PHARMAC seminar: Pregnancy complications 2 of 2, reducing medical interventions in childbirth

my name is Michelle wise and I'm a senior lecturer in the department of obstetrics and gynecology at the University of Auckland and I'm also an obstetrician at Auckland DHB so thank you for inviting me to speak about how to reduce interventions in childbirth I have spent the last nine years looking at this in different ways and I thought I would cover a few different interventions the first is induction of labour we know that one in four women in New Zealand had an induction of labour last year and that's on the rise the other intervention that's very common and very timely at the moment to speak about is the Sirians section and we know that one in four women in New Zealand had a cesarean section last year and that's also on the rise not just in New Zealand it's a global phenomenon and about half of those are elective planned cesareans and the other half our emergency cesarean ZAR unplanned in labour so I thought I would just talk through a few ways of reducing both that has some evidence in the literature about how to do that effectively so with respect to induction of labour I think most of us know by now that if we offer a woman to sweep the membranes or a membrane sweep around 38 39 40 weeks it's likely to reduce her chances of needing a formal induction of labour if she goes overdue she goes at least one week past her due date so that is something that we would routinely offer and we would recommend that women are routinely offered that and I guess the next question is what about the relationship between induction of labour and cesarean section so if you look at your own data most people would say when I induce somebody I tell her that there's an increased chance of her having a cesarean because of the induction so that's one of the problems with I guess observational data is that there's something about the women who we induce which is different from the women who go into labor spontaneously and if you compare those two groups it will seem that if you induce somebody they will have they are more likely to have a cesarean however if you actually take the same group of women say women with high blood pressure or women who ruptured their membranes for example and you compare women having an induction versus women managed expectantly so just waiting for them to spontaneous labor if you actually research those two groups and compare them properly you will always see that they either the induction either reduces their cesarean section rate or at the very least it doesn't increase it so we do notice this discrepancy and I guess it just takes that bit of extra time to understand that so that we can stop saying that an induction leads to a cesarean and in fact re-frame how we counsel women about induction and be quite honest in that for some reasons for induction of Labor it actually can reduce this area and the Americans have gone as far as saying that once you're 41 weeks once you're one week over your due date that actually the reason to induce at that point is not only to reduce the risk of stillbirth but also to reduce your risk of cesarean so ironically one of my key messages today is that offering an induction of Labor can actually reduce your cesarean section rate that was also found in the recent study that came out last year also an American study where they recruited women at 39 weeks gestation and offered them an induction of labor with no medical reason not that I'm advocating that we do that here but I think we can't ignore their finding which was the significant finding that their cesarean section rate was reduced in the women who had an induction so let's move on to cesarean section we have half of our women having an emergency cesarean and labor and the other half having a planned cesarean section so we have tried to examine in New Zealand why the cesarean rate is increasing in my hospital it's actually up to 40% sometimes some months so it's it's not an insignificant intervention and that's what everyone is concerned about at the moment so if I said to the average person on the street why do you think we're having hiya caesareans they would point to that to posh to push phenomenon of women are just requesting it that doctors just find it convenient to schedule it in at nine o'clock on a Wednesday however we don't find that to be the case in New Zealand there are countries where that is the case but not here then you look at how the demographics of women are changing so we recognize that women are becoming more overweight and there's more obesity and pregnancy we also see women being older at the time of their first birth and those trends are definitely associated that so those trends are definitely associated with cesarean section but I don't think that's the whole picture I think there's such variation across the different district health boards around New Zealand and variations amongst providers within one hospital that we have to look at something beyond the women themselves and that's us that's the obstetricians and also the hospital how is the system set up to promote normal vaginal birth I think that's where we can find things that we can change in order to promote normal births so for example does your hospital have a pathway to offer women an external colic version if your baby is presenting breech at term does your hospital have a pathway to be counseled about a vaginal birth after caesarean section if they've had a previous cesarean section so our hospital has both of these and if it's not easy to refer and there's not clinicians who offer these procedures in a safe way then it's not for the women to choose them it's actually us as obstetricians or as hospitals limiting access to these and amazingly you only need to offer three women with reach presentation and ecv in order to prevent one cesarean and you only need to offer two women a VBAC in order to prevent one cesarean so these are not high cost things that a DHB has to find budget for these are things that we just need to be offering routinely within our day to day practice let's talk about unplanned cesarean section and labor the most common cause would be failure to progress or a rest of descent or a rest of dilation in labor I think we see a lot of early intervention when we feel that maybe we could have waited a little bit longer the Americans are leading the way and this is well there are recent policy or guideline around labor is that we certainly can safely let women wait longer during the first stage of labor in order to see if they will go on and have vaginal births so they're actually saying I think at least six hours of good contractions from six centimeters to get to fully dilated which is longer than we usually let women labor in the second stage they've added an extra hour to each part of that so for example if you were a first-time mum with an epidural we would probably call it at three hours the Americans are recommending for with multiple would probably call it at two hours they're recommending three so there's an element of just having more patients in labor with respect to malposition so a lot of babies are presenting occiput posterior and that's a key reason for why the labor isn't progressing as quickly as we expect I try to teach my registrar's when I'm on call with them to learn the maneuver of taking your hand and physically moving the baby from an Oxford posterior position to the normal occiput anterior position and the best time to do that seems to be at the beginning of the pushing part of labor so the number of women with an Opie position who would need to have that performed to prevent one caesarean section is for again no cost to this no budget to this we just need a whole bunch of clinicians who are trained and skilled to be able to perform this safely and be able to offer that routinely in our day to day practice so in summary how do we make these changes I think you need to find local champions who are respected in your setting in order to figure out to prioritize which of these you would want to implement in your setting see what's feasible see what your audience what your clinicians your midwives want to change and figure out how to actually change something because there's a lot we can do to reduce intervention and childbirth that we can do safely and not put any mothers or babies at risk so that's my message to New Zealand thank you

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