Cesarean Section: Guidelines for Appropriate Utilization

282 Pages·1995·8.23 MB·English

by  Bruce L. Flamm (auth.)

CP
Clinical Perspectives in Obstetrics and Gynecology
OB/GYN
Series Editor:
Isaac Schiff, M.D.
CP
Clinical Perspectives in Obstetrics and Gynecology
OB/GYN
Series Editor: Isaac Schiff, M.D.
Published Volumes:
Shoupe and Haseltine (eds.): Contraception (1993)
Lorrain (ed.): Comprehensive Management of
Menopause (1993)
Gonik (ed.): Viral Diseases in Pregnancy (1994)
Flamm and Quilligan (eds.): Cesarean Section:
Guidelines for Appropriate Utilization (1995)
Forthcoming Volumes:
Reindollar and Gray (eds.): Molecular Biology for the
Obstetrician-Gynecologist
Published Volumes (Series Editor: The Late
Herbert J. Buchsbaum, M.D.):
Buchsbaum (ed.): The Menopause (1983)
Aiman (ed.): Infertility (1984)
Futterweit: Polycystic Ovarian Disease (1984)
Lavery and Sanfilippo (eds.): Pediatric and Adolescent
Obstetrics and Gynecology (1985)
Galask and Larson (eds.): Infectious Diseases in the
Female Patient (1986)
Buchsbaum and Walton (eds.): Strategies in Gynecologic
Surgery (1986)
Szulman and Buchsbaum (eds.): Gestational Trophoblastic
Disease (1987)
Cibils (ed.): Surgical Diseases in Pregnancy (1990)
Collins (ed.): Ovulation Induction (1990)
Sanfilippo and Levine (eds.): Operative Gynecologic
Endoscopy (1990)
Altchek and Deligdisch (eds.): The Uterus (1991)
Cesarean Section
Guidelines for
Appropriate Utilization
Bruce L. Flamm
Edward J. Quilligan
Editors
With 24 Illustrations
Springer-Verlag
New York Berlin Heidelberg London Paris
Tokyo Hong Kong Barcelona Budapest
Editors:
Bruce L. Flamm, M.D., Research Chairman, Kaiser Permanente,
Southern California Permanente Medical Group, Riverside, CA 92505,
USA
Edward J. Quilligan, M.D., Professor Emeritus, Department of
Obstetrics and Gynecology, University of California-Irvine Medical
Center, Orange, CA 92668, USA
Series Editor:
Isaac Schiff, M.D., Chief of Vincent Memorial Gynecology Service,
Women's Care Division of the Massachusetts General Hospital and
the Joe Vincent Meigs Professor of Gynecology, Harvard Medical
School, Boston, MA 02114, USA
Library of Congress Cataloging-in-Publication Data
Cesarean section: guidelines for appropriate utilization / [edited
by] Bruce L. Flamm, Edward J. Quilligan.
p. cm.-(Clinical perspectives in obstetrics and
gynecology)
Includes bibliographical references and index.
ISBN-13: 978-1-4612-7556-5 e-ISBN-13: 978-1-4612-2482-2
DOT: 10.1007/978-1-4612-2482-2
1. Cesarean section. 2. Surgical indications. 3. Cesarean
section - Prevention. I. Flamm, Bruce L. II. Quilligan, Edward J.,
1925- . III. Series.
[DNLM: 1. Cesarean Section. WQ 430 C4216 1995]
RG761.C486 1995
618.8'6-dc20 94-29533
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© 1995 Springer-Verlag New York, Inc.
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Preface:
Defining the "Appropriate"
Cesarean Section Rate
I wrote an article for Contemporary Obstetrics and Gynecology
in 1983 entitled "Making inroads against the C-section rate."!
In this article, I examined the various factors responsible for
the relative rapid increase in the cesarean section rate in the
United States between 1970 and 1983, when it rose from 5.5%
to 18%. I suggested that it was possible to achieve a cesarean
section rate between 7.8% and 17.5%, and here I would like to
quote directly from the article: "If a hospital were to pursue a
conservative policy on section, for the usual obstetric popu
lation, what section rate should it expect?" This frequently
asked question is hard to answer because hospital obstetric
populations differ so markedly. However, hospital staffs
should examine their cesarean rates frequently, indication by
indication. Purely as a guide (emphasis mine), the table on
page vi lists some high and low values. These values were
2%-4% for failure to progress, 2%-6% for repeat cesarean
section, 1.3%-3.5% for breech and abnormal lie, 1.5%-3% for
fetal distress, and 1% for third-trimester bleeding.
In 1992, the cesarean section rate in the United States was
22.6%, a somewhat slower increase in the past decade than the
very rapid rise of the 1970s. The rate seems to vary widely
between states, with a low of 16.3% and a high of 28.4%,
between hospitals with lows below 15% and highs above 40%,2
and even between doctors in the same hospital with similar
practices, from 10% to 17%.3 This wide variability depends
primarily on the section rate for failure to progress in labor,
fetal distress, and repeat cesarean sections. Frequently those
physicians who have a very high cesarean section rate do not
encourage vaginal births after a previous cesarean section, are
not active in their management of desultory labors, and are too
ready to label fetal distress when they see a pattern that is
only mildly abnormal. To some, these physicians are guilty of
greed, ignorance, and fear. In my personal opinion, greed plays
a very small role in the cesarean rate. While it is true that
most physicians charge more for a cesarean section than a
v
VI Preface
Cesarean section rates
Percentage
Indication Low High
Failure to progress 2.0 4.0
Repeat cesarean section 2.0 6.0
Breech and abnormal lie 1.3 3.5
Fetal distress 1.5 3.0
Third-trimester bleeding 1.0 1.0
Totals 7.8 17.5
From Quilligan,l by permission of Contemporary
Obstetrics and Gynecology.
vaginal delivery, I have yet to meet a physician who would do
something they believed would harm their patient even if they
were paid ten times as much for a section. On the other hand,
there are fears and misconceptions. I have heard many doctors
say "I have never been sued for a section I did, but I have been
sued for the section I did not do." The fear of not having
performed a section in my opinion is real, although difficult to
prove, and until the public can be educated that cesarean
section delivery cannot eradicate fetal death and damage, this
fear will remain and will be responsible for some unnecessary
cesarean sections. Bruce Flamm and I hope this book will
correct misconceptions that have been responsible for many
unnecessary cesarean sections.
I am still frequently asked the same old question: What is an
ideal cesarean section rate? I still give an answer similar to
the 1983 answer, perhaps somewhat modified. Every hospital
that has an obstetric service should have some committee that
examines every cesarean section that is performed in that
hospital and determines whether it was indicated or not. If it
was not indicated, then the physician who performed the
section should be educated as to why it was not indicated.
Only through repeated educational efforts will individual
physicians lower their section rates. If the hospital rate
remains high, then it seems reasonable that the licensing body
in the state has an obligation to examine the records of that
hospital. Perhaps the rate is justified; if not, education of the
entire staff is in order. How do I define "high" rate? If the
hospital rate is persistently above the level statewide, it would
certainly seem reasonable to look at the r«::cords.
Another way to look at hospital performance is to look at a
segment of the cesarean section rate that depends primarily on
the philosophy of the physicians and their education as well
as their patients' education, the elective cesarean rate or
its reverse, the rate of vaginal birth after cesarean section
(VBAC). The VBAC rate should be on an upward trend toward
50% and certainly at the national level of 25%.
Preface vii
What about the other major factors in fetal distress and
failure to progress in labor? Electronic fetal heartrate moni
toring has been blamed for the rapid increase in cesarean
section rate for fetal distress; however, it is not the monitoring
but the interpretation of the data that is at fault. Unfor
tunately, many of the tracings that have resulted in cesarean
section show a temporary decrease in fetal oxygenation and
are not indicative offetal distress. It must be kept in mind that
the heartrate pattern shown by the monitor has a high false
positive rate for fetal distress; therefore, other measures such
as fetal scalp stimulation, fetal acoustic stimulation, and fetal
scalp sampling must be employed to rule out false-positive
cases. Committees should determine whether these measures
are being used if the section rate for fetal distress exceeds 2%.
Further, let us not forget our educational efforts not only to
get physicians and nurses to correctly interpret patterns and
use ancillary diagnostic tests but also to educate the public
that not all abnormal patterns are indicative of ongoing brain
damage but may be the result of damage that has occurred
days or months before the onset oflabor. Failure to progress in
labor would seem to be the most difficult figure to determine;
however, some important concepts can help guide a committee
examining individual cases. It is paramount that accurate
records be kept of uterine activity, cervical change, and fetal
presenting part descent.
The active management of labor, described later in this
volume, has been very successful in keeping a very low cesarean
section rate at the National Maternity Hospital in Dublin,
Ireland. In my opinion, the two most important parts of that
program are ensuring that the patient is in labor on hospital
admission and the prompt use of oxytocin when the patient
falls off the labor curve. Both these factors require close ob
servation of the patient, and the concept of one-on-one nursing
or midwife care is obviously important.
The key I would like to stress is education, education at
every level-the patient, the nurse, and the physician. It
is the only effective method to lower the cesarean section
rate, but to be effective education must be repetitious. I
wish I could say that simply reading this book will lower the
cesarean section rate; it will not. However, this volume will
give you a series of suggestions and the scientific rationale
behind those suggestions. If followed, these ideas will help
you to decrease your cesarean section rate.
E.J. Quilligan, M.D.
References
1. Quilligan EJ. Making inroads against the C-section rate.
Contemp Obstet Gynecol1983;Jan:221-225.
viii Preface
2. Gabbay M, Wolfe SM. Unnecessary cesarean sections: curing a
national epidemic. Washington, DC: Public Citizens Health
Research Group, May 1994.
3. Dermott RK, Sandmire HF. The South Bay cesarean section
study. II: The physician factor as a determinant of cesarean birth
rates for failed labor. Am J Obstet Gyneco11992;166:1799-1806.
Contents
Preface: Defining the "Appropriate" Cesarean Section
Rate............................................. V
EDWARD J. QUILLIGAN
Contributors ............ . . . . . . . . . . . . . . . . . . . . . . . . . . . Xl
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv
BRUCE L. FLAMM
1 Cesarean Delivery in the United States:
A Summary ofthe Past 20 Years. . . . . . . . . . . . . . . . . 1
BRUCE L. FLAMM
2 Worldwide Utilization of Cesarean Section. . . . . . . . 9
T.J. BROADHEAD AND D.K. JAMES
3 Dystocia and "Failure to Progress" in Labor . . . . . . . 23
EMANUEL A. FRIEDMAN
4 Active Management of Labor 43
PETER BOYLAN
5 Vaginal Birth After Cesarean Section 51
BRUCE L. FLAMM
6 Breech Presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
LUIS A. CIBILS
7 Cesarean Section for Fetal Distress. . . . . . . . . . . . . . . 95
DAVID A. MILLER AND RICHARD H. PAUL
8 Fetal Macrosomia .............................. 115
HUNG N. WINN AND JOHN C. HOBBINS
9 Twin Gestation and Multiple Births. . . . . . . . . . . . . . 125
CORNELIA R. GRAVES AND FRANK H. BOEHM
IX
x Contents
10 Genital Herpes: Contemporary Management ...... 131
ZANE A. BROWN
11 Methods for Safe Reduction of Cesarean
Section Rates .................................. 141
NORBERT GLEICHER, RICHARD H. DEMIR, JEANNE
B. NOVAS, AND STEPHEN A. MYERS
12 Cesarean Delivery: A Medical-Legal Perspective 163
JEFFREY P. PHELAN
13 Economic Considerations in Cesarean Section Use 173
LAURA B. GARDNER
14 Ethical Issues in the Utilization of Cesarean
Section ........................................ 191
THOMAS E. ELKINS AND DOUGLAS BROWN
15 The Patient Who Demands Cesarean Delivery ..... 207
BRUCE L. FLAMM
16 The Impact of Midwifery Care, Childbirth
Preparation, and Labor Support on Cesarean
Section Rates .................................. 223
JANICE R. GOINGS
17 Cesarean Projects at the State and National Level 247
BRUCE L. FLAMM
18 Guidelines for Appropriate Utilization of Cesarean
Operations ..................................... 255
BRUCE L. FLAMM
Index .............................................. 263