Non-Medical Factors That Influence the Cesarean Rate
Logistical Factors
· Hospital mandates "by the bedside" policy for VBAC labors, oxytocin inductions, etc.
· Facility may not have staff available to provide an emergency cesarean. Facility's waiting time for operating room may be too long
· Doctor in his/her office relies on the L & D nurse's assessment if the mother is going "to make it"
· Surgical team happens to be on the floor, OB thinks labor may not progress and recommends a cesarean
Convenience Factors
· Repeat cesareans easier to fit into busy practice (office patients, hospital rounds, outpatient surgery, etc.)
· "every unrewarded hour spent attending difficult labor is one less spent with patients back in clinic or with family at home”
· Pressure to "clear the board", i.e. to complete care for patients on L & D, before the
shift changes and another doctor comes on
· Mothers requesting elective cesareans
Malpractice Factors
· Malpractice insurance company recommending that doctors use a frightening or
biased VBAC consent form
· Recent multi-million dollar law suits for bad outcomes from uterine ruptures
· One of six ob-gyn physicians give up obstetrics for liability related reasons
· Being sued can be emotionally stressful for a period of several years
Financial Factors
· Higher reimbursement rate for cesarean births
· Shorter time to deliver mother
· Which is less costly cesareans or planned VBACS?
· Physician may lose income to other MD willing to perform elective cesarean
Belief Systems
· Labor and birth as "problem" to be fixed, not natural physiological process
· Perceiving cesarean as predictable and "safer" than or "as safe as" labor
· No extensive experience with VBAC
· Seeing the risk of uterine rupture as greater than it is
· Culture of the hospital, some have 11% cesarean rate others 30%
References:
Flamm, B.L., A. Kabcenell, D. M. Berwick, and Jane Roessner. 1997.. Reducing, Cesarean Section Rates While Maintaining Maternal and Infant Outcomes. Institute for Healthcare Improvement, Boston, MA.Cambridge Health Resources. 1998. Safely Reducing Cesarean Rates. Conference, Boston, MA.Medical Leadership Council. 1996. Coming to Term: Innovations in Safely Reducing Cesarean Rates. The Advisory Board Company, Washington, D.C. Institute for Healthcare Improvement Reducing Cesarean Section Rates. National Congress, Orlando, Florida 1996.
ICAN Conference, 2001-What Most People Don't Know About North American Medicine and VBAC,
Ruth Ancheta, ICCE CD(DONA), Nicette Jukelevics, MA, ICCE © Nicette Jukelevics 2001
STRATEGIES to HELP PREVENT a FIRST CESAREAN
· Avoid routine ultrasound to determine size of the baby after 36 weeks
· Avoid a routine induction for term spontaneous rupture of membranes
· Avoid an elective (convenience) induction
· Avoid routine cesarean for history of herpes with no active lesions
· Avoid routine cesarean for “big” baby over 4000 grams (8lb. 13 oz)
· Avoid routine cesarean for twins (vertex/vertex, vertex/breech)
· Ask about external version for breech baby at 37 weeks
· Look for midwifery model of care (non-pharmacological options for pain relief, one-
to-one labor support, positioning, hydrotherapy
· Ask if the hospital has protocols in place to reduce cesarean rates
· Avoid being formally admitted to labor and delivery unit before active labor (ruptured membranes/ and or bleeding, 100%, 4cm dilation, painful contractions every 5 minutes lasting at least 30 sec.
· In early labor, do light activities in day time
· In early labor, rest at night or sleep (with medication if necessary)
· Ask about intermittent fetal monitoring or auscultation rather than continuous EFM
· No strict time limit
· It’s usually not failure to progress before active labor.
Reference: Flamm, B. 1998. Reducing Cesarean Section Rates Safely: Lessons from a “Breakthrough Series”
Collaborative, Birth: Issues in Perinatal Care 25(2):117-124.
QUESTIONS TO AK IF A CESAREAN IS RECOMMENDED DURING LABOR
Is this a medical emergency, or do we have time to talk?
Are the mother’s vital signs stable?
Are the baby’s vital signs stable?
What would happen if we waited?
Would a surgical team be available later, if needed?
Can we try . . . . . . . . . and talk again a little later?
· Hospital mandates "by the bedside" policy for VBAC labors, oxytocin inductions, etc.
· Facility may not have staff available to provide an emergency cesarean. Facility's waiting time for operating room may be too long
· Doctor in his/her office relies on the L & D nurse's assessment if the mother is going "to make it"
· Surgical team happens to be on the floor, OB thinks labor may not progress and recommends a cesarean
Convenience Factors
· Repeat cesareans easier to fit into busy practice (office patients, hospital rounds, outpatient surgery, etc.)
· "every unrewarded hour spent attending difficult labor is one less spent with patients back in clinic or with family at home”
· Pressure to "clear the board", i.e. to complete care for patients on L & D, before the
shift changes and another doctor comes on
· Mothers requesting elective cesareans
Malpractice Factors
· Malpractice insurance company recommending that doctors use a frightening or
biased VBAC consent form
· Recent multi-million dollar law suits for bad outcomes from uterine ruptures
· One of six ob-gyn physicians give up obstetrics for liability related reasons
· Being sued can be emotionally stressful for a period of several years
Financial Factors
· Higher reimbursement rate for cesarean births
· Shorter time to deliver mother
· Which is less costly cesareans or planned VBACS?
· Physician may lose income to other MD willing to perform elective cesarean
Belief Systems
· Labor and birth as "problem" to be fixed, not natural physiological process
· Perceiving cesarean as predictable and "safer" than or "as safe as" labor
· No extensive experience with VBAC
· Seeing the risk of uterine rupture as greater than it is
· Culture of the hospital, some have 11% cesarean rate others 30%
References:
Flamm, B.L., A. Kabcenell, D. M. Berwick, and Jane Roessner. 1997.. Reducing, Cesarean Section Rates While Maintaining Maternal and Infant Outcomes. Institute for Healthcare Improvement, Boston, MA.Cambridge Health Resources. 1998. Safely Reducing Cesarean Rates. Conference, Boston, MA.Medical Leadership Council. 1996. Coming to Term: Innovations in Safely Reducing Cesarean Rates. The Advisory Board Company, Washington, D.C. Institute for Healthcare Improvement Reducing Cesarean Section Rates. National Congress, Orlando, Florida 1996.
ICAN Conference, 2001-What Most People Don't Know About North American Medicine and VBAC,
Ruth Ancheta, ICCE CD(DONA), Nicette Jukelevics, MA, ICCE © Nicette Jukelevics 2001
STRATEGIES to HELP PREVENT a FIRST CESAREAN
· Avoid routine ultrasound to determine size of the baby after 36 weeks
· Avoid a routine induction for term spontaneous rupture of membranes
· Avoid an elective (convenience) induction
· Avoid routine cesarean for history of herpes with no active lesions
· Avoid routine cesarean for “big” baby over 4000 grams (8lb. 13 oz)
· Avoid routine cesarean for twins (vertex/vertex, vertex/breech)
· Ask about external version for breech baby at 37 weeks
· Look for midwifery model of care (non-pharmacological options for pain relief, one-
to-one labor support, positioning, hydrotherapy
· Ask if the hospital has protocols in place to reduce cesarean rates
· Avoid being formally admitted to labor and delivery unit before active labor (ruptured membranes/ and or bleeding, 100%, 4cm dilation, painful contractions every 5 minutes lasting at least 30 sec.
· In early labor, do light activities in day time
· In early labor, rest at night or sleep (with medication if necessary)
· Ask about intermittent fetal monitoring or auscultation rather than continuous EFM
· No strict time limit
· It’s usually not failure to progress before active labor.
Reference: Flamm, B. 1998. Reducing Cesarean Section Rates Safely: Lessons from a “Breakthrough Series”
Collaborative, Birth: Issues in Perinatal Care 25(2):117-124.
QUESTIONS TO AK IF A CESAREAN IS RECOMMENDED DURING LABOR
Is this a medical emergency, or do we have time to talk?
Are the mother’s vital signs stable?
Are the baby’s vital signs stable?
What would happen if we waited?
Would a surgical team be available later, if needed?
Can we try . . . . . . . . . and talk again a little later?