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Dr laleh Amini French board of OB&GYN Iranian Continence Society 2 nd Annual meeting 2011 Tehran- Milad Hospital IRAN.

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Presentation on theme: "Dr laleh Amini French board of OB&GYN Iranian Continence Society 2 nd Annual meeting 2011 Tehran- Milad Hospital IRAN."— Presentation transcript:

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2 Dr laleh Amini French board of OB&GYN Iranian Continence Society 2 nd Annual meeting 2011 Tehran- Milad Hospital IRAN

3  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

4  Why is high rate of C. Section = Malpractice?  WHO ‘s warnings to Iran  Statistics: US: 13-33% UK: 9-25% France: 13-28% Scandinavian countries: 7-17% Iran 45%???

5  About LUTS (Lower Urinary tract symptoms)  SUI/ Urgency? Frequency  Fecal incontinence  Dys pareunia  Vaginal relaxation

6  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

7  Morbidity  Maternal early late  Fetal  Mortality  Maternal  fetal

8  Mortality: WHO International disease Classification  in 2008 (61400 AIDS) / in 1980  France 8/ (Hemorrhages PP)  USA 12/ / in 2008 (Thrombo- emboli, PPCM) 2x UK 3x Australia 4x Italy  UK 8/ Thrombo-emboli  Netherlands: 7/ Eclampsie  Iran: 23/  China : 165/ /

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

10  Placenta accreta/percreta  Uterine rupture  Endometriosis  Intestinal occlusion  Chronic pain

11  Decreased with the increase to 15-17% of C sections, then stable and now increasing

12  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?

13  Independent Risk of GA  It’s morbidity and mortality concerns two persons

14  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

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16  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

17 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

18 C section NVD

19  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

20  What do women want?  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

21  Guideline for Vaginal pain free delivery on maternal request  -> Is an Professional and Ethical issue

22  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.

23  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

24  Epidural  Catheter  Local anesthesic Marcaine 0.125% ( not Xylocaine 0.5%) + Fentanyl or sulfentanyl  Spinal  Marcaine + 100µg MORPHINE

25  Fever  Thrombopenia<

26  Mother  Pain free  Itching  Sleepy  Low BP transitory  Fetus  Sleepy  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

27 Blind, Def, hemiplegic, paraplegic….ms,…

28  WHO partograph:  Control contraction by ocytocine if hypo-cinesia or dynamic dystocia  Use of atropine  Delayed pushing  Expertise in one instrumental extraction

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