Transcript 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