"Does 4 cm dilation constitute active labor?" interview with Dr. Emanuel A. Friedman

Emanuel A. Friedman M.D., of Columbia University, introduced the labor curve, commonly known as “Friedman’s Curve ” to depict the average amount of time it took for a labor patient to dilate each cm. Published nearly 60 years ago, the curve is still followed by a majority healthcare providers to define normal labor.

In 2012, when the National Institute of Child Health and Human Development (NICHD), the Society for Maternal and Fetal Medicine (SMFM), and ACOG held a workshop aimed at “preventing the first Cesarean.” In the workshop, it was discussed that many cesarean sections are simply performed because many women are wrongly categorized as “ failure to progress” based on Friedman’s Curve.

In 2014, ACOG and SMFM issued a consensus statement “Safe Prevention of the PrimaryCesarean Delivery ” to bring down the rising cesarean section rates. The statement redefined normal and abnormal labor and stated that Friedman’s Curve should no longer be used as the basis for modern labor management (ACOG 2014).

A critical study published by Zhang et al. formed the basis of the new guidelines. The study was based on data from the Consortium on Safe Labor and looked at labor records of 62,000 women from 19 hospitals across the U.S. The researchers concluded that “ failure to progress” should be diagnosed at 6 cm and not 4 cm as stated earlier.

ACOG also reaffirmed this statement in 2017 and again in 2018 ACOG Committee Opinion No.766: Approaches to Limit Intervention During Labor and Birth.

Here is an interview with Emanuel A. Friedman about definitions of active and in active labor. He opines that “Woman describes her own labor curve, it is irrelevant to designate a particular point in labor as a demarcation between active and in active labor.”

Sutures are better than staples in third or high-order cesarean sections wound closures

Wound closure with suture is associated with 56% lower odds of wound complications as compared to using staple in third or high-order cesarean sections reports the results retrospective cohort study published ahead of print in February issue of Journal Obstetrics and Gynecology.

The researchers looked at wound closure techniques of all tertiary or higher-order cesarean deliveries over a period of 12 years at a large academic medical center. All the cases were performed by surgeons belonging to a single group practice.

Patients with three or more cesarean deliveries with pfannensteil incision were included in the study.

A total of 551 patients had third or higher order cesarean deliveries, in 192 patients staples were used while 359 received suture closure.

The patients were not randomized to receive either type of wound closure, but the group doctors used staples for most of the cases for the first 6 years and in the later 6 years subcuticular suture closure was preferred. If the subcutaneous fat was 2 cm or deeper, the space was obliterated in all the patients.

Prophylactic antibiotics were routinely used in all patients. The researchers looked at data on wound infection requiring antibiotics, resuturing or wound gaping that required packing 6 weeks post-operatively.

A total of 551 patients had third or higher order cesarean deliveries, in 192 patients staples were used while 359 received suture closure.

Wound complications were observed in about 5% of patients with suture closure as opposed to nearly 12% of patients with staple closure (P=.003).

Even after accounting for number of previous cesareans and operator surgical skills, suture closure has 56% lower odds of wound complications as opposed to staple closure (adjusted odds ratio 0.44, 95% CI 0.23–0.86).

Abstract

Media courtesy: Headley Family Medicine

A year in review: Best of 2017

We are already round the corner to 2018, here are the top 10 most read articles from 2017.

News from ACOG 2017: Changing gloves before abdominal closure brings down the rate of wound infection by almost 50% in Cesarean Section

Results of a randomized controlled trial presented at the ACOG 2017 showed that changing the outer gloves before closing the abdomen decreases the wound complication of infection, cellulitis and dehiscence.

https://obgynupdated.blogspot.com/2017/05/news-from-acog-2017-changing-gloves.html

Clinical review: Updates on Cesarean Section

Here is a roundup of the latest research on Cesarean Section.

https://obgynupdated.blogspot.com/2017/08/clinical-review-updates-on-cesarean.html

The American Heart Association updates BP guidelines in 14 years: now 130 is the new 140

The American Heart Association (AHA)  and The American College of Cardiology (ACC) has changed the definition of hypertension for the first time in 14 years, moving the number from the old standard of 140/90 to the newly revised 130/80.

According to the new definition, 130 to 139 mm Hg systolic and or 80 to 89 mm Hg will be labelled as stage 1 hypertension.

https://obgynupdated.blogspot.com/2017/11/the-american-heart-association-updates.html

First US baby born after uterine transplant delivered in Texas

The first birth as a result of a uterine transplant in the United States took place on Friday in Texas at the Baylor University Medical Center in Dallas. The women had undergone a live donor transplant and have received her uterus from Taylor Siler, 36, a registered nurse in the Dallas area.

https://obgynupdated.blogspot.com/2017/12/first-us-baby-born-after-uterine.html

New use of old drug: Sildenafil Citrate (Viagra) improves amniotic fluid index in oligohydramnios.

Sildenafil Citrate (Viagra) improves amniotic fluid index in pregnancies complicated by oligohydramnios according to a new study published ahead of print on March 6,2017 in Journal of Obstetrics and Gynecology.

https://obgynupdated.blogspot.com/2017/03/new-use-of-old-drug-sildenafil-citrate.html

WHO updates its guidance on Tranexamic Acid for the Treatment of Postpartum Hemorrhage

WHO has recently updated their guidelines for use of Tranexamic acid for treatment of Postpartum Hemorrhage: TXA should now be included in the treatment regimen for PPH along with other drugs, irrespective of the cause of hemorrhage.  

https://obgynupdated.blogspot.com/2017/11/who-updates-its-guidance-on-tranexamic.html

CDC releases ‘long awaited’ guidelines for preventing surgical site infections.

The Center for Disease Control released its much-awaited update to its 1999 guidelines for the prevention of surgical site infections (SSIs). The guidelines were published online May 3, 2017 in JAMA.

https://obgynupdated.blogspot.com/2017/05/cdc-releases-long-awaited-guidelines.html

Finally, an oral drug found effective in treatment of Uterine Fibroids following successful phase-3 trial

Relugolix successfully reduced heavy menstrual blood loss among Japanese women in a Multicenter, Randomized, Double-Blind, Parallel-Group, Phase 3 Study to Evaluate the Efficacy and Safety of Oral relugolix 40 mg as compared with injectable leuprolide in the Treatment of Uterine Fibroids.

https://obgynupdated.blogspot.com/2017/10/finally-oral-drug-found-effective-in.html

Now ‘Switch’ the way you suture: Reinventing suturing technique with the new device

Mellon Medical, a Dutch MedTech developer has reinvented suturing by developing a device which enables the surgeon to suture with only one hand, the other hand remaining free to use as needed. The product is named Switch®, a single use precision instrument that allows the surgeon to suture tubular structures or skin with twice the speed of conventional suturing.

https://obgynupdated.blogspot.com/2017/10/now-switch-way-you-suture-reinventing.html

A simple, novel solution to identify and protect ureter during surgery

AllotropeMedical, a Houston based medical startup has devised StimSite, a novel, hand-held, single use device that precisely identifies ureter during surgery; thus, eliminating the need for ureteral stenting.

https://obgynupdated.blogspot.com/2017/12/a-simple-novel-solution-to-identify-and.html

Nearly 10% of young women worldwide prefer Cesarean section to vaginal birth as delivery option

One in ten young women prefers cesarean section to vaginal birth as her choice of delivery in a seemingly healthy pregnancy, because of fear of uncontrollable labor pains and physical damage says the result of large study published in Journal of Reproductive Health.

All attempts to bring down cesarean section rates in middle income and developed countries have mostly focused on educating the physicians and midwives, changing hospital policies and environment and less on patient education and knowledge about benefits of vaginal births.

It is estimated that 6.2 million unnecessary cesarean sections (CS) are performed worldwide each year and most countries that participated in this study exceeds the optimal limit between 10-19%.

Recently, psychological indication of Cesarean Section has emerged as an important contributing in increasing the global cesarean rate. A survey of 6000 European found that 16.7% of primiparas and 31.7% of multiparas had a CS without medical indications because of severe fear of childbirth.

The current study recruited student from Universities and Schools across 8 OECD countries (Australia, Canada, Chile, England, Germany, Iceland, New Zealand, United States.

Childless young men and women who plan to have one child in near future were sent online questionnaire, of which 6571 completed the survey.

During the final analysis, overall 10.8% of women wanted to have a CS in a healthy future pregnancy, with the highest rate of 16.0% in Australia.

The most common reason cited was fear of labor pains and maintain vaginal integrity, the other being CS is well planned and good for mother’s health.

Regression analysis showed that students who studied health science had significant less fear and lower odds of preferring CS.

Epidural analgesia might theoretically appear a lucrative solution, but it increased the rates of instrumental delivery and created a lasting negative impression in long term.

All women expressed a significant interest in knowing more about anatomy and process of childbirth.

The authors concluded, “Education sessions delivered online, through social media, and face-to-face using drama and stories told by peers (young women who have recently had babies) or celebrities could be designed to maximize young women’s capacity to understand the physiology of labor and birth, and the range of methods available to support them in coping with labor pain and to minimize invasive procedures, therefore reducing fear of pain, bodily damage, and loss of control. The most efficacious designs and content for such education for young women and girls remains to be tested in future studies.”

Abstract, Full Text.

Danish Society of Obstetrics and Gynecology recommends against vaginal seeding in Cesarean births

www.stayathomemum.com.au

The potential risks associated with practice of vaginal seeding (VS) in Cesarean Delivery outweighs the hypothetical benefits and consequently we do not recommend it at present says the national recommendations released by Danish Society of Obstetrics and Gynaecology at the national meeting on 19 January 2017.

The recommendation along with a commentary was published online 22 AUG 2017 in British Journal of Obstetrics and Gynecology.

“We could not identify any other national or international society that had systematically investigated the clinical approach to VS,” write Thor Haahr, MD, PhD, from the Department of Obstetrics and Gynaecology at the Institute for Clinical Medicine, Aarhus University Hospital, Skejby, Denmark.

The recommendations are aimed at providing fellow obstetricians and midwives with the basic information about VS so that it can be discussed with couples and families opting for it.

The recommendations state that:

Maternity wards should not take part in screening, guiding or encouraging women for Vaginal Seeding.

Vaginal seeding is contraindicated in infants born before 37 weeks, born to mothers who meet national criteria for group B streptococci(GBS) prophylaxis during delivery, situations in which the cesarean section is done to prevent vertical transmission of infection such as—primary vaginal herpes infection, HIV infection with HIV-RNA >50 copies/ml and any other situations in which the VS will cause potential harm to the fetus.

Parents who still wish to perform VS, can do so provided “it does not interfere with or delay other procedures.” They should be informed about insufficient evidence in favor of any potential benefit and should be provided with patient information booklet. They should also be educated about signs of infection in neonates should any infection occurs after the procedure.

Interest in VS sparked after Dominguez-Bello and colleagues published the results of their pilot study in 2016 stating that Neonatal colonization can be partially restored in cesarean born babies by VS.  Several other studies have since followed involving VS which stress the importance of more research and publications on this topic.

Microbirthing:The " Vaginal Seeding" is growing fad, but thin evidence concerns physicians!

Although, the risk associated with VS is very low, the immediate concern after VS is early onset neonatal sepsis (EOS) with Escherichia coli or GBS.

David A. Eschenbach, MD, from the Department of Obstetrics and Gynecology, University of Washington, Seattle raised several questions in his accompanying commentary that need to be addressed before VS becomes a routine practice.

His major concern was our current inability to identify that which vaginal bacteria/gut bacteria will produce potential benefit while minimizing the harm. Choosing between ‘harmful’ and ‘helpful’ bacteria is expensive procedure and it is here the cost -benefit analysis comes in.

"We simply are too far behind in knowledge to start this practice without heeding the Society's recommendations," he concluded.

The authors suggest that clinicians whose patients want to adopt the practice should be told about the risk involved and other ways of that have an effect on neonatal colonization, including early skin-to-skin contact, breast-feeding, and diet during pregnancy.

Access Abstract, Full Text 

External Cephalic Version for breech presenting fetus does not hike the cesarean section rates.

Women who had a successful External Cephalic Version (ECV) are not at increased risk of cesarean section as compared to women who had Spontaneous Cephalic Version (SCV) says the results of a study published ahead of print on August 2, 2017 in Journal of Obstetrics and Gynecology Canada. 

  

This is first study conducted to compare the outcome between spontaneous and external version in breech presenting fetuses.

It is estimated that term fetal malpresentation occurs in about 3% of pregnancies—and is a common indication for cesarean. External Cephalic version is an important tool to reduce the rate of cesarean births in breech presentation.

This secondary analysis of Early External Cephalic Version Trial data identified 931 women who had breech presenting fetuses between 34-36 weeks of pregnancy, but cephalic presentation at term.

Out of these study subjects, 557 women have undergone successful ECV while in 374 women the fetus reverted spontaneously.

Obstetric outcomes between the two groups were comparable: 96 women in ECV arm had Cesarean section as compared to 76 in the SCV group. (adjusted OR [aOR] 0.89; 95% CI 0.63-1.26); 393 had vaginal delivery in ECV arm vs 268 in SCV arm. (aOR 0.92; 95% CI 0.68-1.24).

Women in the ECV had 45% increased odds of undergoing instrumental intervention as compared to women in SCV group. (aOR 1.55; 95% CI 0.96-2.50).

Multiparous women with ECV were half as likely to require a cesarean section as compared to women with spontaneous version or no version at all. ( aOR 0.45; 95% CI 0.26-0.80).

The authors concluded, “Women with a cephalic-presenting fetus at birth as a result of successful ECV are not at greater risk of obstetrical interventions at birth when compared with women with fetuses who spontaneously turn to a cephalic presentation in the third trimester.”

Media Courtesy: American Association of Family Physicians 

Use of Monocryl for subcutaneous skin closure minimizes wound complications in cesarean sections

courtesy: https://www.esutures.com/product/images/full/IMG-6441.jpg

courtesy:http://media.xn--benersttning-lcb.se/2012/05/vicryl1.jpg

Subcuticular skin closure after cesarean delivery with poliglecaprone 25 suture IMONOCRYL) decreases the rate of cesarean wound complications by 39% as compared with polyglactin 910 suture (Coated VICRYL) says the result of randomized control trial published ahead of print in Journal Obstetrics and Gynecology.

Monocryl is monofilament, absorbable suture which dissolves slowly and loses strength while Vicryl is braided, absorbable suture that dissolves quickly but maintain strengths.

The type of skin suture and rate of wound infection after cesarean section has not been widely studied. In this study, the researchers compared the two sutures in term of subsequent wound complication rates (SSI, hematoma, seroma, wound separation) after a cesarean section through a Pfannenstiel skin incision followed by subcuticular closure.

This single center RCT conducted at Montefiore Medical Center, New York recruited about 520 women over a course of 1.25 years. About 263 women were randomized to receive the wound closure with monocryl while in 209 women the wound was closed with vicryl.

The groups were similar in terms of demographics, medical comorbidities and perioperative characteristics. They were followed up for a period of 30 days for wound gaping of > 1 cm in length, hematoma or seroma and surgical site infections as per Centers for Disease Control and Prevention criteria’s.

Use of monocryl was associated with significant less infection as compared to vicryl (8.8% compared with 14.4% (relative risk 0.61, 95% CI 0.37-0.99; P=.04).

The researchers concluded that,” Closure of the skin after cesarean delivery with poliglecaprone 25 suture decreases the rate of wound complications compared with polyglactin 910 suture.”

The study was also presented at the 37th annual meeting of Society for Maternal-Fetal Medicine, January 23-28 Las Vegas.

Vaginal cleaning before cesarean delivery significantly reduces infection: A Systematic Review and Meta-analysis.

A simple and inexpensive intervention of vaginal cleaning with an antiseptic solution before cesarean delivery brings down the rate of endometritis note the results of a Systematic Review and Meta-analysis published August 4 in Journal of Obstetrics and Gynecology.

The effect was significantly more in patients in labor or with ruptured membranes at the time of the procedure.

Claudia Caissutti, MD, from the Department of Experimental Clinical and Medical Science, Clinic of Obstetrics and Gynecology, University of Udine, Italy, and colleagues searched MEDLINE, Ovid, EMBASE, Scopus, Clinicaltrials.gov, and Cochrane Library from their inception to January 2017.

They included randomized trials comparing vaginal cleaning with any antiseptic against placebo or no cleaning at all. The final data for review came from 16 RCTs, with a total of 4,837 women in whom vaginal preparation was done immediately before the start of cesarean section.

Most of the trials used povidone–iodine (n = 11) as the cleaning agent, while rest used chlorhexidine diacetate solution n = 3) , metronidazole vaginal gel prep ( n =1), and Cetrimide ( n =1) .

The observed incidence of endometritis in women who received preoperative vaginal cleansing was nearly 50% less as compared to women with placebo or no cleaning (4.5% vs 8.7%; relative risk [RR], 0.52; 95% confidence interval [CI], 0.37 - 0.72). These group also had significantly lower incidence of postoperative fever (9.4% compared with 14.9%; RR, 0.65).

No significant difference was observed in postoperative wound infection among the groups.

In a separate planned subgroup analysis, the observed difference in rates of endometritis was only seen in women who were in active labor and for patients with rupture of membranes. Four trials stratified the data according to women were in labor or not and three trials looked into women with and without ruptured membranes.

When the data was stratified according to type of cleaning agent and prophylactic antibiotics, the results were in according to the overall analysis.

Women who received prophylactic antibiotics had a 67% decrease in endometritis incidence. The authors opined, "Surgical prophylaxis with intravenous antibiotics before cesarean delivery has been clearly demonstrated as beneficial in reducing postoperative infection morbidity, Thus, it is the standard of care and these findings could translate to current practice."

The results of study have confirmed the findings of earlier Cochrane database systematic review published in 2013.

Data is needed to assess the effect of vaginal cleaning in women not in labor and without ruptured membranes.

The authors concluded that, “Vaginal cleansing immediately before cesarean delivery in women in labor and in women with ruptured membranes reduces the risk of postoperative endometritis. We recommend preoperative vaginal preparation before cesarean delivery in these women with sponge stick preparation of povidone-iodine 10% for at least 30 seconds.”

A minimal invasive approach in management of symptomatic post–cesarean section isthmocele: a video case report.

courtesy: researchgate.net 

The cesarean section scar defect, also known as an isthmocele, is a reservoir-like pouch defect on the anterior wall of the uterus, located at the site of a previous cesarean delivery scar. It exact incidence is unknown because of scarcity of data about the condition.

It is commonly found on ultrasound examination (24%-88%). It could range from just thinning of the uterine myometrium to large defects leading to complete absence of myometrium.

It could present with abnormal uterine bleeding(AUB), pelvic pain and infertility in post-operative period. Several obstetric complications such as scar dehiscence, placenta accreta, and ectopic scar pregnancy are increasingly reported along with rising cesarean rates.

It is commonly repaired by vaginal surgery, operative hysteroscopic, combined laparoscopic-vaginal, or minimal invasive laparoscopic approach.  In absence of randomized studies, the efficacy of these approaches or superiority of one over another is not known.

A review of data showed that hysteroscopy is able to correct the scar defect but does not increase the uterine wall thickness, whereas laparoscopy is able to increase the uterine wall thickness.  

This video case report by Aimi G. et al. published in June issue of Fertility and Sterility describes a minimal invasive laparoscopic approach for correcting the scar defect.

A 36-year-old woman with history of 2 previous section presented with persistent postmenstrual spotting and chronic pelvic pain. A transvaginal sonography identified a 20.0 × 15.6 mm defect at the place of previous scar with a 2.6 mm remaining myometrial thickness over the defect.

In this case Isthmocele excision and myometrial repair was performed laparoscopically. After mobilization of the bladder, the isthmocele was identified by transrectal intraoperative sonography. Once identified, the isthmocele pouch was excised and contents drained. The cesarean section scar is excised with the help of cold scissors till healthy myometrium is visible. The defect was closed with a single layer of interrupted 2-0 Vycril sutures. A Hegar dilator was placed in cervix to maintain the continuity of uterus with the cervix.  Finally, visceral peritoneum was closed. Total operative time was 70 minutes.

Post operatively the patient made an uneventful recovery and was discharged home on 2 post-op day. A follow up sonography at 40 days after surgery with transvaginal and transabdominal route showed a complete repair of defect. At 3 months follow-up, postmenstrual spotting and chronic pelvic pain also resolved completely.

The authors concluded that, a laparoscopic approach is procedure of choice when repairing large isthmocele with severe myometrial thinning.  

Here is the video of the surgery

Midpelvic forceps and vacuum deliveries are more traumatic than cesarean section

Taking a decision in favor of cesarean section is considerably safer than attempting midpelvic operative vaginal delivery in terms of reducing severe birth trauma and obstetric trauma reports a study finding published June 5, 2017 in Canadian Medical Association Journal (CMAJ).

Midpelvic arrest in second stage of labor and operative interventions are a test of obstetrician’s skills and experience. In recent year, there has been a shift towards cesarean section, increasing the rates of cesarean section worldwide.

In 2014, a consensus statement by the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine supported operative vaginal delivery over cesarean delivery to bring down the cesarean rate and improve maternal and neonatal outcome. Although, ACOG statement was not specific for midpelvic operative vaginal delivery but included it in more general sense.

Studies on the risk and benefits of these two procedures are lacking and not stratified by the station of fetal head in pelvis, which is an important decisive factor for maternal and fetal outcome.

The researcher team involved in the current study looked at data across a span of 10 years including 187,234 singleton births which included all mid pelvic live or stillbirths via forceps or vacuum and C-section deliveries between 37 and 41 weeks of gestation that resulted in a singleton live birth or stillbirth.

In all the cases, the head was engaged and the leading point of fetal head was as above station +2 cm but below 0 station.

It was seen that infants born by midpelvic operative vaginal delivery in women having dystocia, with prolonged second stage of labor has 81% more chances of severe morbidity and mortality as compared to when they were delivered by cesarean section. It included higher rates of birth asphyxia, meconium aspiration syndrome and intracranial hemorrhage.

Forceps delivery and vacuum delivery exposed the neonate to nearly 5 times the risk of birth trauma, but the rates were considerably high (9.5 times ) in sequential application.

Rates of obstetric trauma were also quite higher using forceps (5 times the risk), vacuum (2.7 times the risk) and sequential instruments (3 times the risk) as compared to delivery by cesarean section. In addition, significant more third and fourth degree perineal tear occurred in women who had midpelvic forceps (19%), midpelvic vacuum (12%), and 20% among women who delivered using a combination of midpelvic vacuum and forceps.

Rates of maternal morbidity and mortality did not differ much in the two groups, but midpelvic forceps and vacuum use was associated with significantly higher rates of post-partum hemorrhage.

In that subset of women in which the midpelvic forceps application was done for fetal distress, the composite maternal morbidity and mortality was 48% lower in vacuum group, but nearly 3 times higher rates of obstetric trauma and higher rates of PPH was observed.

The association between midpelvic operative vaginal delivery and composite severe perinatal morbidity and mortality were significantly stronger in those women who had dystocia but not prolonged second stage of labor. Similar outcomes were seen in women who had fetal distress but not prolonged second stage of labor. Midpelvic forceps and vacuum deliveries are more traumatic than cesarean section.

The study showed that encouraging higher rates of operative vaginal delivery to reduce the rate of cesarean delivery comes at the cost of increase in severe perinatal and maternal morbidity and mortality, especially neonatal birth trauma, severe postpartum hemorrhage and obstetric trauma.

"It is important to understand that similar to cesarean deliveries, midpelvic forceps and vacuum deliveries are invasive procedures with their own risks -- risks that we have now quantified and that should be communicated to women who may encounter them, especially when the risk is as high as one in five," says lead author, Giulia Muraca, a doctoral researcher at the School of Population and Public Health, University of British Columbia (UBC). "Women who are delivered by midpelvic forceps or midpelvic vacuum should be afforded the same standard of informed consent as women who consent to cesarean delivery. Ideally, this should take place prior to labour when women are considering their birth plans."

The full text of the journal article can be accessed here.

A C-section rate of approximately 19 percent seems to be ideal for the health of both women and newborns.

All generalization are false including the recent statement by India’s Union women and Child Development Minister about bringing down the C-section rate to 10%. The minister recently asked the health minister to issue a mandate to all the hospitals displaying the C-section rates. She took this action in response to a Change.org petition against hospitals and doctors profiteering by pushing women towards surgical deliveries instead of natural vaginal birth.

The petition has received 1.3 lakh signatures so far, a number that is not much looking at the total population of the country.

"We have entered into an area, very sorry to say, in the last 20 years, where doctors care more about money than about patients' health. We would like the hospitals to display data on how many cesarean section deliveries they have done," said the Minister.

"The normal Cesarean delivery rate in a country would not be more than 10 percent, because it is usually done as a last resort. In this country, it is extremely high because it brings the doctor more money," she further added.

Well, you cannot generalize and mandate a uniform C-section rate for all the hospitals in all the states across country. It all depends upon the healthcare infrastructure, geographical location, access to prenatal care and surgical expertise and the needs of individual woman.

Pointing a finger at the obstetrician and asking her to stop doing C-section is like treating a symptom instead of going into the root of problem. A hospital can have a C-section rate as high as 70% if it a tertiary care high risk hospital.

A review of trends around the world shows that currently about 18.6% of births take place by Cesarean section.  The rates vary from as low as 2% to as high as 50%. In U.S.A, about 1.3 million babies are delivered by Cesarean every year, which roughly equals to every 1 in every 3 children born in US(33%).

The WHO recommends that the ‘ideal’ rate of C-section for optimum maternal and fetal outcome should be around 10-15%.This was  based on the  observation that some countries with the lowest perinatal mortality rates had cesarean delivery rates that were less than 10 per 100 live births. The study also has insufficient data and relied upon average C-section rate from multiple previous year.

However, new study recently examined the relationship between C-section rates and maternal and neonatal mortality in 194 countries around the globe concluded that C-section rate up to 19 percent is associated with lower maternal and neonatal outcome. C-section delivery rates above 19 percent showed no further improvement in maternal and neonatal mortality rates.[1] Researchers used mathematical modeling to impute C-section rates for countries where data was missing and to account for other contributing factors such as health expenditure.

Latin America and the Caribbean region has the highest CS rates (40.5%) while some countries in Africa have the lowest (7%). Brazil occupies the top slot with a rate that exceeds 50% (55.6%).

The  study  found out that in countries with very low C-section rate, people did not have access to basic healthcare and surgical facilities resulting in high maternal and neonatal morbidity and mortality. In fact, a study by WHO concluded that in countries with C-section rate < 10%, there is an additional need for 0.8 – 3.2 million CS every year to improve maternal and neonatal mortality and morbidity. [2]

Dr. Thomas Weiser, an assistant professor of surgery at Stanford School of Medicine says “As countries increase the number of C-sections they provide, mortality goes down— but only to a point, when the C-section rate tops 19 percent, benefits for maternal and infant health plateau.

Increasing C-section rates in recent years are due to modern technology of continuous FHS monitoring in labor room which is a two-way sword, practicing defensive medicine, rise in on-demand C-sections beside other maternal and perinatal factors that come into play.

According to ACOG " Safe reduction of the rate of primary cesarean deliveries, is the only way to  lower  the repeat  cesarean section rate and total cesarean rate."

To conclude, it is impossible to form a policy regarding relationship between delivery methods and birth outcomes. Each case must be decided taking into consideration social, medical, obstetrical and healthcare factors.

Our goal as an obstetrician should be to see that every woman who needs a C-section should get one and every woman who does not need a C-section should not get one.

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[1] http://jamanetwork.com/journals/jama/fullarticle/2473490

[2] http://www.who.int/healthsystems/topics/financing/healthreport/30C-sectioncosts.pdf

Similar results obtained after use of Glue or subcutaneous Monocryl for cesarean wound closure -- News from SMFM 2017, Las Vegas.

Skin glue: Ethicon.com 

Monocryl 

Use of Glue(Dermabond ) or subcutaneous  Monocryl results in same outcome in terms of safety, healing,  wound complications or cosmetic appearance. The choice of using one over another depends on surgeons’ choice and patient’s preference.

The study will be presented at the 37th  annual meeting of Society for Maternal-Fetal Medicine , January 23-28 , Las Vegas. Cesarean sections rates are on rise, it is the most common surgery performed in U.S. hospitals. Roughly, every one in three baby is born by Cesarean Section. In-spite this, there is still no consensus or evidence about best method for skin closure in Cesarean section.

Yari Daykan and his colleagues from Dept. of Obstetrics and Gynecology at Meir Medical Center in Kfar Saba and the Sackler School of Medicine in Tel Aviv conducted a RCT, in which women undergoing a scheduled Cesarean section were randomized to either have the wound glued using Dermabond or wound closed by using subcuticular Monocryl. [1]

The scars were assessed after 2 months by using Patient and Observer Scar Assessment Scale (POSAS) scores.   The POSAS is a comprehensive scale that is designed for the evaluation of all types of scars by professionals and patients.[2]

The scar site was also evaluated at 1 month for infection, discharge, redness or dehiscence as secondary outcome of the study.

Both the study groups were comparable in terms of indications for C-section, length of surgery, BMI and other demographics.

It was seen that at 8 weeks, scars were comparable in terms of patient score, physician score and subcutaneous thickness, wound infection or wound dehiscence.

Researchers concluded that both methods are safe, equally effective and the choice depends on surgeon and patient's preferences.

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[1] http://www.smfmnewsroom.org/2017/01/skin-closure-options-for-cesarean-delivery-glue-versus-subcuticular-sutures/#more-1584

[2] http://www.posas.org/

Use of Monocryl suture minimizes wound complications in cesarean sections - News from SMFM 2017, Las Vegas.

courtesy: https://www.esutures.com/product/images/full/IMG-6441.jpg

courtesy:http://media.xn--benersttning-lcb.se/2012/05/vicryl1.jpg

Use of poliglecaprone 25 (Monocryl) subcutaneous suture for abdominal wound closure in Cesarean Section reduces the wound complication rate by nearly 50 % as compared to use of polyglactin 910 (coated Vicryl) according to a study that will be presented at the 37th  annual meeting of Society for Maternal-Fetal Medicine , January 23-28 , Las Vegas.[i]

Monocryl is monofilament, absorbable suture which dissolves slowly and loses strength while Vicryl is braided, absorbable suture  that dissolves quickly but maintain strengths.

The first ever Randomized control trial was conducted by Dr. Arin Buresch and her colleagues from Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY.[ii]

Over a course of little more than a year, 550 patients undergoing non-emergency cesarean section were recruited and randomly allocated to either receive poliglecaprone(275() or 275 receiving polyglactin for subcutaneous wound closure of the Pfannenstiel abdominal incision.

The groups were comparable demographically. These patients were evaluated and compared at 30 days for wound gaping of > 1 cm in length, hematoma or seroma and surgical site infections as per Centers for Disease Control and Prevention criteria’s.

8.8% patient had wound complication in poliglecaprone 25 (Monocryl) group as opposed to 14.4% patient in Vicryl group (p=.04).

Dr. Arin Buresch concluded “The difference in wound complications may occur due to the braiding in vicryl suture which conceivably allows bacterial growth in small nooks and crevices. In the future, we hope our study will help guide the decision-making on which suture type is used when closing the skin in cesarean births.”

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[i] https://www.smfm.org/meetings/2-37th-annual-pregnancy-meeting/registration

[ii] http://www.smfmnewsroom.org/2017/01/comparing-skin-closure-options-for-cesarean-delivery-to-determine-which-method-causes-the-least-wound-complications/#more-1609