OB/GYNS Call for Fewer Cesareans

In an ominous editorial in the August 2011 issue of Obstetrics & Gynecology, Dr. John T. Queenan’s commentary, How to Stop the Relentless Rise in Cesarean Deliveries, warns readers that with almost one in three first-time mothers having a cesarean and decreasing VBAC rates since 1996, the U.S. cesarean rate is likely to reach 50% very soon. Dr. Queenan makes several suggestions as to how to reduce the cesarean rate including: achieving an obstetric department commitment to lowering cesareans; better evidence-based patient education on the risks and benefits of cesareans; achieving tort reform; using more nurse midwives; providing equal reimbursement rates for cesarean and vaginal birth and higher reimbursement for supporting VBACs. He also advocates for re-establishing the teaching and training for breech and operative vaginal births. “As of now,” he writes, “the problem is ours to solve. If cesarean delivery rates spiral upward, our profession will lose both credibility and the opportunity to determine our direction, as third-party payers and the government will become involved.”

In the September 2011 issue of Obstetrics and Gynecology, Dr. Howard Blanchette of New York Medical College urges physicians to “reduce the primary cesarean delivery rate, and avoid the performance of a uterine incision unless absolutely necessary.” His commentary, The Rising Cesarean Delivery Rate in America: What Are the Consequences?, concludes that the dramatic rise in cesareans has not resulted in improved outcomes in neonatal morbidity or maternal health. In fact, he corroborates the evidence that has been accumulating for years. The rise in cesareans has led to increasing adverse outcomes for mothers and babies. Dr. Blanchette outlines the changes needed to reverse the rising cesarean rate in America and makes the following recommendations:

  1. Promote trial of labor in women with one previous low transverse cesarean.
  2. Provide extensive counseling on the risks of elective primary cesarean delivery on maternal request.
  3. Avoid cesarean delivery for dystocia until the active phase of labor is firmly established, particularly in nulliparous women, and in induced labor.
  4. Nurses, obstetricians and midwives must remain competent and current in their knowledge of fetal heart rate monitoring interpretation, given that the sensitivity of non-reassuring fetal heart tones as an indication is only 50%.
  5. Compensate obstetricians at the same level for both labor after cesarean and elective repeat cesarean delivery.

Dr. Tami Michele agrees with Dr. Blanchette, and states that women themselves can take an active role in lowering their chance of having a primary or repeat cesarean section. “An experienced doula is essential in lowering the cesarean rate, and I encourage every woman to have one. Both doulas and childbirth educators provide education on avoiding induction of labor, methods to avoid labor dystocia, and effective pushing techniques for second-stage. While continuous fetal monitoring is mandatory in a hospital which supports labor after a cesarean, women without a prior cesarean can request intermittent fetal monitoring. When continuous monitoring is necessary, many hospitals have ambulatory monitors with the capacity to also be used under water.”

The Doula Business Advisor blog is designed to support the establishment and long-term sustainability of private doula businesses. Patty Brennan is the author of The Doula Business Guide: Creating a Successful MotherBaby Business.

Posted by Patty Brennan on November 29, 2011 • Filed under Doula Business Advisor
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