Presentation on theme: "Vaginal Delivery IN the 21ST CENTURY"— Presentation transcript:
1 Vaginal Delivery IN the 21ST CENTURY Dr laleh AminiFrench board of OB&GYNIranian Continence Society 2nd Annual meeting 2011Tehran- Milad Hospital IRAN
2 Terms you hear in recent times Natural (NVD)By allusion to caesarian section which is artificialPhysiology (phusis nature, Logia:science)! Physio logie studies function (amalkard) and properties vijegiha khassayes) of organs and living tissuesPhysiologic ( means gesmi) by opposition to psychologicSafe!!!!The other ways are unsafe?In waterA newborn psychology (1960s) sophrologyPainlessPain free
3 Around the world Why is high rate of C. Section = Malpractice? WHO ‘s warnings to IranStatistics: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? FrequencyFecal incontinenceDys pareuniaVaginal relaxation
5 They DO General Public Health is the main issue In GOD we trust, every body else has to show dataBased 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
7 Public health definitions Mortality: WHO International disease Classificationin (61400 AIDS) / in 1980France 8/ (Hemorrhages PP)USA 12/ / in (Thrombo- emboli, PPCM) 2x UK 3x Australia 4x ItalyUK 8/ Thrombo-emboliNetherlands: 7/ EclampsieIran: 23/China : 165/ /
9 Late Maternal Morbidity Placenta accreta/percretaUterine ruptureEndometriosisIntestinal occlusionChronic pain
10 Fetal mortalityDecreased with the increase to 15-17% of C sections , then stable and now increasing
11 Fetal morbidityBesides complications related to the condition leading to a cesarean section:Pulmonary DistressJaundiceRe hospitalizationsImmune system (humeral/Cellular)Diabetes , LeukemiaAsthma and allergyGut infectionsLearning disabilities?
12 General Anesthesia maternal morbidity/mortality Independent Risk of GAIt’s morbidity and mortality concerns two persons
13 Anesthetic morbidity mortality 5% of GA in Elective C sections in the USA2% in France for elective C sectionAmerican Society of Anesthesiology Guideline 2004?-> GA only when Loco-regional anesthesia is contra-indicatedInternational Society of Obstetrics Anesthesia:GA is Unacceptable for elective C section
15 Maternal Physiology of Childbirth Pelvic relaxation is there to allow vaginal deliveryPost partum LUTS in NVD > Post CesareanPost partum fecal incontinence in NVD> Post Cesarean:Pudendal denervationSphincter stretching damage*12 months post partum returns to NormalPersistant 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 qualityMother and child relationship
17 Balance advantages and disadvantages C sectionNVD
18 C section on maternal request context NIH context of C section on maternal requestAnd conclusions:C sections should not be an alternative to lack of pain relief techniquesC 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 NVDWhy don’t they want C sectionDo doctors prefer C section?Why?MoneySecurity :Maternal safety ( they don’t trust midwifes)Fetal safetyDon’t take risksThey do what they know bestThey 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 despiteAll the given information and in absence ofany contra indication.
22 Pain free vaginal delivery What is it?Loco-regional anesthesia or iv opiods (remifentanyl)Who does perform it?The anesthesiologistHow?By inserting a catheter or doing a single injectionWhen?When patient can’t bare the painWhat are the results?For the patientFor the healthcare provider
23 Loco-regional anesthesia EpiduralCatheterLocal anesthesic Marcaine 0.125% ( not Xylocaine 0.5%)Fentanyl or sulfentanylSpinalMarcaine µg MORPHINE
25 Consequences Mother Fetus On the midwife On the OB&GYN Pain free ItchingSleepyLow BP transitoryFetusTransitory low BP of Mum gives transitory bradycardiaOn the midwifecontrolled expulsionPrecise repairingPost partum uterine revision if necessaryOn 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 dystociaUse of atropineDelayed pushingExpertise in one instrumental extraction