Re: Caesareans on the rise again ? (long)
From: art fougner, md (evsono@pipeline.com)
Tue Aug 29 05:27:21 2000
currently the best way to prevent a section is called contraception.
art
At Mon, 28 Aug 2000, jkulkin wrote:
>
>This is the report I referenced a few weeks ago. I think everyone should read it
>especially since the college wrote it. I know of employer groups looking hard at
>hospiral C/S rates and getting ready to possibly divert business to facilities
>with serious quality initiatives in place. During this time of low unemployment
>and a shrinking labor mass, employers want to spend dollars on cost effective,
>quality care. They want measures and not rhetoric. No one disputes the increase
>recognition of VBAC complications. It's just a piece of the picture. This
>article is clearly the tip of a new type of cieberg that American medicine hasn't
>seen. When employers asked for care to be managed years ago, they didn't
>appreciate what they were getting into. They are "very aware" now of what can be
>done to improve the system. it's quite remarkable to sit around a table of
>benefit managers and hear them discuss, reaonably intelligently from a scietific
>perspective, the pros and cons of ERT or non sedating antihistamines.
>
>JK
>
>RModugno@aol.com wrote:
>
>> Comments anyone?
>>
>> Caesareans on the Rise Again
>>
>> By LAURAN NEERGAARD
>> .c The Associated Press
>>
>> WASHINGTON (AP) - Caesarean sections started dropping slowly in the early
>> 1990s after an outcry that American women undergo too many - but now they're
>> on the rise again.
>>
>> Most puzzling: Why C-sections are increasing in first-time moms, not just in
>> women who previously had one. And where pregnant women live determines how
>> likely they are to wind up on the operating table - C-sections are more
>> common in the South than out West.
>>
>> Now, with Caesareans inching back up to 22 percent of U.S. births, the
>> nation's leading obstetricians' group is issuing new guidelines to reduce
>> unnecessary C-sections and reserve the surgery for mothers and babies who
>> truly need it.
>>
>> There are many suspects in the C-section rise - state-by-state variation
>> particularly suggests doctors' habits sometimes can overshadow medical need.
>>
>> ``Maybe we've become too technical,'' says Dr. Jean Walker, an attending
>> obstetrician at Chicago's Rush-Presbyterian-St. Luke's Medical Center, which
>> is taking new steps to lower C-sections. ``We're going back to natural things
>> like walking more often and birthing balls and really encouraging natural
>> descent of the fetus.''
>>
>> To do that, Rush just began a nursing change - back to more continuous,
>> hands-on care during early labor, especially for first-time moms whose labor
>> takes longer, a big reason for C-sections. After all, studies show women who
>> have continual care from nurses or midwives get fewer C-sections than when
>> busy nurses just pop by every so often to check how early labor is
>> progressing.
>>
>> Make no mistake: Caesareans can be life- or health-saving for many mothers
>> and babies. Fetal distress, disorders that make labor risky for the mother, a
>> baby simply too big or wrongly positioned all are important reasons for
>> C-sections - and hospitals that specialize in high-risk pregnancies will
>> perform more.
>>
>> But avoiding unnecessary C-sections also is important. Women's risk of death,
>> although still small, is three to seven times higher than during vaginal
>> delivery, says the American College of Obstetricians and Gynecologists. Not
>> to mention increased pain, longer hospital stays and a higher risk of
>> post-delivery infection.
>>
>> C-sections have risen for three years, climbing another 4 percent in 1999 to
>> account for 22 percent of live births, the government reported this month.
>>
>> That's lower than the nation's high of 25 percent in 1988 - but nowhere near
>> the federal goal of a 15 percent C-section rate this year. And it reverses a
>> steady decline in C-sections between 1989 and 1996.
>>
>> Now look state-by-state: Fewer than 17.5 percent of births in Utah,
>> Wisconsin, Colorado, Alaska or Vermont are C-sections. But more than one in
>> four births are C-sections in Mississippi, Louisiana, Arkansas and New
>> Jersey.
>>
>> Worse, the most dramatic variations in hospitals' C-section rates are among
>> first-time moms with healthy babies in the right birth position, says the
>> ACOG.
>>
>> Those discrepancies suggest doctors' habits play a big role, says Dr. Roger
>> Freeman of the University of California, Irvine, who chaired the new ACOG
>> guidelines that outline practices and conditions linked to higher C-sections
>> - and urge doctors to check for ways to improve.
>>
>> Among the list:
>>
>> A previous C-section is the biggest risk factor for having another. If the
>> surgical cut was in the lower abdomen - not the upper - ACOG says most
>> healthy women can try vaginally delivering their next baby as long as a
>> surgeon is standing by if emergency surgery is needed. Most low-risk mothers
>> who try can deliver vaginally, says ACOG, encouraging women to carefully
>> discuss this option with their doctors.
>>
>> Yet the rate of vaginal births after C-section fell to 23.4 percent last
>> year, down 17 percent since 1996.
>>
>> Slow labor is a big reason for C-sections in first-time moms. ACOG cautioned
>> against surgery too early, and Chicago's Walker also stressed patience,
>> saying here that nurses are key. ``With younger nurses, I get more phone
>> calls saying, 'Nothing's happening, she needs a C-section,''' while older
>> nurses are ``a little more attentive, more patient'' with slow labor.
>>
>> ACOG says demanding a painkilling epidural too early, before the cervix is
>> dilated 4-5 centimeters, increases your C-section risk. But this is
>> controversial - Walker urges women to ask for a less potent ``walking
>> epidural'' that she says doesn't increase the risk.
>>
>> For breech, or feet-first, babies, doctors should consider trying to turn the
>> baby headfirst by ``external version,'' pushing on the mother's abdomen
>> before automatically operating, ACOG advised.
>>
>> While ACOG targets doctors, consumer advocates advise pregnant women to ask
>> about C-section rates when choosing a physician and hospital. Pick one with a
>> lower rate, or who's open to a second opinion for nonemergency surgery, and
>> ``it's more likely you're going to avoid an unnecessary C-section,'' says
>> Public Citizen's Dr. Sidney Wolfe.
>>
>> *************************************
>>
>> *************************************
>> Robert Modugno MD MBA FACOG
>> Marietta, GA
--
art fougner, md
A series of 1000 cases begins with but a single anecdote.
