FMSC Final - Labor and Delivery

obstetric dilemma

• too little too late (delivering late/not enough care)

  • increased risk for other and newborn

  • don’t deliver early enough to save a mother and newborn

    • eclampsia

    • obstructed labor

• too much too soon (excessive or early intervention)

  • increased risk for mother and newborn

  • cascade medical intervention

    • cesarean delivery

    • risks related to surgery

Modes of Delivery

• vaginal birth

  • spontaneous

  • induced or augmented

  • assisted

    • forceps

    • vacuum extraction

• cesarean birth

  • primary (first) or repeat (had a previous c-section)

  • low-risk (singleton, head-first, full term, not given birth before)

• vaginal birth after cesarean

stages of labor and delivery - stage 1

stages of labor and delivery - stage 2

stages of labor and delivery - stage 3

secundagravidas (second-time mothers) vs nulliparas (first-time mothers) labor

• labor is faster in women who have given birth before

• women undergoing cesarean prior to progression? leads to faster cervical dilation compared to clinical standard labor

• labor is non-linear

benefits of vaginal delivery

• fewer medications if desired

• more freedom to move

• shorter hospital stay

• breastfeed sooner

• fewer complications in subsequent pregnancies (e.g., placenta previa, placenta accreta)

• oxytocin - mother/infant bond

• infant

  • less respiratory distress at birth

  • beneficial vaginal microbiome (reduces obesity, autoimmune conditions, and allergy/asthma)

risks of vaginal delivery

• pain and exhaustion

• perineal tears (3rd/4th degree)

• hemorrhoids and bowel issues

• urinary incontinence

• pelvic floor trauma

• negative reactions to epidural

• (VBAC only) slightly higher risk of uterine rupture

the effect maternal microbioata has on the child

• can influence child’s risk for disease

• for example, if unhealthy microbiome (dysbiosis) can vertically transmit diseases to child

reasons for planned cesarean birth

*Can be life saving for mother/infant

• Previous C-section

• Expecting multiples

• Placenta previa

• Breech baby

• Certain birth defects, Fetal macrosomia (big babies)

• Uterine fibroid/obstruction/pelvic size

• Maternal indication (e.g., HIV, herpes)

reasons for unplanned cesarean birth

*Can be life saving for mother/infant

• Fetal distress

• Failure to progress

• Umbilical cord prolapse

• Placental abruption

• Maternal indication (pre-eclampsia

risks of cesarean birth

• Infection

• Loss of blood or excessive bleeding

• Blood clot – embolism

• Injury to bowel or bladder

• Longer recovery

• Longer hospital stay

• Longer time to expression of breastmilk

• Abdominal adhesions

• Increased risk in future pregnancies (placenta accreta, uterine rupture)

risks of adverse maternal and neonatal outcomes by mode of delivery (vaginal delivery vs cesarean delivery)

• maternal: vaginal delivery risk lower (8.6%) compared to cesarean delivery risk (9.2%)

• neonatal - cesarean risk higher except for shoulder dystocia

global and regional rend pf ceserean delivery as years go by

percentage of cesarean section goes up as years increase

what is the variability between countrys for cesearean deliverys?

wide variability

U.S. Cesarean delivery trends

• steady decline in the early 1990s → increased rapidly from 1996 - 2009 → rate plateaued after

Cesarean rates by states

Increase in MD, and Florida regions

cesarean rates in U.S. vs M.D.

U.S: 32.3%

MD: 35%

what is a troubling epidemic for c-sections?

troubling epidemic of unnecessary c-sections around the world

what are commonly used explanations for the high cesarean rate?

• mothers are getting older

• more multiples being born

• babies are getting bigger

• maternal health is worse: obesity, diabetes, and hypertension

• mothers are asking for elective cesareans

• hospital practice patterns have changed - hospitals are doing C-sections for the same medical reasons as before, but they are deciding to do them earlier or with less strict criteria [same indications but lower threshold]

primary cesarean and VBAC rates as guidelines changed over time

Primary cesarean rate went up and VBAC rate went down

How do guidelines affect VBAC availability?

• VBAC availability is extremely sensitive to guidelines

key factors in decision to perform C-sections

• fear of litigation and legal consequences

• perceptions of low risk and safety related to Cesarean delivery

• Personal convenience by doctors, midwives viewed this as a reason for unnecessary Cesarean delivery, and disagreements in decision making and cooperation

• influence of private health care systems

• lack of hospital guidelines or lack of awareness of the guidelines

• clinicians reported maternal request as one of the factors, influenced by preferences, demands, and fears/anxiety of the woman

how has the proportion of home and birthing center births changed from 2004-2020?

• 134% increase 2004-2020 in the proportion of home and bc births

what can the healthcare system to reduce unnecessary c-sections?

• remove incentives

• evidence, review, feedback

• publish c-section reimbursement rates (how much they make)

• midwifery - led units

what can birthing people to reduce unnecessary c-sections?

• ask questions

• delay going to the hospital, if possible

• midwives, doulas

• research your hospital’s c-section rate

  • go to birth facility (connected to hospital)

summary

• Obstetrics is balancing risks/benefits for both mother and infant

  • One of the few providers that is caring for 2 patients at once!

• Vaginal delivery has benefits that extend beyond delivery

  • However, it is not without risks

• The U.S. (and many other countries) Cesarean rates far exceed what may be medically necessary

• Can be life-saving, but risks associated with Cesarean delivery

• Reasons for these trends may have more to do with practice changes than changes in who is giving birth

• Ways to advocate for changes