The Standardized Cesarean Section

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Back in June 2019, we did an episode on The Evidence-Based Cesarean Section. Back then, we talked a bit about incision types, infection practices, and some in surgical technique. In the November 2020 Green Journal, two of our podcast guests - Dr. Josh Dalhke and Dr. Jeff Sperling, in addition to their coauthors - make the case for standardizing cesarean delivery technique.

The text is definitely worth a read, as it’s a succinct review of the most current literature. Some of the practices you may employ already; others you may be surprised by! We talk a bit more with these two authors about the recommendations, what was most surprising, and what things are to come.

This checklist comes from the article, and is definitely worth discussing at your institutions. We’ll let the podcast speak for itself otherwise.

Dahlke et. al, O&G, Nov. 2020 — hyperlink above

Preventing the Primary Cesarean, Part II

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We’re re-visiting an old episode of ours on preventing the primary cesarean, with some more and differently focused information. We heard some great feedback from our last episode so we’re incorporating some of that here! This time around, we want to focus some more on how to promote normal labor and physiological birth! 

Let’s start off with talking about shared decision-making. This is a framework for taking situations with various individuals with different sets of knowledge, belief systems, and priorities and coming together to form a mutually satisfying plan to get everyone where they want to go. ACOG CO 587 reviews this in part, stating SDM can increase patient engagement and reduce risk with resultant improved outcomes, satisfaction, and treatment adherence.

Shared decision making can take the form of a variety of tools in prenatal care and on the labor floor:

  1. Partograms - allowing patients to see where they are in their labor course compared to others.

  2. Birth plans - providers and patients can come together early in their course of the pregnancy to identify patient goals and desires for their labor. Also allows recognition of some goals/desires may not be feasible due to the patient’s individual risk factors, pregnancy complications, etc. 

  3. Patient education resources - we love www.birthtools.org, but there’s a number that exist (and some probably specific to your institution) that can help set expectations for the birthing process.

In identifying a patient’s desires in labor, one of the most common questions has to do with analgesia. Prental care is an excellent time to discuss both pharmacologic and non-pharmacologic options for coping. While epidurals are common in the USA, continuous labor support is another option for coping and also has been shown to reduce cesarean rates in trials. It can take on many forms, and be administered by anyone a laboring person trusts:

  1. Physical support - positioning, use of touch, application of cold and heat and control of environment.

  2. Emotional support - being present with the laboring woman, use of distraction.

  3. Instructional/informational support - assistance with relaxation and breathing, using effective communication techniques.

  4. Advocacy labor support - building trust, providing security and giving laboring women control.

Nutrition and hydration during labor is another common sticking point. It is very common for nutritional deprivation at NPO or clear liquid diets to occur in labor. This is for ostensibly, a good reason: fear of aspiration of stomach contents in the event for need for general anesthesia, or for vomiting due to decreased GI motility. However, a Cochrane review demonstrated no statistical difference in maternal or newborn outcomes related to type of birth or Apgar scores at five minutes. Nutritional deprivation provided no benefit or harm, and so evidence does not support nutritional deprivation. This review further stated that nutritional deprivation can cause maternal distress, unbalanced nutritional status, and increased pain in labor.

What about our original fear of aspiration? Current studies don’t show that nutritional deprivation ensure low stomach residue or acidity. When combined with decreased use of general anesthesia in modern obstetrics, concern for aspiration risk does not provide sound basis for implementation of withholding food or fluid from women in labor.

Next, let’s review the benefits of collaborative care models:

Labor is a team sport that contains the woman, her support person/people, her nurse, and provider (midwife/obstetrician/family practitioner). It shares the workload for this 24 hour in house care, providing a variety of perspectives on the case, in a mutually respectful environment. Now certainly, there are challenges to what sounds so harmonious: interdisciplinary mistrust, inconsistent communication, variable skill sets, scheduling logistics, hospital structure, to name a few. However, we know that this is evidence based! Studies where there have been 24 hour laborists and strip review and collaboration have led to significant decrease in NTSV rate. Why does it work? Well, it likely promotes consideration of alternative options, with experts of multiple perspectives and skill level.

Lastly, systems-based and structural design challenges may also contribute to cesarean. This work is nascent, but check out the awesome work by the folks at Ariadne Labs’ Delivery Decisions Initiative to learn more.

Preventing the Primary Cesarean Section

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This mega-episode was inspired by a two-part Grand Rounds series written by our PGY-4 Brown OBGYN class. We’ll dive into some of the history of cesarean, the challenges and data with respect to deciding on cesarean delivery, and current evidence-based strategies to reduce the risk of primary cesarean in low-risk women.

Cesarean sections have been around for a long time, the very first of which was documented around 1750 BC. However, surgery was originally performed only on a dead or dying mom with the hope of saving the child, or so the infant could be buried separately from mom per religious edicts. And then for the first 3000 years of cesarean, the mortality rate for women was… 100%. And it stayed this way until the mid-18th century! Anesthesia was introduced in 1846 with the discovery of ether, and as the 19th century progressed sutures and antibiotics became live-saving measures that allowed women to survive cesarean.

With the urbanization of the western world through this time period, more women began to deliver in hospitals as cesarean became a viable alternative, rather than delivering at home. In the USA, by 1955, 99% of births occurred in hospital. The rate of cesarean in the US stayed low until the 1970s, which coincided with the introduction of electronic fetal monitoring. A cesarean rate of <10% prior to EFM increased to 17% by 1980, 25% by 1988, and 31.9% in 2016.

Now with the increased use of cesarean, we should expect some benefit to it. And there certainly are! There are life-saving implications for both mother and baby, and when needed, the surgery is absolutely a necessary tool for an obstetrician. That said, cesarean does not come without its own risks. For mothers, cesarean is associated with more risk of bleeding, infection, thrombosis, increased pain, worse satisfaction with the birth experience, and risks to future pregnancy such as increased risk of repeat cesarean and risk of placenta accreta spectrum (PAS) disorders. For infants, cesarean carries slightly higher risks of respiratory difficulty during the transition, breastfeeding difficulty, and intracranial hemorrhage (if laboring prior to cesarean; rates of IVH between SVD and non-laboring cesarean are about equal).

One of the criticisms of cesarean delivery are that its use does not seem standardized. There is a high level of variation between countries, and in the US, there is high variation between states, cities, and even hospitals in the same city! As an example, here are the nulliparous term singleton vertex (NTSV) cesarean rates between US states for 2016:

While no rate of cesarean has proven to be the “optimal” or “ideal” amount, some observational data may provide some clues. The WHO has compared countries’ rates of cesarean with respect to both maternal and neonatal mortality, and also attempted to normalize these countries’ resources by demonstrating their relative wealth. For both maternal and neonatal mortality benefit, the rate seems to sit around 20% — you can see these graphs from the WHO below.

In order to safely choose our use of cesarean delivery, there are evidence-based guidelines to recall. The ACOG/SMFM Obstetric Care Consensus #1 on safe prevention of the primary cesarean delivery is one such tool. In this document, there are three important thresholds to remember. This is nicely outlined in checklist format by the folks at the California Maternal Health Quality Collaborative (CMQCC):

The use of partographs also has some limited data to support their use to help monitor labor progress. While one version over another hasn’t been shown to be superior, in a before-and-after study, the presence of their use helped to reduce cesarean rates, likely because of the closer attention to normal labor progress that was effected by them.

We additionally came across some other exciting ways to try to help reduce cesarean rates or examine cesarean utilization. Some of these things include:

  • Open Access to Cesarean Data 

    • Beth Israel Deaconess’ NTSV rate was a target of a large, stepwise quality project, with a decrease from 35% to 21% over 8 years. However, their single best year of improvement was from 2014-2015, when cesarean data was fully unmasked and shared amongst all physicians who practiced there. Similar findings have been demonstrated in the CMQCC hospitals. Simply put, no one likes to be an outlier amongst their peers!

  • Cesarean Audit Committees

    • These committees meet to review all unplanned cesarean delivery, prepare and interpret data, and look for opportunities for improvement in terms of physician/midwife, nurse, or patient education.

      • These committees offer the advantage of individualized feedback for improvement of practice based on more nuanced classifications that adjust for risk in population than just “NTSV.” 

      • Meta-analyses have demonstrated reduced cesarean rates stemming from a cesarean audit in concert with multifaceted programs to reduce cesarean delivery.

  • Utilizing Labor Dystocia Checklists

    • Several quality collaborative groups use checklists, such as the one from CMQCC above; these are evidence-based, objective, and don’t call into question a provider’s interpretation of labor progress. 

      • Overall decrease PCS by preventing premature C/S for indications of labor dystocia. 

      • Some institutions have gone as far as to institute “double doctor” reviews for cesarean for labor arrest, allowing for a second opinion, particularly regarding the feasibility of operative vaginal delivery.

  • Improved, transparent team communication 

    • Improved communication between physician or midwife, bedside nurse, patient, and support persons allows for appropriate expectations for labor or induction, and allows all members of the team to “be on the same page.”

    • At our institution, we are trialing using a whiteboard to document the partograph in the labor room; this allows the patient to compare patient to where they are on partograph compared to “standard labor progress.”

Have a technique you’re using at your hospital to help reduce primary cesarean delivery? Share it with us! We’d love to hear from you via email or the comments section of the website.

Trial of Labor after Cesarean (TOLAC)

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In 2016, the US cesarean delivery rate was 31.9%. With ever increasing volumes of cesarean delivery, TOLAC has become a popular option for patients desiring vaginal delivery. On today’s episode, we examine TOLAC and share some counseling pointers in thinking about your patient. ACOG PB 205 is the requisite reading for the topic.

While there are no RCTs comparing TOLAC to planned cesarean, the relative benefits are easy to see: there is less recovery time, the patient avoids major surgery, and the potential sequelae of complications from major surgery — worsened bleeding, more opportunity for infection, more risk of complications requiring additional procedures. However, TOLAC is not without risk. We primarily counsel with respect to uterine rupture. Evaluations of “rupture” though have varied in the literature; it’s important to keep a discerning eye, as what is classified as rupture in some series is very different than what is in others. ACOG suggests the rate of uterine rupture in a patient with one low transverse cesarean delivery is around 0.5 - 0.9 %. Otherwise, maternal risks are fairly equal. Neonatal risks are also considered fairly equal, though with some increased risk associated with TOLAC.

ACOG PB 205

ACOG PB 205

We can think about patients who should be counseled against TOLAC:

  • Those at high risk of uterine rupture: ie. those with classic uterine incision, T-incision, prior uterine rupture, or extensive prior uterine fundal surgery like a myomectomy.

  • Women who are not otherwise candidates to have vaginal deliveries: ie. previa.

  • Women who desire homebirth: While ACOG does not definitely say that you cannot TOLAC in this instance, if you don’t access to emergency cesarean delivery, it is recommended that these patients have a discussion regarding the hospitals resources and possibly referral to a hospital that does have access to emergency cesarean delivery.

We can also consider patients for whom there may be a question of whether TOLAC is appropriate:

  • Low vertical incision? 

    1. Few studies, but those that have looked at them have shown similar rates of vaginal deliveries as low transverse. Can consider TOLAC!

  • Twins? 

    1. Studies show similar rates of successful VBAC in twins as in singleton gestations 

  • Obesity 

    1. Unfortunately, higher BMI seems to have an inverse relationship with success of VBAC. 85% of normal weight women achieve VBAC while only 65% of morbidly obese women do. However, morbidly obese women also can have more complications with an elective repeat cesarean, so counseling should be individualized

  • Induction and augmentation of labor 

    1. Mechanical dilation can be used - ie. cervical foley 

    2. Misoprostol has been shown to have increased risk of uterine rupture, so should not be used in term patients who have had c/s or other major uterine surgery for induction 

    3. However, in women undergoing second trimester labor inductions (ie. for missed abortion, induction of labor for stillbirths), use of prostaglandins have shown similar results in women who have had scars on their uterus and those without; so these women can still have prostaglandins, especially because no fetal considerations 

  • What if they’ve had a uterine rupture? 

    • If the site of rupture or dehiscence is in the lower part of the uterus, their risk of uterine rupture in labor is 6%. If it is in the upper segment of the uterus, the rate of dehiscence in labor is up to 32%. While there is no high quality data to guide this, recommendations are generally for subsequent pregnancies to be delivered by cesarean between 36-37 weeks.

Counseling should be individualized, and the MFMU has excellent calculators to help guide you and your patients to a decision about TOLAC:

(not in labor) https://mfmunetwork.bsc.gwu.edu/PublicBSC/MFMU/VGBirthCalc/vagbirth.html

(at admission) https://mfmunetwork.bsc.gwu.edu/PublicBSC/MFMU/VGBirthCalc/vagbrth2.html

The Evidence-Based Cesarean Section

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Today we go through the steps of cesarean delivery from an evidence basis. We hope this helps everyone from the new interns starting up in just a few weeks to senior residents thinking more about their technique and teaching. The essential article on this from AJOG in 2013 can be found here. However, there have been a number of other articles and talks since, including one regularly given at the ACOG Annual Meeting (check out the 2017 edition by Dr. Strand here), that you all may be aware of and that we encourage you to check out.

One of the more challenging things to relay in the podcast is incisional technique, particularly comparing the traditional Pfannenstiel technique to newer techniques such as Joel-Cohen or Misgav-Ladach. We summarize the differences in those techniques here:

(C) CREOGs Over Coffee (2019)

What’s the difference in these skin incisions?

  • Pfannenstiel: traditionally taught as a curved incision made two finger breadths above the symphysis pubis, with the mid portion of the incision generally within the superior-most aspect of the pubic hair.

  • Joel-Cohen: a straight incision made 3cm below the imaginary line that connects the ASIS on either side. Ultimately this is slightly higher than the Pfannenstiel.

  • Maylard: curved incision made 5-8 cm obove the pubic symphysis. The rectus fascia and muscle are cut transversely, and the inferior epigastric arteries must be ligated.

  • Cherney: using the same skin incision as a Pfannenstiel, but then blunt dissection is used to identify the rectus muscle tendons at their insertion to the public symphysis. They are cut 1-2 cm above their insertion point. On closure, the muscles should be reattached to the anterior rectus sheath, as reattaching to the pubic symphysis may serve as a nidus for osteomyelitis.