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Vaginal Delivery IN the 21ST CENTURY

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Presentation on theme: "Vaginal Delivery IN the 21ST CENTURY"— Presentation transcript:

1 Vaginal Delivery IN the 21ST CENTURY
Dr laleh Amini French board of OB&GYN Iranian Continence Society 2nd Annual meeting 2011 Tehran- Milad Hospital IRAN

2 Terms you hear in recent times
Natural (NVD) By allusion to caesarian section which is artificial Physiology (phusis nature, Logia:science)! Physio logie studies function (amalkard) and properties vijegiha khassayes) of organs and living tissues Physiologic ( means gesmi) by opposition to psychologic Safe!!!! The other ways are unsafe? In water A newborn psychology (1960s) sophrology Painless Pain free

3 Around the world Why is high rate of C. Section = Malpractice?
WHO ‘s warnings to Iran Statistics: US: 13-33% UK: 9-25% France: % Scandinavian countries: 7-17% Iran 45%???

4 Don’t they know about Pelvic Relaxation?
About LUTS (Lower Urinary tract symptoms) SUI/ Urgency? Frequency Fecal incontinence Dys pareunia Vaginal relaxation

5 They DO General Public Health is the main issue
In GOD we trust, every body else has to show data Based on Public health definitions of morbidity and mortality from an epidemiologic point of vu (objective and not subjective) Evidence based medicine, epidemiologic studies, randomized clinical trials, and National registries

6 Definitions Morbidity Maternal early late Fetal Mortality fetal

7 Public health definitions
Mortality: WHO International disease Classification in (61400 AIDS) / in 1980 France 8/ (Hemorrhages PP) USA 12/ / in (Thrombo- emboli, PPCM) 2x UK 3x Australia 4x Italy UK 8/ Thrombo-emboli Netherlands: 7/ Eclampsie Iran: 23/ China : 165/ /

8 Early Maternal Morbidity
Immediate: Hemorrhage > 500cc Per-op complications ( urinary, bowel injury) Infection (wound, Urinary) DVT/PE PP Myocardiopathy Medication: Painkillers, Narcotics, antibiotics Transfusions Hospital stay

9 Late Maternal Morbidity
Placenta accreta/percreta Uterine rupture Endometriosis Intestinal occlusion Chronic pain

10 Fetal mortality Decreased with the increase to 15-17% of C sections , then stable and now increasing

11 Fetal morbidity Besides complications related to the condition leading to a cesarean section: Pulmonary Distress Jaundice Re hospitalizations Immune system (humeral/Cellular) Diabetes , Leukemia Asthma and allergy Gut infections Learning disabilities?

12 General Anesthesia maternal morbidity/mortality
Independent Risk of GA It’s morbidity and mortality concerns two persons

13 Anesthetic morbidity mortality
5% of GA in Elective C sections in the USA 2% in France for elective C section American Society of Anesthesiology Guideline 2004? -> GA only when Loco-regional anesthesia is contra-indicated International Society of Obstetrics Anesthesia: GA is Unacceptable for elective C section

14 Give the Great Architect a bit more credit

15 Maternal Physiology of Childbirth
Pelvic relaxation is there to allow vaginal delivery Post partum LUTS in NVD > Post Cesarean Post partum fecal incontinence in NVD> Post Cesarean: Pudendal denervation Sphincter stretching damage *12 months post partum returns to Normal Persistant Fecal incontinence = Missed/ Not repaired Sphincter Rupture

16 Fetal Birth Physiology
Effect of Labor and stress of Birth: Cathecolamines , Cortisol, Endorphines… Enhances: Cytokynes TH1/Th2, Neutrophiles, Lipopolysaccharide responsiveness, CD3/CD56+,CD16+,Il 8…. Alteration of DNA methylation +++ is higher in C section ( Diabetes, Leukemia) Breast feeding quality Mother and child relationship

17 Balance advantages and disadvantages
C section NVD

18 C section on maternal request context
NIH context of C section on maternal request And conclusions: C sections should not be an alternative to lack of pain relief techniques C section should not be an alternative because of lack of standards in safe management of labor

19 Essential Questions What do women want? Do doctors prefer C section?
Why do they want C section (if they do?) Why don’t they want NVD Why don’t they want C section Do doctors prefer C section? Why? Money Security : Maternal safety ( they don’t trust midwifes) Fetal safety Don’t take risks They do what they know best They might not know much else

20 The issue In Iran Guideline for
Vaginal pain free delivery on maternal request -> Is an Professional and Ethical issue

21 Good Clinical practice
Clear maternal consent and information on each process, risks and benefits, potential complications and…. Those who don’t want to give birth despite All the given information and in absence of any contra indication.

22 Pain free vaginal delivery
What is it? Loco-regional anesthesia or iv opiods (remifentanyl) Who does perform it? The anesthesiologist How? By inserting a catheter or doing a single injection When? When patient can’t bare the pain What are the results? For the patient For the healthcare provider

23 Loco-regional anesthesia
Epidural Catheter Local anesthesic Marcaine 0.125% ( not Xylocaine 0.5%) Fentanyl or sulfentanyl Spinal Marcaine µg MORPHINE

24 Contra-indications Fever Thrombopenia<

25 Consequences Mother Fetus On the midwife On the OB&GYN Pain free
Itching Sleepy Low BP transitory Fetus Transitory low BP of Mum gives transitory bradycardia On the midwife controlled expulsion Precise repairing Post partum uterine revision if necessary On the OB&GYN

26 Things would never happen
Blind, Def, hemiplegic, paraplegic….ms,…

27 Labor active management
WHO partograph: Control contraction by ocytocine if hypo-cinesia or dynamic dystocia Use of atropine Delayed pushing Expertise in one instrumental extraction

28 Film

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