Meeting the challenge of the rising cesarean birth rate

Article Abstract:

The proportion of births in the US that are accomplished via cesarean section stood at just under 25 percent in 1987, a situation viewed with concern. Although published research results have demonstrated good perinatal outcomes when attempts were made to reduce the number of cesarean deliveries, the practice continues unchecked, for the most part. An experience with a 5-year educational program (1982 to 1986) to reduce the cesarean rate in Denver, Colorado is described. The program aimed its message at physicians, nurses, and community groups interested in childbirth. It included information on how to manage patients with different complications or characteristics that are often the reason a cesarean section is proposed, such as previous cesarean section, distressed fetus, failure of labor to progress, breech position, and twin deliveries. Thirty lectures on these and related topics were offered to physicians during the study period; programs for other groups were also presented. Results showed that the cesarean rate for the community as a whole rose from 17.3 to 19.3 percent during the study period. Although the rate for repeat cesareans held constant, the rate for first cesareans climbed steadily. Hospitals where resident physicians took the major responsibility for patient care were the most receptive to the educational program. Objective, intellectual arguments regarding the safety of vaginal birth may be considered ''impractical'' in the US because they are ''legally hazardous''. Suggestions to correct the situation are discussed: (1) a ''cesarean birth monitor'' should be appointed for each hospital; (2) changes in practice patterns, so that the physician is not expected to remain with the laboring woman until delivery; and (3) changes in the legal system that will reduce the cost of liability insurance for obstetricians. It is unrealistic to believe that education and knowledge will slow the cesarean rate; practical considerations must be addressed. (Consumer Summary produced by Reliance Medical Information, Inc.)

Social aspects, Laws, regulations and rules, Education, Physicians, Medical professions, Colorado, Denver, Colorado

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Ranking the risk factors for cesarean: logistic regression analysis of a nationwide study

Article Abstract:

There has been a steady increase in the cesarean section rate in many countries. Improved electronic fetal monitoring and the threat of malpractice suits have changed the indications for cesarean section. The effects of individual risk factors that influenced decisions to perform a cesarean section were reviewed in a nationwide study conducted in Israel. In the three-month study period, 2,179 out of 22,815 births (9.6 percent) were cesarean deliveries. Of these, 1,744 were emergency cesarean deliveries and 435 were elective cesareans. The most frequent indications for cesarean section were breech presentation (30.4 percent), fetal distress (27.1 percent), difficult labor (27.0 percent), and a previous uterine scar (18.3 percent). The two most important factors influencing the decision to perform a cesarean section were breech presentation of the fetus (30-fold increased risk) and the presence of one previous uterine scar (18-fold increased risk). Complications of pregnancy in descending order of risk for cesarean section include: placenta previa, abnormal placement of the placenta; abruptio placenta, early detachment of the placenta; maternal disease (high blood pressure, diabetes, preeclampsia and kidney disease); first-time delivery; low-birth-weight twins; and advanced maternal age. The ethnic background of the mother and the type of hospital attended (teaching institution versus community hospital) also influenced decisions to perform surgery in this study conducted in Israel. (Consumer Summary produced by Reliance Medical Information, Inc.)

Health aspects, Israel, Risk factors, Practice, Surgery, Pregnancy, Complications of, Pregnancy complications, Obstetrics

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The cesarean delivery rate can be safely reduced in a developing country

Article Abstract:

The cesarean delivery rate is increasing in most Western countries. How fetal mortality relates to the increase in cesarean deliveries is controversial. In some studies, new protocols adopted to reduce cesarean deliveries did not increase perinatal mortality, the rate of death occurring 28 days before and after delivery. Cesarean delivery is generally indicated when labor fails to progress, when the fetus cannot be accommodated by the birth canal, if there is a history of a previous cesarean section delivery, if the fetus is in distress, or if the fetus presents feet or buttocks first (breech). The effect of new guidelines to reduce the cesarean section rate upon perinatal mortality was studied in a maternity hospital in a developing country. The two-year periods before and after the introduction of new obstetrical management guidelines were studied. The cesarean section rate dropped for all indications from 16.8 percent to 8.0 percent. The maternal death rate decreased from 202 to 57 deaths per 100,000 births. The perinatal death rate decreased from 71.9 to 56.2 deaths per 1,000 births. The use of oxytocin, a labor-augmenting agent, increased from 3.4 percent to 17.4 percent. A drop in the cesarean section rate did not adversely affect overall obstetrical mortality. (Consumer Summary produced by Reliance Medical Information, Inc.)

Infant mortality, Zimbabwe, Perinatal death

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