722 20.8 100809 6.9
1996 738,603 19.7 58,516 55.4 797,119 20.7 105600 7.3
1997 737,347 19.7 61,686 56.1 799,033 20.8 109898 3.7
1998 758,691 20.0 67,179 57.3 825,870 21.2 117293 8.1
1999 791,924 20.8 70,162 58.2 862,086 22.0 120607 8.1
2000 848,662 21.7 75,369 60.1 923,991 22.9 125388 8.2
2001 898,058 23.2 80,353 62.7 978,411 24.4 128179 8.2
2002 957,589 24.7 86,257 65.3 1,043,846 26.1 132034 8.3
2003 1,026,992 26.1 92,396 68.0 1,119,388 27.5 135805 8.3
SingletonSingleton Multiple Total Multiples
% change 1993-2003 25% 23% 26%
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Cesarean by Plurality:United States, 1989 and 1996
0
20
40
60
80
100
19891996
1989 22.1 54.25 88.81996 19.7 53.4 90.3
Singleton Twin Triplets+
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Reasons for Interest in Cesareans
• Most common surgical procedure in U.S.• 40% of Federal Medicaid Dollars
Obstetrical Care• Payers identify it as a way to save • “Low risk” patients receive expensive
intervention. WHY?
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Total Cesarean Rates:United States, 1989-1996
19
20
21
22
23
24
25
NVSSNHDS
NVSS 22.8 22.7 22.6 22.3 21.8 21.2 20.8 20.7 20.8NHDS 23.8 23.5 23.5 23.6 22.8 22 20.8 21.8 NA
1989 1990 1991 1992 1993 1994 1995 1996 1997
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Vaginal Birth After Previous “C” Rates: United States, 1989-1996
0
10
20
30
40
NVSSNHDS
NVSS 18.9 19.9 21.3 22.6 24.3 26.3 27.5 28.3 27.4NHDS 18.5 20.4 24.2 25.1 25.4 29.7 35.5 33.6 NA
1989 1990 1991 1992 1993 1994 1995 1996 1997
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Declining Cesarean Delivery RatesCalif Hosp Dschg Abstracts ‘83-’94
• 6,146,809 Deliveries• Cesarean Rate 22.8%
Peak of 25% fell to 21% in ‘94, virtually allattributable to decrease “C” for women with previous “C.”
AJOG 1998;179
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VBAC RATESRace and/or Hispanic Origin
0
5
10
15
20
25
30
Non-Hispanicblack
Non-Hispanicwhite
Hispanic
198919962002
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VBAC RATESAge of Mother
0
5
10
15
20
25
30
Under 30 years 30-39 years 40 years and over
198919962002
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VBAC LATE 90’sIncreasing awareness of risks
2000
2002
2004
20%
12.7%
9%
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Early StudiesVBAC
• Retrospective• Non randomized• Lack of comparison groups• No adjustment for confounding factors• No data on neonatal outcome linked to uterine
rupture estimated 2 to 6/1000 VBACs
Probably underestimated maternal and perinatal morbidity and mortality
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VBAC Rate Continues to Slide
10
15
20
25
30
1991 1993 1995 1997 1999 2001 2004Num
ber o
f VB
AC
s pe
r 100
Birt
hs
Source: Centers for Disease Control and Prevention
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Is the Lowest Rate the Best Rate ?‘98 to ‘00
750,000 singletons (293) institutionsLow Risk Mothers (Term)
“C-”Rate
Low CS Hosp
High CS Hosp
P<.01
Fetal hemorrhageBirth asphyxiaMeconium aspiration synFeeding problemsInfectionInfused medication
Fetal hemorrhageAsphyxiaBirth traumaMechanical vent
P<.02 Pressors Transfusion for shock Mechanical vent
Compared to average “CS” Hosp
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2000’s
• “C” on maternal request• Pelvic floor morbidity• Increasing number of women of AMA• Safer and safer• ? Correct comparisons• Impact of previa, accreta
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Will the Trend Continue?• Inductions• Overweight/Obesity• Aggressive interventions• Training• Malpractice• Decrease in birth injuries and maternal mortality• Pelvic floor disorders• Changes in patients’ attitudes and preference• ~ 2.5% of births by requested “C” (2003)
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Conclusions• The “C” birth rate is influenced by a number of factors.• There may be opportunities to effect a change.• The appropriate “C” Rate cannot be established by a
Task Force.• More intensive local, regional and national peer review
have more to offer. • The best route of delivery for a given patient is decided
by the doctor, the patient, the individual circumstances and the resources available.
• Patients must be thoroughly and accurately informed as they participate.