JUST SAY NO TO VAGINAL BIRTH JEFFREY P. PHELAN, MD, JD

THE FUTURE FOR VAGINAL BIRTHTHE 1990 PREDICTION“ONLY THOSE FETUSES IN A VERTEXPRESENTATION WITH AN EFW 2500 TO 4000GRAMS, A REACTIVE FETAL ADMISSION TEST,AND A NORMAL LABOR CURVE WILL BEPERMITTED A TRIAL OF LABOR. THE RESTWILL UNDERGO A CESAREAN.”JEFFREY P. PHELAN, MD, JDCONTEMP OB/GYN 1990;35:88.

JULY 1994MANAGED CARE DEMANDING OB C/S RATES

CESAREAN DELIVERY 1989-2007RATEPER100LIVEBIRTHS35302520151050VBACTOTAL CESAREAN DELIVERYPRIMARY CESAREAN DELIVERY89 91 93 95 96 97 99 01 03 0 5 0 6YEARDATA NATIONAL CENTER FORHEALTH STATISTICS

NOVEMBER 1996

VAGINAL BIRTH AFTER CESAREANPROCEDURAL BASED INFORMED CONSENTProposed procedural based informed consentFor a vaginal birth after cesareanMODIFIED OBG MAN NOV 1996This proposed consent should be modified in keeping with the law of the reader’s stateand after consultation with an attorney.Initial1. I understand that I have had one or more prior cesarean(s). _____2. I understand that I have the option of undergoing an electiverepeat cesarean or attempting a vaginal birth after a cesarean (VBAC). _____3. I understand that approximately 70% of women who undergoa VBAC will successfully deliver vaginally (naturally). _____4. I understand that the risk of a uterine rupture during a VBAC in someone such as myself,who has had a prior incision in the noncontracting part of my uterus, is around 1%._____5. I understand that VBAC is associated with a higher risk of harmto my baby than to me. _____6. I understand that if my uterus ruptures during my VBAC, theremay not be sufficient time to operate and to prevent the death ofor permanent brain injury to my baby. _____7. I understand that I can have my VBAC at a higher level hospitalbut I have chosen to remain at (Name of Hospital). _____8. I understand that the decision to have a VBAC is entirely my own, andthe option of an elective repeat cesarean has been discussed with me. _____9. I understand that VBAC carries a lower risk to me than does a cesareandelivery. _____10. I understand that if I deliver vaginally, I most likely will have fewer problems afterdelivery and a shorter hospital stay than if I have a cesarean delivery. _____11. I understand that if I deliver vaginally, there is a chance I could develop at some timein the future, stress urinary incontinence (a loss of urine whenever I cough, sneeze, or jump)or difficulty having a normal bowel movement. _____12. I understand that during my VBAC, the use of oxytocin (Pitocin) hormoneto make my uterus contract may be necessary to assist me in my vaginal delivery,and the “risks” of this drug have been thoroughly explained to me. _____13. I understand that if I choose a VBAC and end up having a cesarean during labor,I have a greater risk of problems than if I had had an elective repeat cesarean. _____14. I have read or have had read to me the above information and I understand it. _____I have received all the information I want. After discussing the matter with my doctor,I want to attempt a VBAC.___________________________________________I want a repeat cesarean._____________________________________________(Sign your name next to your choice)__________________________________________________________________Print Patient’s NamePatient’s SignatureDate TimeWitnessed by

CESAREAN DELIVERY 1989-2007RATEPER100LIVEBIRTHS35302520151050VBACTOTAL CESAREAN DELIVERYPRIMARY CESAREAN DELIVERY89 91 93 95 96 97 99 01 03 0 5 0 6YEARDATA NATIONAL CENTER FORHEALTH STATISTICS

VAGINAL BIRTH AFTER CESAREANPHYSICIAN AVAILABILITY-1999“PHYSICIAN IMMEDIATELYAVAILABLE THROUGHOUT ACTIVELABOR CAPABLE OF MONITORINGLABOR AND PERFORMING ANEMERGENCY CESAREAN.”ACOG PRACTICE BULLETING NO. 5-JULY 1999

THE DECLINING VAGINAL BIRTH RATETHE REASONS IN THE 90’SLOW BIRTH WEIGHT FETUSBREECH PREGNANCYMULTIPLE PREGNANCYFORCEP/VACUUM USEFETAL MACROSOMIACONGENITAL ANOMALIES

CESAREAN DELIVERY 1989-2007RATEPER100LIVEBIRTHS35302520151050VBACTOTAL CESAREAN DELIVERYPRIMARY CESAREAN DELIVERY89 91 93 95 96 97 99 01 03 0 5 0 6YEARDATA NATIONAL CENTER FORHEALTH STATISTICS

CITRUS VALLEY MEDICAL CENTERC-SECTION RATE 2000-2009504540353025201510502000 2001 2002 2003 2004 2005 2006 2007 2008 2009Year

CITRUS VALLEY MEDICAL CENTERFORCEPS/VACUUM 2000-2009ForcepsVacuum6.05.04.03.02.01.00.0200020012002200320042005YEAR2006200720082009

THE SHIFT TO VACUUMCITRUS VALLEY MEDICAL CENTERINCIDENCE100806040200FORCEPS VACUUM91%97%9%3%2000-2004 2005-2009YEARS

THE DECLINING VAGINAL BIRTH RATEWHAT HAPPENED IN THE LAST DECADEPRIOR UTERINE SURGERYPERINEAL PRESERVATIONUNENGAGED PRIMAGRAVIDAOCCIPUT POSTERIOR

*PLAUCHE, ET AL OB GYN 1984;64:792**LEUNG, ET AL AJOG 1993;169:945UTERINE RUPTURE RISKNO SCARPRIOR C/S,REPEAT*VBACPROGRAM**0 0.2 0.4 0.6 0.8 1INCIDENCE

UTERINE RUPTUREPARTIAL OR COMPLETE EXPULSIONPARTIAL-FETUS OR PLACENTA EXPELLEDINTO THE MATERNAL ABDOMENCOMPLETE- WHEN THE FETUS AND THEPLACENTA ARE EXPELLEDINTO THE MATERNAL ABDOMEN

UTERINE RUPTUREWHAT ARE THE CLINICAL RISKS ?UTERINE RUPTURERISKOVERALL 1/100WITHOUT NOTICE 1/200WITHOUT NOTICE & 1/800PARTIAL OR COMPLETEEXPULSION

PERINEAL INJURYIMPROVING PATIENT OUTCOME•PRIOR 4 TH /RV FISTULA-OFFER C/S•METHODICAL REPAIR 3 RD /4 TH•FREQUENT CONSULTATION

ENGAGEMENTWHEN THE BIPARIETAL DIAMETER ISAT THE LEVEL OF THE PELVIC INLETOR THE PRESENTING PART IS ATSTATION ZERO OR ZERO TO MINUS 1.WILLIAMS OBSTETRICS 14 TH EDITION-1971HELLMAN, LM, PRITCHARD, JA EDITORS

INCIDENCEUNENGAGED PRIMAGRAVIDA AT TERMINCIDENCE AT ONSET OF LABOR100806040200ENGAGED91%9%UNENGAGED95%5%AUER 1949 BURKE 1958AUER ET AL: AMJ OBSTET GYNECOL 1949; 58:291.BURKE ET AL: AM J OBSTET GYNECOL 1960; 104: 132.

UNENGAGED PRIMAGRAVIDA AT TERMCESAREAN DELIVERY RATESENGAGED UNENGAGEDINCIDENCE1009080706050403020100?24%1%36%AUER 1949 BURKE 1958AUER ET AL: AM J OBSTET GYNECOL 1949; 58:291BURKE ET AL: AM J OBSTET GYNECOL 1960; 104:132.

UNENGAGED PRIMAGRAVIDA AT TERM“…HAVE LONGER FIRST AND SECONDSTAGES OF LABOR: {THAN THEIRENGAGED COUNTERPARTS}”ROSHANFEKR, D ET ALOBSTET GYNECOL 1999; 93: 329.

INCIDENCE9080706050403020100FETAL ENGAGEMENTBRAIN DAMAGED BABY (N=177)15%ENGAGED UNENGAGED85%PRIMAGRAVIDA16%MULTIGRAVIDA84%CHILDBIRTH INJURY PREVENTION FOUNDATION-2003

UNENGAGED PRIMAGRAVIDAFORK IN THE HEALTHCARE ROADUNENGAGED PRIMAGRAVIDAPRESENTS FOR DELIVERYC/STOL

UNENGAGED PRIMAGRAVIDA AT TERMCLINICAL MANAGEMENT•OFFER ELECTIVE C/S•CONSIDER C/S, FOR DYSFUNCTIONALLABOR OR FHR ABNORMALITIES•OPERATIVE VAGINAL DELIVERY?

RISK OF NEONATAL ENCEPHALOPATHYOCCIPUT POSTERIOR PRESENTATIONINCIDENCE100806040200NORMAL96.2%NOT-OPENCEPHALOPATHY89.6%3.8%OP10.4%BADAWI: BMJ 317:1555

BRAIN DAMAGED INFANTS (N=423)VERTEX PRESENTATIONS (N=398)ORIENTATION DURING DELIVERY PROCESSUNKNOWN-218 (55%)KNOWN-180 (45%)KIRKENDALL CL, PHELAN JPAM J OBSTET GYNECOL 2003; 189(6):S211.

BRAIN DAMAGED INFANTSVERTEX ORIENTATIONDOCUMENTED (N=180)OA-106 (59%)OP-47(26%)OTHER-2(3%)OT-25(14%)OA-OCCIPUT ANTERIOROP-OCCIPUT POSTERIOROT-OCCIPUT TRANSVERSEKIRKENDALL CL, PHELAN JPAM J OBSTET GYNECOL 2003; 189(6):S211.

FETAL BRAIN INJURYOCCIPUT POSTERIOR PRESENTATIONINICIDENC10080604020E 0NORMAL96%NOT-OP74%BRAIN INJURY4%OP26%BADAWI: BMJ 317:1555KIRKENDALL & PHELAN: AM J OBSTET GYNECOL 2003;189(6):S211

RESULTSON COMPARISON, THE ORIENTATION OFTHE VERTEX IN NEUROLOGICALLYIMPAIRED INFANTS DUE TO HYPOXICISCHEMIC ENCEPHALOPATHY WAS9.1 X MORE LIKELY TO BE IN AN OPPRESENTATION THAN BADAWI’SNEUROLOGICALLY NORMAL CONTROLGROUP. [47/180 (26%) VS 15/400(3.8% OR 9.1, 95% CI (47.6, 16.6) P=0.000001]

OCCIPUT POSTERIORFORK IN THE HEALTHCARE ROADOCCIPUT POSTERIORPRESENTS FOR DELIVERYC/STOL

OCCIPUT POSTERIORCLINICAL MANAGEMENT•CONSIDER C/S, FOR DYSFUNCTIONALLABOR OR FHR ABNORMALITIES•OPERATIVE VAGINAL DELIVERY?

CESAREAN BIRTHWHAT DOES THE FUTURE HOLD?

WHAT DID WE LEARNABOUT C-SECTIONS & VAGINAL BIRTH?THERE WILL ALWAYSBE VOLCANOS!!!