amini

Dr laleh Amini French board of OB&GYN Iranian Continence Society 2nd Annual meeting 2011 Tehran- Milad Hospital IRAN



Natural (NVD) 



Physiology (phusis nature, Logia:science)!

Physio logie studies function (amalkard) and properties vijegiha khassayes) of organs and living tissues 



Physiologic ( means gesmi) by opposition to psychologic

Safe!!!! 



By allusion to caesarian section which is artificial

The other ways are unsafe?

In water 

A newborn psychology (1960s) sophrology

Painless  Pain free 

 Why

is high rate of C. Section = Malpractice?  WHO ‘s warnings to Iran  Statistics: US: 13-33% UK: 9-25% France: 13-28% Scandinavian countries: 7-17% Iran 45%???

 About

LUTS (Lower Urinary tract symptoms)



SUI/ Urgency? Frequency

 Fecal  Dys

incontinence

pareunia

 Vaginal

relaxation



General Public Health is the main issue



In GOD we trust, every body else has to show data



Based on Public health definitions of morbidity and mortality from an epidemiologic point of vu (objective and not subjective)



Evidence based medicine, epidemiologic studies, randomized clinical trials, and National registries

 Morbidity 



Maternal •early •late Fetal

 Mortality 



Maternal fetal

 Mortality:

WHO International disease Classification

 342000

in 1980  

   

in 2008 (61400 AIDS) /

526000

France 8/100 000 (Hemorrhages PP) USA 12/100 000 17/ 100 000 in 2008 (Thromboemboli, PPCM) 2x UK 3x Australia 4x Italy UK 8/100 000 Thrombo-emboli Netherlands: 7/100 000 Eclampsie Iran: 23/100 000 307 1389 China : 165/100 000 40/100 000

Immediate:  Hemorrhage

> 500cc  Per-op complications ( urinary, bowel injury)  Infection (wound, Urinary)  DVT/PE  PP Myocardiopathy  Medication: Painkillers, Narcotics, antibiotics  Transfusions  Hospital stay

 Placenta

accreta/percreta  Uterine rupture  Endometriosis  Intestinal occlusion  Chronic pain

 Decreased

with the increase to 15-17% of C sections , then stable and now increasing

 Besides

complications related to the condition leading to a cesarean section:

 Pulmonary

Distress

 Jaundice  Re

hospitalizations  Immune system (humeral/Cellular)  Diabetes , Leukemia  Asthma and allergy  Gut infections  Learning disabilities?

 Independent

 It’s

Risk of GA

morbidity and mortality concerns two persons

 5%

of GA in Elective C sections in the USA  2% in France for elective C section  American

Society of Anesthesiology Guideline 2004? 

-> GA only when Loco-regional anesthesia is contra-indicated

 International

Society of Obstetrics

Anesthesia: 

GA is Unacceptable for elective C section

 Pelvic

relaxation is there to allow vaginal delivery Post partum LUTS in NVD > Post Cesarean  Post partum fecal incontinence in NVD> Post Cesarean: Pudendal denervation Sphincter stretching damage *12 months post partum returns to Normal Persistant Fecal incontinence = Missed/ Not repaired Sphincter Rupture

Effect of Labor and stress of Birth:  Cathecolamines , Cortisol, Endorphines… Enhances: Cytokynes TH1/Th2, Neutrophiles, Lipopolysaccharide responsiveness, CD3/CD56+,CD16+,Il 8….  Alteration of DNA methylation +++ is higher in C section ( Diabetes, Leukemia)  Breast feeding quality  Mother and child relationship

C section

NVD

 NIH

context of C section on maternal request  And conclusions:  

C sections should not be an alternative to lack of pain relief techniques C section should not be an alternative because of lack of standards in safe management of labor



What do women want? Why do they want C section (if they do?)  Why don’t they want NVD  Why don’t they want C section 

 

Do doctors prefer C section? Why? Money  Security : 

 

Maternal safety ( they don’t trust midwifes) Fetal safety



Don’t take risks



They do what they know best They might not know much else



 Guideline

for

Vaginal pain free delivery on maternal request  ->

Is an Professional and Ethical issue

 Clear

maternal consent and information on each process, risks and benefits, potential complications and….

 Those

who don’t want to give birth despite All the given information and in absence of any contra indication.

 What 

Loco-regional anesthesia or iv opiods (remifentanyl)

 Who 

is it?

does perform it?

The anesthesiologist

 How? 

By inserting a catheter or doing a single injection

 When? 

When patient can’t bare the pain

 What  

are the results?

For the patient For the healthcare provider

 Epidural  

Catheter Local anesthesic Marcaine 0.125% ( not Xylocaine 0.5%) +  Fentanyl or sulfentanyl

 Spinal 

Marcaine + 100µg MORPHINE

 Fever



Thrombopenia< 70 -000



Mother Pain free  Itching  Sleepy  Low BP transitory 



Fetus Sleepy  Transitory low BP of Mum gives transitory bradycardia 



On the midwife controlled expulsion  Precise repairing  Post partum uterine revision if necessary 



On the OB&GYN

Blind, Def, hemiplegic, paraplegic….ms,…

 WHO

partograph:



Control contraction by ocytocine if hypo-cinesia or dynamic dystocia



Use of atropine



Delayed pushing



Expertise in one instrumental extraction