Thursday, November 4, 2010

Eight Reasons The Cesarean Rate is Too High

From the Midwife Nextdoor blog

The October edition of ObGyn News featured a commentary entitled: The Cesarean Section: A View From The Trenches. David Priver, MD, described himself as “nothing more than an everyday ob.gyn who has written no papers nor taught many residents”, yet he has crystallized many of the primary reasons we have not made progress in reducing our c-section rate. Dr. Priver states that over his 36 years of practice, his c-section rate never exceeded 10%. He modestly describes himself as having “no extraordinary wisdom, skills or dexterity” but offers points that he believes, if taken into consideration by OBs, could successfully decrease the c-section rate.

* The c-section rate has increased costs but hasn’t improved outcomes.
* As the incidence of c-section increases, so does the incidence of placenta accreta. This often requires hysterectomy and blood transfusions. OBs need to take seriously the future risk they are creating for women each time they make a decision for c-section.
* OBs are paid more for doing c-sections than vaginal deliveries. Dr. Priver suggests that “guiding a woman through a labor and vaginal delivery” takes more skill and judgement than doing a c-section. He recommends paying OBs up to $1000 more for accomplishing a vaginal delivery in a first-time mother or a woman desiring VBAC.
* We must change a system that nearly ensures an OB will be sued if the outcome if not perfect, even if s/he did nothing wrong.
* OBs today are too impatient. Dr. Priver points out that women and their physicians used to wait until 42 weeks before inducing labor. He believes that oligohydramnios (low amniotic fluid) is a “pseudo-issue” that is used to expedite delivery, although evidence does not show benefit of induction.
* In the case of VBAC, women should be allowed to begin labor before a decision about type of delivery is made. When the woman starts spontaneous labor, she should be assessed and a decision made regarding whether or not to attempt VBAC. Dr. Priver is strongly against use of Pitocin augmentation during a VBAC, believing that a stalled labor may be a warning not to “push the process”.
* Vaginal birth when baby is in a frank breech position should be the rule, not the exception. Dr. Priver uses the rule of “watchful waiting” in these cases, and as long as progress is being made and baby is doing well, labor may continue.
* Breech delivery techniques and skillful use of forceps are rapidly becoming a lost art, which will further drive up the cesarean section rate–unnecessarily.