Letter to the Editor: "Oh, Snap!" Edition
Wednesday, December 29, 2010 at 7:50AM
By Jill
In response to a commentary in the October edition of ObGyn News by David Priver (summarized on Birth Sense here), Dr. Katharine Morrison wrote the following gem, which was published in the December edition.
C-Section Rate is Insane
Yes! Dr. Davis M. Priver has correctly identified all the major issues in our insane cesarean section rate in his commentary (“The Cesarean Section: A View from the Trenches,” October 2010, p. 18).
- The drift away from inducing at 42 completed gestational weeks or earlier, which is not supported by any scientific study.
- The unwarranted fear of the vaginal breech.
- A lack of understanding that spontaneous labor is infinitely superior to any form of induction.
- The demise of the operative vaginal delivery—those who are experts are not asked to teach the residents this very valuable skill.
- Hysteria around vaginal birth after cesarean, which is most often a safer alternative than the repeat cesarean.
I would add to these the reliance on electronic fetal monitoring, which has not changed the cerebral palsy rate one iota and has never been shown to be superior to intermittent auscultation. We are not following our own literature, the American College of Obstetricians and Gynecologists Practice Bulletins. Or common sense, and yet seem unable to stop.
Dr. Priver also gives voice to the most important points; we have not helped women or their infants in any way by delivering them by cesarean section. On the contrary, we have a generation of young women with scarred uteri whose future deliveries will be at higher risk for placenta accreta, cesarean hysterectomies, bowel and bladder injuries, and death.
We must stop making excuses, stop blaming litigation and patient, and return obstetrics to safe, scientifically supported practices.
Katharine Morrison, M.D.
Buffalo, N.Y.
Reader Comments (20)
What can I say? BRILLIANT! :)
It's wryly amusing to consider women's uteri as "scared" rather than "scarred". Particularly when it's fear that drives most of the conventional approach to birth.
Love this! After a horrible "the works" hospital birth, I have vowed to never birth in the hospital unless someone I trust looks me straight in the face and says "you and/or baby will die if we don't go now." If that were to ever happen, I want one of these people to be the doctor waiting for me at the hospital.
Even at our university funded hospital (which caters more towards the poor side of town), the c-section rate is over 30% (or was last time I checked). While they boast a 'birth center' and offer doulas free of charge to any patient who wishes to sign up for one, almost every mom I know who's gone there has been augmented with pit for PROM or labor slowing at the end, and OBs still fear VBACs if they don't deliver before or on their due date. One friend actually took blue or black cohosh unsupervised to avoid a RCS.
While a lot of it is doctors fearing litigation and the ever present "dead baby/mom" threat, some of it is that most moms aren't educated on 'the system', how to work it to their advantage, and get a good birth outcome in a hospital.
Agree with all points!
Snap! And Sweet! Muy nice!
Not to mention, we have never asked the question, how likely is a daughter born by C-section to be afraid to deliver her own babies vaginally? OR...are we damaging our own genetic codes with all of these C-sections so that our daughters will have currently unknown, new complications with their own births? It sounds Sci-fi now, but so did our current technology one hundred years ago.
Wow, she is awesome. I heart her.
BRAVO!
PS-I wish I had a way to read the full text of the original article. Does anyone have it?
OR...are we damaging our own genetic codes with all of these C-sections so that our daughters will have currently unknown, new complications with their own births? It sounds Sci-fi now, but so did our current technology one hundred years ago.
Er, yeah... But no, evolution doesn't work that quickly. I agree that daughters of mothers who had C/S are probably more psychologically "prepped" to accept C/S themselves, but not physically.
I want to divorce my husband and marry that women. That's all I can say.
Bravo, Dr. Morrison! Standing ovation here! And let's not forget that inductions and cesareans affect babies too--with imprints that can subtly alter the way they function, interact in relationships and view themselves and the world.
TFB, get in line!
The Original Article from OBGYN News:
DR. PRIVER is semiretired from a private practice in San Diego. He is director of obstetrics and gynecology at La Maestra Family Clinic and is a staff physician at San Diego Planned Parenthood. Dr. Priver said he had no conflicts of interest relevant to this commentary.
As I ponder the implications of the latest badly needed effort issued by the American College of Obstetricians and Gynecologists to try to impact this country's entirely unacceptable 32% cesarean section rate (Ob.Gyn News August 2010, p.1), I am moved to share my perspectives on this matter.
I have been nothing more than an everyday, practicing ob.gyn. who has written no papers nor taught many residents, but who simply tried to synthesize an attitude toward obstetrical care based upon the deliveries of more than 7,000 patients over 36 years. When I began in this field, the primary CS rate was about 6%. Mine never exceeded 10% over all the years I practiced. I also cared for at least 300 women who had vaginal birth after cesarean, with only one uterine rupture that was of a noncatastrophic nature and resulted from my inadvisable violation of my own rule against augmenting labor in VBAC patients.
Perhaps a look at how someone with no extraordinary wisdom, skills, or dexterity accomplished this low rate might help focus our specialty's leadership on steps that could actually have a potential for success.
The first point is that this massive increase in the CS rate has not improved obstetrical outcomes, only its costs. With the exception of premature infants, who do substantially better now than they used to because of advancements in neonatal care, mothers and newborns have not benefited from more CS …deliveries.
The second point is that a ticking time bomb will manifest itself in years to come as we section 18-year-olds who will eventually have a fourth repeat CS by age 30. As the number of CS goes up, so does the incidence of placenta accreta (Obstet. Gynecol. 1985;66:89-95), a catastrophic condition that usually requires transfusion and hysterectomy.
Finally, we might wonder why obstetricians are paid the same — or even more – for doing a CS, which involves an expenditure of 30-45 minutes of time, as opposed to guiding a woman through a labor and vaginal delivery, which often requires infinitely more judgment and skill. Consider what would happen to the CS rate if obstetricians were paid $800-$1,000 more to accomplish a vaginal delivery of a primigravida or VBAC patient. This sounds to me like a pilot project that's worth a try.
In no particular order, here are what I see as the problems:
Professional Liability
The near certainty that an obstetrician will be sued for a less-than-perfect outcome simply must come to an end.
ACOG is to be congratulated for taking a stand against the dishonest expert witness. Predictably, with many millions of dollars at stake, this industry – along with its attorney-accomplices – has fought back by suing those who are willing to provide peer review of expert testimony. It is becoming more difficult to recruit such reviewers when there is a serious risk that they themselves will wind up under assault.
Tort reform has, unfortunately, not been a prominent part of current efforts at health care reform.
Impatience
Neither patients nor their doctors are comfortable waiting for labor to start. It used to be that no one even thought about inducing labor until 42 weeks. With accurate early sonographic dating, kick counting, and antenatal testing, there was little reason to intervene earlier. All of a sudden, about 20 years ago, the pseudo-issue of oligohydramnios began to be used as a reason to deliver earlier, despite an absence of studies showing that it improved outcomes (BJOG 2004;111:220-5). What studies do show, however, is that inducing the labor of a primigravida carries with it more than a doubling of the CS rate (Obstet. Gynecol. 2010;116:35-42). Therein lies a good portion of the problem.
The Demise of Operative Obstetrics
It may come as a surprise to today's young obstetricians that forceps were devised as a method of simplifying a difficult birth – and for hundreds of years, they did just that.
As Dr. Joseph DeLee pointed out in his 1920 classic, “Prophylactic Forceps Operation” (Am. J. Obstet. Gynecol. 1920;1:34-44), applying forceps fairly early in the second stage was not only easy to do, but resulted in less maternal and neonatal injury than did the alternative of prolonged and difficult pushing.
Having trained under some true forceps masters, I used forceps extensively throughout my practice years with great success.
I was disheartened by an ACOG practice guideline advising that forceps not be employed in a primigravid labor until a full 3 hours of pushing with epidural anesthesia had gone on (ACOG Practice Bulletin 17, June 2000, reaffirmed 2009). I knew full well that by that time, the fetal suture lines become distorted by molding and the maternal tissues become edematous. This makes proper forceps application difficult and is a formula for producing bad outcomes, which, not surprisingly, leads to criticism of the forceps procedure as dangerous.
My practice was to closely observe the rate of progress in the first 45 minutes of the second stage. If, in my judgment, the pelvis was adequate but dystocia was occurring because of malrotation, deflexion, or inadequate maternal pushing effort, then that was the time to intervene with forceps, as long as the vertex had reached at least +1 station. Under these circumstances, and with the use of dense regional anesthesia, application was easy and axis traction generally required very little effort.
Forceps delivery is a skill that can be learned by almost anyone, and the issue is not how to do it, but when to do it.
In my opinion, it is still well within the realm of possibility to resurrect this productive and worthwhile obstetrical tool. I'm sure many of my generation would be pleased to educate current trainees in the straightforward principles involved in forceps deliveries.
Moreover, once this skill has been learned, there should be ongoing oversight and credentialing, just as is done with other surgical procedures.
Finally, those who take the time and trouble to become adept at these procedures should be adequately compensated for using them for the benefit of their patients.
Lack of an Analytic Approach to VBAC
Clearly, some patients are better VBAC candidates than are others. What little risk there is to this process can be significantly reduced by employing a careful selection process.
Although there are a few categories of patients who are a priori poor candidates for VBAC (such as the woman with an android pelvis who was sectioned for an 8+ pound baby), in general it is impossible to determine ahead of time whether VBAC is a good idea.
The best approach is to plan to make no decision until the patient presents in labor.
Our pediatric colleagues have been telling us for years that a disproportionate share of newborns who were delivered without any labor are admitted to the NICU for respiratory problems. The scheduled repeat CS should become a thing of the past.
In my experience, most VBAC candidates fall into one of two categories, both of which lead to easy decisions: First, there are those women who arrive at around 5-6 cm dilated, 100% effaced, and 0 station with strong, regular contractions. These women will nearly all deliver, and we need employ no management strategy other than to stay out of the way.
Second are those who arrive with premature rupture of membranes, cervix 1 cm dilated, 40% effaced, and floating. These women should go straight to the operating room for a repeat CS.
This leaves 20%-30% of women who fall somewhere in between (say, 3 cm dilated, 80% effaced, and −1 station). For them, a 4- to 6-hour period of observation is appropriate, at the end of which a repeat CS is warranted if active labor is not occurring.
Under no circumstances should Pitocin augmentation be used, as studies have shown a major increase in the risk of uterine rupture when induction or augmentation is employed (Am. J. Obstet. Gynecol. 2005;193:1656-62). An arrest of labor is simply not a reassuring sign and should be deemed as a warning not to push this process.
By employing these approaches, we should be able to achieve a 60%-70% success rate for VBAC, which is quite acceptable.
Vaginal Breech Deliveries Disappear
If we accept that the incidence of breech presentation at term is 3%-4%, then I will assume I was confronted with this situation about 250 times during my years in practice. Of these, probably about 175 were determined to be frank breeches with an adequately flexed vertex, rendering them acceptable candidates for labor.
I employed the policy that continued watchful waiting could be maintained as long as satisfactory spontaneous progress was being made and there was no evidence of fetal compromise. With very few exceptions, epidural anesthesia would have been used to allow for whatever manipulation might be needed during the delivery.
My best estimate is that about 100 of these deliveries were successfully carried out vaginally. Although there was a tendency toward somewhat low 1-minute Apgar scores (probably because of transient umbilical cord compression), the 5-minute values were routinely favorable, as neonatal teams were always present and minor resuscitation was carried out expeditiously. In other words, the protocol was followed religiously. There was not one such delivery which, in retrospect, should not have been carried out.
Occasional assistance such as Piper forceps or extraction was required, but these are remarkably simple procedures.
Unfortunately, a very poor quality study was published some time back that concluded that elective vaginal breech deliveries should no longer be done (Lancet 2000;356:1375-83). And in fact, they are no longer being done. This study suffered from numerous deficiencies and, in my opinion should never have been published.
Among its defects were the following:
▸ Many of the births were carried out by inexperienced operators.
▸ Cases were not eliminated when the morbidity was clearly unrelated to birth route.
▸ Cases were not eliminated from centers where there was no imaging to evaluate flexion of the fetal head; 31% of the deliveries did not have this imaging done.
▸ Morbidity was called “serious” when it was not (for example, more than 2 hours of poor muscle tone).
▸ Only short-term morbidity was considered. After 2 years, there was no difference between the two groups regarding neurodevelopmental delay.
I suspect that this matter is now moot, as those who are currently charged with training residents do not themselves have the knowledge or experience to teach the technique.
Fortunately, this issue accounts for only a small percentage of primary CS, and the damage can be largely alleviated if such patients are not subsequently consigned to having the rest of their babies by CS.
In addition to the above reasons for the increase in the CS rate, there are others of somewhat less importance, such as the increase because of multiple births, which largely result from assisted reproductive technology. Hopefully, conditions may eventually permit the elimination of multiple-embryo implantations.
It is important that we recognize why CS rates have gone up so substantially. Contrary to many prevailing views, I believe that there still exists a substantial possibility to reverse this trend.
I encourage ACOG and third-party payers to take the lead in promoting a new look at some of these old issues and begin to support the training of residents and fellows to develop the skills and confidence that were many years ago imparted to this enthusiastic – but otherwise quite ordinary – ob.gyn. resident.
Thank you for the additional article, Dr. Dorn!
Dr. Priver's categorization of VBAC patients is kind of dogmatic, no? Show up at 5-6 cm and everyone stays out of the way for you to deliver. Show up with PROM at 1 cm and go to the OR? If only slightly more favorable, 4-6 hours of monitoring progress and then go to the OR? That would have ruled out both of my vaginal deliveries (primary VB and a VBAC), as it doesn't allow anyone to have a puttering labor and forbids augmentation.
Interesting to read about Dr. Priver's use of forceps! "My practice was to closely observe the rate of progress in the first 45 minutes of the second stage. If, in my judgment, the pelvis was adequate but dystocia was occurring because of malrotation, deflexion, or inadequate maternal pushing effort, then that was the time to intervene with forceps, as long as the vertex had reached at least +1 station. Under these circumstances, and with the use of dense regional anesthesia, application was easy and axis traction generally required very little effort." I think most of us would be very reluctant to consent to forceps after just 45 minutes of pushing, particular since it sounds like most of his forceps patients had a heavy epidural. It does rewrite the "failure to descend" script from c/s to operative vaginal delivery.
Re: the generation of women with scarred uteri... I worked with a woman several weeks ago who had 3 previous cesarean deliveries. She moved several hours away from her family starting two months before her due date to live in close proximity to the hospital so she could go there as soon as labor began. Not because she was trying for a VBAC, but because she had severe placenta accreta (suspicion for percreta) and would require a cesarean hysterectomy. It wasn't my place to talk to her about her previous deliveries, but I wondered so hard about what her indication had been for the first c/s and whether she was offered a TOLAC with the second.
I think I've just found my new OB. :)
great post!!! also appreciated the full article including the critique of the earth-changing though flawed breech study.
Thank you for posting the entire piece, Dr. Dorn.