OB-GYN-L Messages for June, 2005: Re: Too Few C-sects, Dr. Sandland Responds

Re: Too Few C-sects, Dr. Sandland Responds

From: Anna Meenan, MD

annam@uic.edu

Wed Jun 29 16:57:33 2005

-- Anna Meenan, MD

Am J Obstet Gynecol. 1994 Sep;171(3):797-8. Related Articles, Links

Fractured clavicle is an unavoidable event.

Chez RA, Carlan S, Greenberg SL, Spellacy WN.

Department of Obstetrics and Gynecology, University of South Florida College of Medicine, Tampa.

OBJECTIVES: The three purposes of this study were to determine the incidence of fractured clavicle in newborns delivered at our hospital, to identify preventable risk factors associated with these fractured clavicles, and to identify the acute sequelae of fractured clavicle in these infants. STUDY DESIGN: We performed a retrospective chart review of all women delivered during an 8-month period. Newborns with radiologically proved fractured clavicles were compared with a control group of infants delivered immediately before and immediately after the study patient. Maternal, labor, delivery, and newborn factors were analyzed statistically. RESULTS: A fractured clavicle occurred in 0.9% (34/3880) of vaginally delivered newborns; none occurred with an abdominal delivery. The only statistically significant risk factors were gestational age, shoulder dystocia, and newborn weight. No infant with fractured clavicle had a 5-minute Apgar score < 7, an abnormal cord blood pH, or an abnormal neurologic examination. CONCLUSIONS: We did not identify a specific perinatal factor that can be changed to avoid clavicle fracture. The injury appears to be an unavoidable event without permanent sequelae. Thus it is not an indicator for quality improvement.

Acta Obstet Gynecol Scand. 1996 Apr;75(4):378-81. Related Articles, Links

Prospective study of incidence and predisposing factors for clavicular fracture in the newborn.

Many A, Brenner SH, Yaron Y, Lusky A, Peyser MR, Lessing JB.

Department of Obstetrics and Gynecology "A", Tel-Aviv Sourasky Medical Center, Serlin Maternity Hospital, Tel-Aviv, Israel.

OBJECTIVE: To determine the incidence of clavicular fracture, associated fetal and maternal risk factors and its connection with quality care control. SUBJECTS AND METHODS: A total of 3030 newborns delivered vaginally were evaluated for clavicular fractures by three separate physicians. The study group included all newborns with fractured clavicle. A control group consisted of 52 newborns delivered vaginally with no history of fractures. Maternal records were evaluated for possible predisposing factors. RESULTS: Forty-six (l.5%) newborns were found to have clavicular fractures. When compared to the control group, they were found to have a higher birthweight (3710+/-352gm vs 3235+/-405gm) an older maternal age (30.5+/-5 bs 27.7+/-6), a longer second stage of labor (34 min vs 23 min), higher rate of instrumental deliveries (13/46 vs 6/52) and shoulder dystocia (6/46 vs 1/52). Nearly 80% of newborns with clavicular fractures weighed less than 4000 gm. Multivariate analysis demonstrated two independent variables; birthweight over 3500 gm and maternal age >29. CONCLUSION: Clavicular fractures are associated with higher birthweight, older maternal age, longer second stage of labor, instrumental deliveries and shoulder dystocia. However, in most cases this injury cannot be predicted prior to delivery and thus cannot be an indicator of quality control.

At Wed, 29 Jun 2005, art fougner, md wrote: > >Anna > >i think the article may have missed a possible link to clavicular >fractures as an adverse outcome monitor. would be worth checking. > >art > >At Wed, 29 Jun 2005, Anna Meenan, MD wrote: >> >>Your point? >> >>-- >> Anna Meenan, MD >> >>At Wed, 29 Jun 2005, art fougner, md wrote: >>> >>>All newborn clavicular fractures are reported to the NY State Health >>>Dept as an adverse outcome ... >>> >>>art >>> >>>At Tue, 28 Jun 2005, Stmidwife@aol.com wrote: >>>> >>>>I was given permission by Dr. Helen Sandland to post her response, which w s >>>>originally posted on a blog sight to the recent circulated newspaper >>>>article. The original article is below her response, I know it was posted on this >>>>list. Thought you might be interested. >>>> >>>>Sue >>>> >>>>Just for clarification--my babies were most likely to be born at 39 >>>>weeks--none were born "post-mature", there was no increase in macrosomia or diabetes. >>>>I have had NO permanent brachial plexus injuries--a couple of transient on s >>>>that healed completely--over 17 years. >>>>I get one or 2 more clavicle fractures a year but they are not deemed >>>>significant unless there is a brachial plexus injury and there wasn't in t ese. I >>>>was well within published norms for clavicle fracture but the reason I fee I >>>>had one or tow more a year than thte other OB's is that I as doing 3 times >>>>the average percentage vaginal births. That is the only issue--there is no >>>>increase in REAL problems--actually less since I didn't have to deal with ost >>>>-op complications!! >>>>I have had no brain damaged babies and hope to keep it that way! >>>>It is the position of WHO and MArch of Dimes that low birth weigth and >>>>prematurity are the biggest problem faced by newborns--they have allocated ver 7 >>>>million dollars this year to study the problem. I was very proud of my low >>>>prematurity rate --never thinking for a nano sceond that I would be cited >>>>because my babies were more likely to be TERM (not post term) and heavier(N T >>>>MACROSOMIC) >>>>Oh well--life is forever a mystery---but I will continue to do my thing in >>>>Mississippi. It was very important that I send my children a clear message n >>>>this---how could I cut women open just so they could keep kayaking on the C pe >>>> Fear River??? >>>>My soul is very much at peace with my decision to leave--I would have lost >>>>all my self-respect and sleep had I caved. >>>>Posted by: _Helen Sandland_ (mailto:drsandland@yahoo.com) >>>> >>>>Original article >>>> >>>>Dr. Sandland – known for the past decade as the doctor local women ent to >>>>if they desired natural, vaginal deliveries – moved to Mississippi ast week >>>>after being told by New Hanover Regional Medical Center administrators to o >>>>more c-sections. >>>>She refused. >>>>“I leave NHRMC with my morals and backbone absolutely uncorrupted �? Dr. >>>>Sandland wrote in her resignation letter dated May 15. “I am going o practice >>>>with a long-time friend, whose scruples I admire, and in a place where >>>>unnecessary surgery is not encouraged.�? >>>>During a time when national health officials have sounded the alarm that t e >>>>cesarean section rate is at an all-time high and needs to be sliced, Dr. >>>>Sandland’s case raises questions about what factors are pushing the numbers >>>>higher. >>>>The rate doubled in five years and continued to increase until 1990, when t >>>>peaked at 22.7 percent. It held steady and slightly declined through the >>>>1990s before picking up again in 1998. The rate now sits at 26.1 percent of >>>>4,021,726 births nationally. North Carolina’s rate is 26.4 percent. >>>>“I don’t see any end in sight right now,�? said Dr. ruce Flamm, regional >>>>chairman of The American College of Obstetricians and Gynecologists, saying >>>>there’s little concrete data on how many c-sections are unnecessary “All of >>>>the current pressures seem to be going in the direction of more c-sections, not >>>>less.�? >>>>He and other national medical experts are concerned with the trend; a trend >>>>they believe is pushed by medical liability issues, convenience for both >>>>doctors and patients, and perhaps hospitals’ financial and staffing pressures. >>>>“There are some doctors who say the only cesarean section I have ev r been >>>>sued for is the one I didn’t do,�? Dr. Flamm said. “ t’s a sad but true >>>>situation.�? >>>>Not only is there a decreased chance of getting sued if a c-section is >>>>performed, but it’s less time consuming to perform c-sections inste d of waiting >>>>out long and sometimes difficult labor. >>>>But, as many obstetricians will point out, pressure by doctors or hospitals >>>>is only part of the equation. Some women, they say, really are looking for >>>>c-section because they fear the pains of labor or want to schedule it when >>>>grandparents are in town or around holidays. >>>>Regardless of the reason, health officials across the country are concerned >>>>with the rates. >>>>Leading medical groups such as the Centers for Disease Control and >>>>Prevention, National Institutes of Health and the World Health Organization have all >>>>spoken out against the increase, demanding the medical community investiga e >>>>ways to lower the rate to 15 percent or below. >>>> >>>>Dr. Sandland thought she was doing just that. >>>> >>>>In the decade she has delivered babies and cared for their mothers in New >>>>Hanover County, she has always had a rate below 10 percent. >>>> >>>>“I’ve always maintained I’m a midwife with a MD beh nd my name,�? she said >>>>from her two-story Pine Valley home last week while preparing to move. � ��It’s >>>>better for Mother Nature to decide when it’s time, not the doctor. y >>>>philosophy is you don’t interfere unless you really have to.� ? >>>>Her philosophy, admittedly different from the mainstream, attracted many >>>>patients who wanted the best chance of having a vaginal delivery. Dr. Sandl nd >>>>became known as one of the few doctors in the area who would try to deliver >>>>breech babies naturally or pursue a vaginal birth with a woman who already ad >>>>one child with a c-section. Her solo practice boomed. >>>>If her lack of medical malpractice lawsuits and gratitude of patients are f >>>>any account, she was not only popular, but also successful. >>>>Fellow Wilmington obstetrician Dr. Joshua Vogel said though she was >>>>considered too set in her ways or a renegade by some doctors, he admired he talents >>>>to deliver naturally in situations when other doctors would have >>>>automatically pushed for a c-section. “She was a valuable asset fo patients,�? he said. >>>>Dr. Sandland said she became the target of the hospital’s professio al >>>>review and credentials committees. Because it is confidential by law, she ould >>>>not legally discuss the peer review process. >>>>But the Star-News viewed two letters addressed to her from committee >>>>members. Written on New Hanover Regional letterhead dated July 6 and July 7 2004, >>>>the letters discuss the conversation committee members had with her. >>>>The first letter, written by Dr. Cobern Peterson, chairman of the >>>>Professional Review Committee, stated “concerns�? regarding er practice. They include >>>>higher than average infant birth weights, much lower than average c-sectio >>>>rates and later than average gestational age of neonates at delivery. >>>>The letter states “the main concern reiterated several times was an overall >>>>practice attitude rather than any individual case.�? >>>>The next letter, written by Dr. Janelle Rhyne, acting chairman of the >>>>Credentials Committee, states Dr. Sandland’s privileges at the hosp tal would be >>>>reappointed for a period of six months but monitoring would continue. >>>>It reads, “Your c-section rate is to be within an acceptable range s >>>>determined by the NHRMC OB/GYN Department with a plus or minus deviation of two.�? >>>>No reason was given in the letters, other than adding the committee would e >>>>watching other outcomes like collarbone fracture – something expe ts say is >>>>a minor, common complication of vaginal deliveries. >>>>New Hanover Regional spokeswoman Kendra Gerlach said two standard deviatio s >>>>equates to five or six percentage points above or below the average. >>>>The c-section rate at New Hanover Regional is 27.9 percent. At the time, D . >>>>Sandland said, it was about 26 percent. That meant the committee was >>>>requiring her to reach at least a 20 percent c-section rate. To do so, sh ’d have to >>>>more than double her current rate. >>>>“It’s just not something I could see happening,�? sh said. “You just don’t >>>>change your practices overnight. I certainly wasn’t going to change them to >>>>meet some arbitrary quota.�? >>>>Jack Barto, chief executive officer of New Hanover Regional, said he was n t >>>>familiar with the letters but that it sounded to him more like a “ uideline�? >>>> than a “quota.�? >>>>But Dr. Sandland said that in a March conversation with Mr. Barto, part of >>>>the reason became clear. >>>>“Barto said in a separate meeting that a c-section rate of 25 perce t would >>>>reduce the likelihood of getting sued,�? she recalled. >>>>Mr. Barto confirms he had a meeting with Dr. Sandland but would not discuss >>>>the conversation. >>>>“I had a private conversation with one of my physicians,�? h said, >>>>asserting he did not recall discussing liability issues. “I talked ith her about a >>>>variety of topics.�? >>>>The hospital’s chairman of the OB/GYN department, Dr. Bora Duruman, declined >>>>to comment on Dr. Sandland but said doctors are not pressured to do >>>>c-sections nor do they pressure patients toward c-sections unless the proc dure is >>>>medically necessary. >>> >>>-- >>>art fougner, md >>> >>> "If you don't know where you are going, you will wind up somewhere else." >>>Lawrence Peter Berra >>> >-- >art fougner, md > > "If you don't know where you are going, you will wind up somewhere else." >Lawrence Peter Berra >

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