What Do the National Data Tell Us?

32.3 in 2008!
35

30

25

North Carolina
20
Wake County

Orange
15
Mecklenburg

10

0
2001 2003 2005 2007 2008
30

PRIMARY CESAREAN RATE 2008 (Not identical to NTSV Rate)

25

20

15

10

0
 Primary Cesarean Ranking in North Carolina
35.00%

30.00%

25.00%

20.00%

15.00%

10.00%
20 43 45 47 49 51 61 73 85 88
2 10
5.00%

0.00%
 Maternal request
 Medical-legal concerns
 Increasing age of pregnant women
 Increasing complications in pregnancy
 Maternal obesity
 Provider preference
 Induction of labor protocols
 Training of providers
 Increased payment for CS v Vaginal Birth
 VBAC standards
 Rates of “no indicated risk” Cesareans
Surrogate for “maternal request”

Cesarean Birth in the US: Epidemiology, Trends and Outcomes

Clinics in Perinatology June 2008 McDorman, et al
 AMA 2003
malpractice
crisis states:
◦ Arkansas
◦ Connecticut
◦ Florida
◦ Georgia
◦ Illinois
◦ Kentucky
◦ Mississippi
◦ Missouri
◦ Nevada
◦ NJ
◦ NY
◦ NC
◦ Ohio
◦ Oregon
◦ Penn
◦ Texas
◦ Washington
◦ West Virginia
◦ Wyoming

• Of the five states with highest rates of CS, four are among AMA’s 2003
malpractice crisis states
• Of 19 malpractice crisis states, four in highest CS rate group, eight in
second highest group; five in middle group; two in second lowest group
 Declerq et al: No evidence to support
increasing rates of maternal health problems
as significant cause of rising CS rates

 Difficult to disentangle from maternal age-

related increases in CS rates

 Treat medical problems medically; surgical

problems, surgically
 Robert Cefalo
 BMI < 30 BMI ≥ 30 & BMI ≥40
≤39.9
Oxytocin duration if induced 6.5 hr 7.7 hr 8.5 hr
Time in active labor 14.9 hr 16 hr 19.3 hr
Time in active labor if del vag 14.4 hr 15.2 hr 17.8 hr
Birth Weight 3286 3399 3489
CS 21.3% 29.8% 36.5%
CS for FTP 12.4% 12.0% 22%

36 week of greater, ≤Para 3, singletons; secondary analysis

of an RCT

Effect of maternal obesity on duration & outcomes of PG

Cervical ripening and labor induction. Pevzner et al, Obstetrics &
Gynecology, Dec 2009
 ≤34.9 ≥35
Induction 17% 29.4%
Prior CS 10.4% 15.0%
Cesarean 15.9% 26.2%
OR Time 56.4 min 65.2 min
Surgical site infx 3.3% 13.8%
Macrosomia 14.6% 28.6%
Apgar@1 <7 11.8% 18.8%
NICU Admit 5.0% 9.3%
Respiratory 2.5% 6.1%
Complications
 No differences: EGA at birth, low 5 min Apgar, congenital
malformations, intubation of infant, LOS in NICU, PPV
 All maternal complications in obese diabetic v non-diabetic mother
Baron et al. Journal of Maternal Fetal Neonatal Medicine. 2010; 8; 906-913.
 CS rates in privately insured vs publically funded
patients
◦ Closer relationship between doctor/patient therefore
may be harder to “withhold” a cesarean
◦ Older population in private hospitals
◦ Racial disparities favor private situation
 Higher rates of cesarean deliveries before
midnight
 Different practice styles
◦ Non-random distribution of patients with private doctors
Explaining sources of payment differences in US Cesarean Rates: Why do
privately insured mothers receive more cesareans than mothers who are not
privately insured? Grant D. Health Care Management Science , 2005.
 Induction of Labor
 Increased rate of induction
◦ National Center for Health Statistics 2003
 Percent of IOL among all U.S. births:
 1989 -- 8%
 2003 -- 21.6 %
 1.31 OR for CS if IOL vs. spontaneous labor
 Bryant et al; Ped and perinatal epidem. 2009
 International analysis in 9 countries looking at
classification of CS, >47,000 births evaluated
◦ 38% of all CS in induced nulliparous women
Brennan et al. Comparative analysis of international cesarean delivery rates
using 10-group classification identifies significant variation in
spontaneous labor. AJOG 2009
 Sample of data from one hospital in
PQCNC’s 39 Weeks Project
 Among patients admitted1-2 cm dilated
Overall Foley (7) Cytotec Cervidil No
(1) (8) Ripening
Vaginal 49 2 1 6 40
CS 1st 13 2 0 2 9
Stage
CS 2nd 2 3 0 0 2
Stage
74% Vaginal 28% 100% 75% 78%
Vaginal Vaginal Vaginal Vaginal

Among 1st stage c-sections: 5/13 were at 1-3 cm

and average birth weight was 2915 grams with all
latent phase CS done for FTP
 Provider Training
 1992-2001 at a single hospital in the UK
 No change in demographics of patients,
birthweight, documented malposition
 Increased preference for vacuum over forceps
in 2nd stage: O.2 VE/1 Forceps (1992)
1.9 VE/1 Forceps (2001)
 Increase failure of operative vaginal delivery
attempts
 Decreased number of attempts over all
Changing trends in operative delivery
performed at full dilation over a 10 yr
period. J Ob GYN 2010 May, Loudon
Increased reimbursement for CS v vaginal birth
likely not a big factor:
Increasing reimbursement by $1000 for CS
associated with little more than 1% increase in
CS rates in model

Physician Financial Incentives and Cesarean

Delivery: New conclusions from the
healthcare cost & utilization project. Darren
Grant. Journal of Health Economics 2009.
 1985: 5%
 1996: 28.3%
 2006: 8.5%

 NIH 2010 consensus conference: “Concerns

over liability have a major impact on the
willingness of physicians & healthcare
institutions to offer TOL”.
 Hospitals capable of emergency cesarean with
resources “immediately available”
 TOLAC not contraindicated with twins,
unknown scar if likely LTCS, two prior CS, low
vertical scar
 ECV, induction (no cytotec) reasonable
options
 Most women with one prior LTCS should be
counseled about VBAC and offer TOLAC
 http://www.bsc.gwu.edu/mfmu/vagbirth.html
 Increased likelihood of success
◦ Prior vaginal birth
◦ Spontaneous labor
 Decreased likelihood of success
◦ Recurrent indication for initial CS (Dystocia)
◦ Increased age
◦ Non-white ethnicity
◦ EGA > 40
◦ Preeclampsia
◦ Short interpregnancy interval
◦ Increased neonatal birth weight

 Increased risk of uterine rupture

◦ Single layer closure with prior surgery
◦ Interpregnancy inteval < 18 months
◦ Varying data on uterine wall thickness measured at 37-38
weeks—not ready for prime time
Neonatal Respiratory Morbidity Rates
Neonatal Length of Stay

Least
Success
TOL
CS with
Labor

CS without
Labor Most
Failed
VBAC
 Index pregnancy
◦ Peripartum hysterectomy
 Primary CS v vaginal delivery:
OR 6.48
 Repeat CS v vaginal delivery:
OR 3.69
 Peripartum hysterectomy and
cesarean delivery: a population-
based study. Stivanello. Act Ob
Gyn Scan 2010 March
◦ Endometritis
 7-10% rates
◦ Wound Infections
 5-15%
◦ Post Partum Hemorrhage due
to atony, requiring transfusion

Bateman, Anethesia and Analgesia,

May 2010
 NSVD Op. Vag CS no Labor CS w/labor
TTN 2.5% 3% 6-7% 5%
RDS 1% 1% 5% 3%
IVH 0.2% 0.1% 0.6% 0.4%
Injury 2% 12% 0.8% 2%
Why higher risk of IVH with CS with NO labor?
Those at higher risk for IVH get a CS?
CS not as atraumatic as we think?

Why higher risk of neonatal injury with operative

delivery?
Initially declined but over 8 years, rate increased
Assumed to be due to operator experience
 Abnormal Abnormal
placentation placentation
by prior CS with previa

# of prior % of 143 # of Clark MFMU

CS prior CS 1985 2006
None 0.2 (n=29) (N=91)

One 0.3 None 5% 3.3%

Two 0.6 One 24% 11.0%

Three 2.3 Two 47% 40%

Four 2.3 Three 40% 61%

Five or 6.7 Four or 67% 67%

more More
 Maternal Mortality
◦ Elective repeat C/S 13.4/100,000
◦ TOL 3.8/100,000
 NTSV
(Nulliparous, term, singleton, vertex)
Nulliparous, > 37 weeks, Singleton, Vertex

OB
Indications
for CS

CS by
Maternal
Request

NTSV
 Patient education regarding normal course of
labor
 Await spontaneous labor
 Avoid inductions with unfavorable cervix
 Effective cervical ripening using same technique
 Induce >41 weeks
 Admit patients in active labor, not prodromal
 Standardize effective pitocin protocol
 Labor support
 Be patient with prodromal labors