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