If the primary and overall cesarean rates continue to escalate at the same pace as in recent years, the cesarean rate will be over 56% by 2020, warns two prominent obstetricians in the August edition of Obstetrics and Gynecology. Although cesareans are safer than ever before, they are still riskier for both mothers and babies than vaginal births. And, cesarean surgery increases the risks in future pregnancies for placenta previa, placenta accreta, hysterectomy, and mortality relative to vaginal births. Indeed as the cesarean rate has skyrocketed in recent years, the incidence of potentially catastrophic complications caused by the first cesarean has increased dramatically. Obstetricians are alarmed and are seeking ways both to decrease the primary cesarean rate and to increase the VBAC rate.
In the August edition of Obstetrics and Gynecology, Dr. John T. Queenan, Deputy Editor, addresses the challenge of reducing the primary cesarean rate. He warns that, “if cesarean delivery rates spiral upward, our profession [obstetrics] will lose both credibility and the opportunity to determine our direction, as third-party payers and the government will become involved.” Two of his most important recommendations are that OBs do fewer inductions and that they eliminate cesareans performed for dystocia before active labor is established. Both of these topics need to be addressed in childbirth education classes. An innovative program at St. John’s Mercy Medical Center in St. Louis, MO proved that adding detailed information about the risks and benefits of elective induction to the childbirth class curriculum can decrease the number of elective inductions. Childbirth educators also can help to reduce the number of cesareans done for dystocia before labor is well established. Encourage women to labor at home for as long as possible; to not be too disappointed if they are sent home from the hospital in early labor; and to ask for more time if cesarean surgery is suggested for “failure to progress” as long as both mother and baby are coping well with labor. Also, emphasize that there is a lot of variation in the length of “normal” labor and that recent research from National Institutes of Health supports that labor may take more than 6 hours to progress from 4 to 5 cm and more than 3 hours to progress from 5 to 6 cm. In addition, Dr. Queenan calls for better patient education using evidence-based information about the risks and benefits of vaginal birth and cesarean delivery (presumably to highlight the benefits of vaginal birth and the risks of cesarean surgery); for more births by nurse-midwives; for equal compensation for vaginal births and cesarean surgeries; and for re-establishing medical training for breech and operative vaginal deliveries.
In the same issue of Obstetrics and Gynecology, Dr. James R. Scott, Editor-in-Chief, discusses strategies to increase access to and the desirability of VBACs. In the August 2010 practice bulletin on VBAC, ACOG (The American College of Obstetricians and Gynecologists) continues to recommend that TOLACs (trial of labor after cesarean) only be done in hospitals capable of emergency deliveries. However, ACOG acknowledges that not all facilities have this ability and that patients should be allowed to accept the increased level of risk if they want to have a TOLAC in a facility that cannot immediately perform cesarean surgery. Dr. Scott recognizes that immediate availability [for cesarean surgery] is not mandated for other obstetric emergencies such as placental abruptions or umbilical cord prolapse. As have virtually all other experts on the cesarean crisis, Dr. Scott calls for tort reform so that physicians need not fear malpractice suits in case a well-planned TOLAC turns disastrous. He also discusses the factors that are associated with successful TOLAC such as spontaneous onset of labor. Childbirth educators need to present information about TOLAC and VBAC even in a class of first-time parents in order to encourage TOLAC for those women for whom it may be appropriate in the future.
It is reassuring that ACOG leadership recognizes the role of education in bringing down the cesarean rate. Now, more than ever, childbirth educators need to teach about the healthy birth practices that promote safe and healthy birth. For those who teach in hospitals, they should not be prevented from presenting current evidence about factors that may increase risks for cesarean surgery. It’s time we were all on the same page.