Older Moms, Fear of Lawsuits Add to High Rate of Surgery


Logic dictates that delivery by caesarean section is a last resort in saving baby, mother, or both from undue harm. And while the surgery is still the more unlikely way a woman will deliver, 20% of all women undergo C-sections, making it the most common surgery performed today.

In the United States, C-sections skyrocketed from about 3% of all births 25 years ago to 22.8% in 1989--an all-time high, according to the National Center for Health Statistics. Now the rate has dropped a bit. But there is vigorous debate about whether the rates will continue to--or even should--go lower.

The controversy stems primarily from a disagreement over how safe it is for a woman who has already had one C-section to attempt childbirth vaginally. According to one expert, a decision on how far rates should drop should be preceded by examining how they got so high in the first place.

"There is now a long list of medical and obstetric complications of pregnancy for which caesarean delivery is recommended or usually applied," said Florida obstetrician Ronald A. Chez, writing in a recent special issue of the journal Contemporary OB/GYN.

What sent the rates spiraling upward? A consensus of experts thinks technology of the womb, more older women having babies, and fear of litigation are major contributors. Add to that the old idea taught in medical school--"once a caesarean, always a caesarean"--and the numbers exploded.

"When fetal monitoring came into use, physicians weren't properly trained in how to read them, which led to many unnecessary C-sections," says Dr. Michael McMahon, associate professor of maternal-fetal medicine and director of Continuous Quality Improvement in Obstetrics and Gynecology at the University of North Carolina in Chapel Hill.

"Inappropriate induction of labor and misuse of epidural anesthesia also contributed," he says, as well as women having fewer babies, larger babies and waiting longer (until age 35 and up) to give birth.

C-section rates increase with age because older women have higher-risk pregnancies. But overwhelmingly it is the fear of litigation that makes physicians err on the side of caution. The American College of Obstetrics and Gynecology reports that 77% of obstetricians are charged with malpractice at some point in their career.

"If the physician is aggressive with performing a C-section he is viewed as cautious and safe. If a physician is too aggressive with trying to get the baby out vaginally it is more frowned upon," McMahon says.

Aiming for a Drop to 15% by 2000

Doctors, hospitals, insurance companies and natural childbirth advocates have spent the past decade working toward a national goal to safely bring down the number of caesarean births. The U.S. Department of Health and Human Services set an ultimate national goal of dropping the caesarean rate to 15% by the year 2000.

"An attainable goal, but one that is unlikely," says Dr. Bruce Flamm, of Kaiser Permanente Medical Center in Riverside.

Flamm co-authored a collaborative study published earlier this year involving 28 health organizations that lowered their C-section rates through better labor management strategies, more patient and physician education and establishing criteria for vaginal births after caesareans, or VBACs. It is the VBAC--which has a 60% to 80% success rate--that deserves the most credit for lowering the total number of C-sections, experts say. Yet VBACs are controversial. Publicity over VBAC-related lawsuits at hospitals such as County USC Medical Center have had national repercussions. Many hospitals, County USC Medical Center included, now require women wishing to have a VBAC to sign a consent form because of the risks involved.

"Consent forms are a good idea for the VBAC situation. However, what I object to is the part of the form that lists and stresses rare complications," says Flamm. "There is the danger that the consent form will talk every woman out of having a vaginal birth."

Flamm says uterine rupture, which is the biggest concern involved in a VBAC, occurs in less than 1% of the cases. Infant death or brain damage are rarer still.

"If you ask women to sign a piece of paper that says they accept that there is a chance their baby could have brain damage as a result of choosing a VBAC then you'll find most women will say, 'Sign me up for a caesarean section right now,' " says Flamm.

An Understanding Beforehand Helps

It is one reason he and other experts believe the caesarean rate will go back up. Flamm says women with a strong desire to avoid C-sections often do. In cases in which there isn't fetal distress, he says, the decision can go either way.

"If the labor doesn't progress, the doctor might say we can go another hour or we can do a caesarean, and a very tired and worn out woman may opt for the C-section. This is why an understanding between the doctor and the woman before labor begins is important," he says.

Doctors find there is a perception among many woman that C-sections are safer and less painful. Yet while caesarean surgery can be lifesaving, it is still more risky than vaginal birth. Increased caesarean surgeries have caused more harm to women, not less, says McMahon.

"Women need to gather all the information they can before making a decision with their doctor," says Flamm.

Shawnna Richards of Sweethome, Ore., did just that and is comfortable with her plan to have a second caesarean section when her baby is due in October.

Labor did not progress in her first pregnancy. Although she was not induced and dilated fully on her own, after 26 hours--including two hours of pushing--her baby would not drop far enough into the birth canal. Fetal distress led to a caesarean. According to her doctor she has a 50% chance of delivering vaginally, but she wants another caesarean. Her doctor is behind her.

"The doctor feels my decision is the right one, not only because of the medical aspects, but also my mental attitude toward it," she says. "My feeling is that I want a healthy baby, and after my first experience, the least stress possible for myself. I don't feel any less of a woman or upset with myself for not being able to deliver in a traditional way."


Find more information about caesarean births on the Internet at http://www.childbirth.org/section/section.html. Or call the International Cesarean Awareness Network at (310) 542-6400.


The Caesarean Procedure

It takes just five minutes from the time the initial incision is made to the birth of your baby during a caesarean section, yet altogether the surgery can take close to 45 minutes. The procedure may go in a slightly different order then listed below or some steps might be left out depending on your situation, but in general here's what to expect from start to finish:

* Catheter inserted for urine collection.

* IV started.

* Medication given for stomach acids.

* Continual monitoring of heart monitor and blood pressure leads.

* Partial shave of pelvic area and antibacterial wash of the abdomen.

* Skin incision (transverse is most common).

* Incision in layers between skin and uterus.

* Uterine incision.

* Bag of waters broken.

* Disengage baby from the pelvis.

* Birth with either hands, forceps or vacuum extractor.

* Umbilical cord clamped and cut.

* Evaluate newborn.

* Remove placenta and repair uterus.

* Stitching layers between uterus and skin.

* Repair skin (usually top layer is stapled).

Source: Dr. Bruce Flamm, Kaiser Permanente Medical Center

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