1. Increasing Cesarean Rates: The Problem and Solution
Ayman Shehata
Tanta Conference 2017

2. The problem
The incidence of Caesarean deliveries is increasing every day passing faraway beyond WHO recommended rate of 15% for all deliveries .
In 2014, the United States cesarean, section rate was 32.2%, which increased from 20.7% in 1996.
Latin America the rate was 40.5%, Europe (25%), Asia (19.2%)and Africa (7.3%).
In 2016, Japan conducted a retrospective study done at 125 institutions and concluded that the overall CS rate was found to be 37.3%
In Australia the rate of CS was increased from 19.22% in the year 1995 to 33.6% in the year 2010.

3. The problem
In Egypt, WHO stated that the Caesarean section (CS) rate in Egypt was 27.6% in the year 2010.
According Ministry of Health and Populations reported data; more than 50% (50.8%) in 2014.
Ministry of Health and Populations [Egypt],El-Zanaty Associates[Egypt], ICF International. The Egypt demographic and Health Survey (2014EDHS).Main Findings. Cairo, Egypt 2015.

4. University Hospitals
Alaa-Eldin Ebrashy et al (2011) determined and compared the rates and indications of CS deliveries in Cairo University Hospital and Al Mattaria Teaching Hospital they found that the rate of cesarean section was (37.8%) and (36.5%) at Cairo University Hospital and Al Mattaria Teaching Hospital respectively .
El Khyat et al (2013) at 5 year period where they found that the rate of Cesarean sections was gradually increasing from 38.84% of deliveries in 2008, to 41.17% in

5. University Hospitals
At Ain Shams University Hospitals Ihab Serag et al (2014) conducted a study to evaluate the incidence of peripartum emergency hysterectomy in 5-year retrospective study starting at 2003 till end of They found that Caesarean rate increased from 31% at 2004 to 38% at 2008 at their tertiary care hospitals.
In Assuit University Hospitals, Caesarean section rate was 32% (443/1357) in 2008 and increased to 38% (626/1628) in 2011.

6. Tanta University Hospitals
The rate was:
41% in 2013
45% in 2014
46% in 2015
59.7% in 2016

7. The possible factors employed in the rising CS rates
Maternal
Health care provider
Medico-legal
Social

8. Maternal issues Fear of labour pains Intolerance of labour pains
Misconception about genital damage after vaginal delivery;
Misconception about safety of CS delivery for the baby;
Lower tolerance to any complications or outcomes other than the perfect baby.
Cesarean section on request (CDMR)
Maternal

9. Health care Provider Health professional Financial issues
Ignorance of vaginal delivery arts
Ignorance of how to anticipate complications in vaginal delivery
Ignorance of CTG, Partogram
Intolerance to long lasting deliveries
Fear of rupture uterus in TOLACS
Malpractice
Health care Provider

10. Medico-legal issues Medico-legal aspects
Medico-legal responsibilities if fetus was lost in normal labour.
Medical litigations for complications either fetal or maternal
Neglicance and medical reports
Medical courts and civil aspects
Compensations
Insurance
Medico-legal aspects

11. Social factors
Social factors control the time and type of delivery, for example in China, scheduling CS and choosing the time of CD delivery is linked to luck and fate for the future of the baby.
Choosing specific birthdate 11/11/2011
Social aspects

12. Impact of Cesarean on maternal health
Cesarean delivery has been associated with higher rates of maternal hemorrhage, infection, and even death but it is protective against perineal lacerations.
Harper MA, Byington RP, Espeland MA, et al. Pregnancy-related death and health care services. Obstet Gynecol. 2003;102:273–278.
Handa VL, Harris TA, Ostergard DR. Protecting the pelvic floor: obstetric management to prevent incontinence and pelvic organ prolapse. Obstet Gynecol. 1996;88:470–478.

13. Impact of Cesarean on maternal health
Evidence suggests that vaginal delivery may be associated with pelvic organ prolapse and fecal and urinary incontinence but CS has not.
Risks of TOLACS
The risk of abnormal placentation that can lead to a need for preterm delivery and cesarean hysterectomy.
Future fertility may be affected by CS

14. Impact of Cesarean on neonates
Cesarean delivery is associated with lower rates of intra- partum hypoxic injury and neonatal mortality.
With vaginal delivery, there is also always a risk of shoulder dystocia and permanent brachial plexus injury.
Alternatively, neonates delivered via cesarean appear to experience higher rates of transient tachypnea and possibly primary pulmonary hypertension.
Infants born to mothers who have had prior cesareans are at increased risk of stillbirth, and in cases of TOLAC, uterine rupture carries a risk to the neonate.
For pregnancies complicated by abnormal placentation, delivery before term may be required.

15. STOP

16. Solutions
Medical issues
Legislations
Education
Social media

17. Solutions MEDICAL ISSUES
When discussing lowering the cesarean rate, it is important to consider the most common indications for cesarean delivery, which are:
Prior cesarean
Failed progression in labor,
Abnormal fetal heart rate (FHR) tracing.
Malpresentations
Multiple gestations
Suspected fetal macrosomia

18. TOLACS
Attempting TOLAC, will lead to increase in VBAC rate by about10%.
Although many women do not wish to bear the risk of a TOLAC, evidence suggests that more than 10% do, and that the current environment is restricting the wishes of many pregnant women with a prior cesarean.
VBAC should likely not be universally available at every hospital in the country, but there are many hospitals where a safe TOLAC could be offered. Organizational changes in obstetric units such as having laborists available around the clock will improve the safety of a TOLAC, which remains a viable way to reduce the cesarean delivery rate overall.

19. Labor management
Most indicated cesarean deliveries are performed for failed progression of labor during the first or second stage.
Further, the majority of these primary cesareans will lead to future cesareans because of the low VBAC rate.
The single most common indication is for failed progression in the first stage of labor, commonly diagnosed as “active phase arrest.” This diagnosis is based on labor norms established more than 50 years ago that have likely been relied on too absolutely.

20. Freidman curve
When progress was slower than this, a laboring woman could be said to be “falling off of the labor curve.” In this light, no progress for 2 hours was considered active phase arrest and became a common indication for a cesarean delivery.
In a prospective study, researchers demonstrated that waiting for cervical change during the active phase of labor for at least 4 hours in the setting of adequate contractions or 6 hours without adequate contractions would lead to 60% of such women going on to deliver vaginally without evidence of harm to either the mother or the infant. In a similar study, investigators found not only a reduced cesarean rate and no evidence of increased neonatal morbidity but also reduced maternal risk.
Cheng YW, Shaffer BL, Nicholson JM, Caughey AB. Second stage of labor and epidural use: a larger effect than previously suggested. Obstet Gynecol. 2014;123:527–535.

21. Second stage of labour
The amount of time beyond which a second stage of labor was characterized as prolonged was also likely too short.
An additional hour for the second stage has been traditionally utilized for women with an epidural, this appears to lower incidence of CS.
When a recent study examined the 95th percentile of differences between women without epidural in the second stage, a difference of 2 hours or more was identified in both nulliparous and multiparous women.

22. Second stage of labour
Thus, management in the second stage should entail ongoing assessment of progress during the second stage, but should allow for at least 2 hours of second stage in multiparous women and 3 hours of second stage in nulliparous women, and an additional 2 hours in women with an epidural.
In a recent small trial that randomized women to the additional hour in the second stage versus a more rapid delivery, the cesarean rate in the additional hour group was less than half that in the rapid delivery group (19.5% vs 43.2%, P<0.05).
Cheng YW, Shaffer BL, Nicholson JM, Caughey AB. Second stage of labor and epidural use: a larger effect than previously suggested. Obstet Gynecol. 2014;123:527–535.

23. Second stage of labour
In addition, during the second stage, when the fetal vertex is engaged and has descended to +2 station, operative vaginal delivery remains a beneficial to achieve vaginal delivery, although this has declined in recent years.37
It is important that the next generation of providers continue to be trained to perform operative vaginal deliveries.
Gimovsky AC, Berghella V. Randomized controlled trial of prolonged second stage: extending the time limit vs usual guidelines. Am J Obstet Gynecol Mar;214(3):361.e1-6.

24. Abnormal FHR tracings
After abnormal progression in labor, the second-most- common indication for a cesarean during labor is an abnormal or indeterminate FHR tracing.
Currently, FHR tracings are broken into categories 1, 2, and 3. Category 1 tracings are entirely benign and generally of no concern.
Category 3 tracings are almost always an indication for immediate delivery and rarely controversial.
The majority of FHR tracings, however, fall into category 2.
In a recent study, more than 90% of FHR tracings were category 2 during the second stage of labor. Thus, category 2 tracings, are challenging and are not particularly predictive of neonatal acidemia. Although these have some features of concern such as FHR decelerations, category 2 tracings may have other reassuring features such as moderate variability.

25. Categories of Abnormal FHR tracings
Ayres-de-Campos D, Spong CY, Chandraharan E, for the FIGO Intrapartum Fetal Monitoring Expert Consensus Panel. FIGO consensus guidelines on intrapartum fetal monitoring: Cardiotocography. Int J Gynecol Obstet 2015;131:13-24.

26. Abnormal FHR tracings
Certainly, too many cesareans are performed for category 2 FHR tracings.
Intervening steps should be taken before operative delivery.
A range of resuscitative measures include maternal position change, intravenous fluids, and ensuring adequate blood pressure after obtaining regional analgesia.
In addition, in the setting of repetitive FHR decelerations, if oxytocin augmentation is being utilized, it can be decreased or halted.

27. Abnormal Fetal heart rate tracing
Another approach for such repetitive decelerations has been the use of an intrauterine pressure catheter and amnioinfusion.
Finally, if there is no moderate variability to reassure the clinician, fetal scalp stimulation with a response of FHR acceleration is useful to ensure a pH of more than 7.20
close attention to the FHR pattern and recognition to ensure that there are only a few particularly concerning patterns will certainly prevent a number of cesareans.
Despite the ubiquitous use of continuous FHR tracings for 40 years, ongoing clinical research is needed to ascertain the best use of this technology.

28. Fetal Malpositions
Persistent fetal malposition occurs in approximately 5% of fetuses and is associated with an increased risk of cesarean delivery and both maternal and neonatal complications.
One approach to malposition is patience. Similar to the epidural in the second stage of labor, fetal malposition will lead to longer first and second stages of labor.
In such cases, rotation of the fetal occiput is useful. Historically, this was accomplished with forceps, particularly Kielland forceps. Because fewer ob/gyns are being trained to perform forceps rotations, however, manual rotation of the fetal occiput is more often attempted.
This approach has been shown to significantly reduce the risk of cesarean delivery and is relatively safe and easy to teach.

29. Malpresentation
Currently, the vast majority of breech pregnancies are delivered via cesarean. Thus, the primary approach to reducing cesareans in the setting of breech presentation is the use of external cephalic version (ECV).
In general, ECV will be effective in approximately 70% of attempts and the majority of women with a successful ECV will go on to deliver vaginally.
In addition, ECV success has been shown to be improved with the use of regional anesthesia; this concomitant approach should be more widely used.
Finally, moxibustion (Chinese medicine approach) has been shown to reduce breech presentation and should be mentioned to patients with a breech-presenting fetus

30. Moxibustion
Moxibustion is an externally applied TCM treatment using a Chinese herb called Moxa (Artemisia argyi), commonly known as ‘Mugwort’.  
For external use Moxa is compressed and rolled into a cigar-shaped herbal stick.  Moxa sticks are then lit and held over acupuncture points.  The radiant heat produced has the effect of stimulating the point.

32. Breech tilt

33. Twin gestations
Supportive evidence exists for an attempt at vaginal delivery in the setting of a twin gestation if the presenting twin is cephalic.
In particular, a recent randomized trial found no improvement in neonatal outcomes in the setting of planned cesarean for a twin gestation.
Thus, continued training of providers in vaginal delivery for both vertex–vertex and vertex–breech twins is imperative to allow this option for all women with twin gestations.
Barrett JF, Hannah ME, Hutton EK, et al; Twin Birth Study Collaborative Group.A randomized trial of planned cesarean or vaginal delivery for twin pregnancy. N Engl J Med. 2013;369:1295–1305.

34. Induction of labour for postterm
When induction is compared to expectant management, it does not appear to be associated with an increase in the risk of cesarean delivery.
In prospective randomized trials of women at 41 weeks’ gestation and beyond, the risk of cesarean delivery was lower in the women who were induced.
In fact, routine induction of labor in the wrong settings may increase the risk of cesarean delivery.
In particular, using length of time to define a failed induction of labor can lead to an increase in cesareans.

35. Induction of labour
Thus, ACOG, SMFM suggested that no induction be called a failed induction until at least 24 hours of induction attempt or at least 12 to 18 hours after membrane rupture.
Additionally, induction techniques should include cervical ripening agents (eg, prostaglandins, Foley bulb) in approaches to the unfavorable cervix.
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;123:693–711.

36. Other interventions to reduce CS
Painless labour
Doula Pool for underwater birth
Delayed admission in the latent phase of labor

38. Solutions
Medical issues
Legislations
Education
Social media

39. Legislations New laws by Parliament for safe medical practice
Ministry of health:
Follow rate of C. deliveries
Put manual guidelines for each conditions to limit liberal use of CS
Birthing campaigns
Distribution of flyers to all local hospitals and nurses to be aware about hazards of CS

40. Education Workshops for vaginal delivery arts
Assisted vaginal delivery techniques
Contact of people to increase the knowledge about CS hazards by leaders
University role

41. Social media Talk show programs Web opportunities Web forums
Newspapers

42. Take home messages
Although cesarean delivery may be a safe alternative to attempting vaginal delivery, its use in 1 in 3 women giving birth appears to be too high.
Further, the effect of cesarean delivery on future pregnancies is likely not well considered when the first cesarean is being performed.
Practices that have become standard over decades should be carefully questioned and replaced by standardized, evidence-based practices. This may safely decrease the cesarean rate.
Given the practice environment and cultural and medical-legal pressures that clinicians face, however, the healthcare system will need to adopt systems approaches to decrease the national cesarean delivery rate.
Quality improvement will allow clinicians to adopt the range of practices described here. Without such environmental changes, however, clinicians may not be able to alter practice patterns that have been the norm for so long.