Pressure to reduce repeat C-sections can have consequences for outcomes
Pressure to reduce repeat C-sections can have consequences for outcomes
Preventing primary cesareans now preferred approach
Amid growing pressure to reduce cesarean rates, the American College of Obstetricians and Gynecologists (ACOG) in Washington, DC, is urging physicians to take a more cautious approach toward vaginal births after cesarean (VBACs). Instead, leading obstetricians are advocating more modest changes in labor management that can prevent primary cesareans.
ACOG’s revised Practice Bulletin on VBACs and an accompanying news release take aim at aggressive health plan policies: "Because individual risk factors must be considered, ACOG rejects as inappropriate any global mandates’ by third parties for a trial of labor after a previous cesarean delivery."
The ACOG bulletin reflects concerns that overreaching policies towards VBACs can lead to poor outcomes. Last spring, the Los Angeles Times reported that a county hospital’s policy of requiring a trial of labor in virtually all cases led to $24 million in legal settlements for fetal injuries and deaths. The hospital currently restricts or discourages VBACs in certain circumstances and requires signed consent for all women who choose vaginal deliveries after cesareans.
"Over the past two to three years, there were increasing reports of cases of uterine rupture of patients who were undergoing a trial of labor with a previous cesarean delivery," says Stanley Zinberg, MD, MS, ACOG’s vice president for practice activities. "These reports became numerous enough, and the impacts of these uterine ruptures were serious enough, to warrant another look at the issue."
Zinberg says he knows of one health plan that required a trial of labor for patients with prior cesareans, which he says is "absolutely against the ACOG policy, which calls for the patient to make this decision."
VBACs, which represent about a third of all cesareans, were once considered a prime opportunity for lowering rates for these procedures. While the ACOG bulletin states that a VBAC may be beneficial for women with a prior low-traverse cesarean, the cautionary tone is likely to lead to fewer attempted VBACs.
"It’s a pendulum. Very often things will swing too much in one direction," acknowledges Bruce Flamm, MD, FACOG, area research chairman of Kaiser Permanente Medical Center in Riverside, CA, and chairman of the C-section collaborative of the Institute for Healthcare Improvement.
"We went from just a couple thousand VBACs a year a decade ago to 100,000 VBACs a year," he says. "That’s a huge change in the course of a decade."
Liability worries fueled C-section boom
Cesareans, which cost about twice as much as vaginal births and carry risks associated with surgery and anesthesia, were relatively rare in the United States until the 1970s. Yet legal concerns and new technologies spurred a growth in the procedures, and by the late 1980s, one in four births occurred by cesarean.1 (See chart, p. 143.)
Physicians now face unprecedented pressure to reduce their rates. Cesarean rates have become a quality indicator of hospitals and health plans measured by the National Committee for Quality Assurance in Washington, DC, and are included in various consumer report cards. The federal "Healthy People 2000" project set a goal nationally of reducing cesarean rates from about 21% to 15%.
Yet that target rate is arbitrary, not based on scientific evidence, ontends Zinberg. And it doesn’t reflect the individual patient characteristics that affect rates at hospitals and medical groups. "Most people agree that the national cesarean rate is probably too high," he says. "Those who understand the problems related with obstetrical delivery know that a specific benchmark cannot be cited at this time."
Artificial targets can plague physicians, he says. "I’ve received letters from ACOG members who were threatened with being de-listed because they had a 50% cesarean rate in one month," he says. "They had four deliveries. Two were cesareans. Both were prolapsed cords. There’s no intelligent evaluation of what the [cesarean] data represent."
Rates of serious complications related to VBACs remain low — about 1% for uterine rupture, for example. And ACOG continues to recommend VBACs as an option for women with low-traverse scars. But ACOG is underscoring the importance of a patient’s informed choice.
"It is ultimately up to the patient and her physician whether to attempt VBAC or undergo a repeat cesarean delivery after thorough counseling of both benefits and risks," says Zinberg.
The answer for many physicians: Prevent primary cesareans with a back-to-basics approach — less reliance on technology, better labor management, and revival of alternative birthing techniques such as breech deliveries.
"A lot of us are working more aggressively on lowering the primary cesarean section so the VBAC issue doesn’t come up," says Barry Smith, MD, chairman of obstetrics and gynecology at the Dartmouth-Hitchcock Medical Center in Lebanon, NH, and director of the New Hampshire Cesarean Birth Quality Improvement Project.
Small changes can bring results. When the Institute for Healthcare Improvement (IHI) in Boston recently convened a national congress on safely reducing cesarean rates, the recommendations focused on such things as reducing time pressures and making policies more conducive to vaginal birth. (For a list of recommendations, see box, p. 144.)
For example, Lawrence (MA) General Hospital reduced its cesarean rate from 26% in 1993 to 17% in 1997, primarily through changes in identifying and managing the active phase of labor, says Susan Leavitt, RN, MSN, nurse manager of antepartum and intrapartum services.
Dystocia, or failure to progress in labor, accounts for 35% of all cesareans nationally, and many of them are unnecessary, says Leavitt, who participated in the IHI breakthrough series on cesareans and then became an IHI faculty member. "We focused on why we have had such a high rate of dystocia in the past 25 years," she says. "Women’s pelvises shouldn’t have changed that much."
Make sure women are really in labor
Many cases of "dystocia" actually involve women who haven’t yet attained the active phase of labor — a fact Leavitt and her colleagues found when they analyzed the hospital’s labor and delivery practices. "We discovered that we did a lot of latent phase C-sections," says Leavitt. "They had closed cervixes." Physicians performed cesareans after 16 or 20 hours of no progress in the labor and delivery room. "In reality, they weren’t ever in active labor to begin with," she says.
Lawrence General now does not admit women unless they are in active labor, which is defined by cervical change.
Dartmouth-Hitchcock Medical Center also implemented guidelines designed to reduce cesareans due to lack of progress. For example, women are encouraged to walk during labor and to get into positions they find comfortable. "We’re trying hard to get people not to lie in bed in labor," says Smith. "We’re trying to encourage ambulation, which we think allows people to make more progress in labor."
Smith also is involved in training medical residents and other physicians in age-old techniques to avoid cesareans. "In our program, we’re going back to teaching and trying to make sure that the skills of forceps delivery are not lost," he says. "There are many patients for whom forceps delivery is appropriate."
Some physicians, including Smith, perform vaginal breech deliveries. The breech option "depends on a lot of factors, including the experience and training and skill of the obstetrician," says Smith.
Physicians bring in second opinion
A focus on policies that lead up to cesareans can create a better working environment in labor and delivery.
New York University Medical Center in New York City studied obstetrical practice for two years and came up with internal best practices and guidelines, says Jesse Green, PhD, senior director for clinical evaluation. Physicians also seek a second opinion before performing a cesarean. In reality, physicians "consult with each other all through the process."
Rethinking policies that lead to cesareans can benefit all women in labor, says Leavitt. Overall perinatal morbidity and mortality for infants actually declined from 3.5% to 2.7% during the four years when Lawrence General Hospital focused on reducing its cesareans. Leavitt speculates that the improvement came from overall changes in labor and delivery policies.
"It’s back to basics," she says. "It’s back to believing that women were created to give birth. You give women the opportunity to do that. You take that technolog, and you use it judiciously.
"We wanted to change the emphasis from reducing section rates to improving the birthing experience," she says.
Reference
1. Flamm BL, Berwick DM, Kabcenell A. Reducing cesarean section rates safely: Lessons from a "Breakthrough Series" collaborative. Birth 1998; 25:117-124.
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