Where are we with controlling cesarean birth rates?
By Roger K. Freeman, MD
In this special communication, Dr. Freeman provides
his perspective on ACOG's recently released task force report.
The American College of Obstetricians and Gynecologists' Task
Force on Cesarean Delivery rates was charged with assessing the known factors
that contribute to high variation in cesarean delivery rates; determining ways
to compare physicians, nurses, hospitals, states and regions; and recommending
methodologies that could be used to evaluate practitioners and hospitals. Interestingly,
the highest-risk patients, such as those with non-vertex presenting fetuses,
placenta previa, and prolapsed cord, account for only about one third of C/S
deliveries and there is very little variation among providers. Low-risk term,
singleton, vertex-presenting nulliparous patients and those with a single prior
low-segment C/S delivery and a singleton, term, vertex fetus account for two
thirds of C/S deliveries and variation among providers is high. Comparisons
based on these two standardized categories of patients, therefore, represent
a vehicle through which feedback can be provided to obstetricians on their own
patterns of delivery. These data also can be supplemented by solid outside comparative
benchmark statistics for deliveries from states and regions.
The ACOG task force also identified a number of specific practices
that are known to be associated with higher C/S delivery rates for dystocia.
These include C/S delivery in labor when: (1) cervical dilation is less than
4 cm; (2) epidural analgesia is administered with minimal cervical dilation;
and (3) inadequate uterine activity is identified with or without the use of
Other identified factors include elective induction of labor
in nulliparous patients, C/S delivery for suspected macrosomia in nondiabetic
patients without a trial of labor, and C/S delivery for term breech presentation
without offering an attempt at external cephalic version.
Identifying practices such as these among providers who have
above average standardized C/S delivery rates provides a means of pointing to
contributing factors that may help them to safely reduce their C/S delivery
Between 1990 and 1997, the national C/S delivery rate decreased,
but the trend now seems to be moving in the opposite direction. This is primarily
due to increased concern over the risk of uterine rupture in patients attempting
vaginal delivery who have had a prior C/S (VBAC). The 30-minute decision-to-incision
guideline promulgated by ACOG clearly will not protect all fetuses when there
is a uterine rupture. ACOG's 1999 recommendation that obstetricians be immediately
available for VBAC patients who are in labor has caused some to suggest
that the standard of care for VBAC patients is a decision-incision time of less
than 30 minutes. As a result, many obstetricians are offering a trial of labor
to fewer patients who have had one previous low-segment transverse C/S. In addition,
some insurance companies are requiring a consent form that frightens many patients,
causing them to decline an attempt at VBAC.
The Task Force also addressed the risksprimarily to the
pelvic floorof vaginal delivery and identified some strategies that may
help reduce these problems. Finally, cost considerations driven by managed-care
payors appear to no longer be driving reductions in C/S delivery rates as these
insurers have come to realize that an elective repeat C/S is often less costly
than a long labor that results in either a vaginal delivery or a C/S birth.
For those who are interested, ACOG has prepared a detailed document
that goes into the details and evidence base for their recommendations. The
executive summary is reprinted at right. It is my opinion that there is significant
value in decreasing C/S delivery rates when vaginal delivery is a safe option,
and the evidence suggests that there are many opportunities to do so.
Dr. Freeman is Professor of Obstetrics and Gynecology, University
of California, Irvine, and Director of Obstetrics and Gynecology, Normal Newborn
Careline, Long Beach Memorial Medical Center, Long Beach, Calif.
Roger Freeman. Where are we with controlling cesarean birth rates?. Contemporary Ob/Gyn 2000;7:63-66.