Kevin, M.D. - Medical Weblog

Boarded in OB/GYN. 13 yrs experience in small rural hospital without in-house anesthesia. I remenber in '88 in residency being pushed to lower the C/S rate. Much too high at 21%. So i did agressive VBACs for a dozen years. No problems. Now VBACs are not safe without in-house anesthesia and immediate operative capability, so no more VBACs at our only hospital. That was our only weapon to lower the C/S rate. CU warns the general population to avoid C/S. How? Haven't read the article, but i'm curious. I, personally, have never regretted any C-sections i've done. Haven't kept a percentage tally in years. Every patient is an individual case. The only question is: does this individual patient in this specific situation warrent operative delivery?
 

At my hospital, the overall C/S rate is 14 %. However, half of these is done for no medical reason at all, only because the woman in question (or her husband) demands it. If we say no, they turn to the Board of Health and we are forced to operate them.
In contrast with dr. Hubbard, I have done many cesareans with a bad taste in my mouth, both during and afterwards.
The bad taste gets even worse when the woman in question becomes pregnant again and gets a placenta previa or even worse, placenta accreta.
Makes you think about old Hippocrates. Primum non nocere.
 

Who funded this article to lower C-Section rates, the American Trial Lawyers association? Wait till they prove juvenile delinquincy rates are lower among C-section babies than Vaginal Dleiveries. Then they'll sue the OB-GYN when the pizza delivery man gets mugged.
 

You doctors are irrational. The US has 3-4 times more C-sections than every other industrialized nation, without ANY better results.

Doesn't it worry you that you are forcing your patients to go under major surgery, cutting them, drugging them, lacerating them . . . . for no quantifiable benefit.

You blame it all on the liability regime. Well, if that were true, wouldn't you expect lower C-section rates in states with caps??? Surprisingly, YOU DON'T.

It has more to do, I imagine, with a COMPENSATION Regime that REWARDS OBs for doing c-sections. Who cares if you slice open a woman if it means a downpayment on a lexis. Spare me yr self-serving denials--of course, you deny it because you have a financial interest in doing so.
 

Unfortunately, Anonymous 11:18 has a good point. I am not quite certain how it works in the US, but here we get reimbursed from the government for each C-section w do, no matter if there is a valiud indication or not. A normal vaginal birth gets us only a pittance.

Of course, if you manage to get complications on the C-section, such as an infection, then you've really struck gold, the money virtually pours in.

Two years ago I managed to get the C-section down to 11 % at our hospital, and was rewarded with an unpleasant phone call from the hospital economist, reminding me on what side my bread was buttered..so now we're up to 14 % again...
 

Anon 11:18,

I think your comments are the irrational ones. Caps or no caps, if a physician doesn't do a C-section, and there's a bad outcome, his or her ass is hauled into court because of a lawsuit, and then the malpractice premiums go through the roof no matter how bogus the lawsuit. The ObGyn literature has clearly shown a relationship between increasing cerebral palsy lawsuits and increased numbers of sections. And as far as I know, in many managed care plans, there's one flat fee for pre-natal care. I may be wrong and I'd have to ask my colleagues, but I don't think there's much of a financial incentive for doing sections.
 

I had a VBAC and had to fight to get it done. They were scared. It was against the hospital policy, I was told. I got the feeling that it was more about liability than about money.
 

I guess the Lexus and big money idea is why NOBODY graduating from medical school is going into OB_GYN. I'd rather have my testicles set on fire then be a Lawyer target and go into OB-GYN. If I was a hospital risk manager i'd demand 100% of deliveries be C-Sections. Why take the malpractice risk? The reason the C-section rate is high is because every OB-GYN has a target on their chest so every uterus has a target on it. OB-GYN is the most Fucked-up medical liability crisis their is.
 

Interesting comments. I did look at the CU article. All it said was: 1) a lot of C/S's are unneccessary; 2) query your OB about their C/S rate; and 3) favor midwives. Some thoughts: Midwives do have a lower C/S rate but they might have a population self-selected for low risk. I don't have exact data but I believe here in Hawaii reimbursment for C/S is about $200 over vaginal delivery. Is that reward enough to tip the scales? You can lease a Lexus for less than $600 per month. So...3 extra sections/month and I get my Lexus! Just kidding. Here's something I do occasionally; when you perform a procedure that someone might be looking over your shoulder at, xerox a copy of the reference (text or journal) that validates your decision and put it in the chart. If you can't substantiate your action, why are you doing it? And if you can back up your decision, why do you care about CU, or midwives (bless their hearts), or ATLA, or Mothering magazine, or the hospital accountant. Tell them to come to L&D at 3am and make a decision. Happy New Year from Hawaii.
 

Welcome to JACHO -- the decision is out of the hands of many (esp rural) physicians.

In my area, we have some OB's, some FP's that do OB, and some CRNA's. Very few to no 24 hour anesthesia within 150 miles. VBAC is now big city medicine -- and even then only at teaching hospitals or tramu centers. Even many of them won't perform a VBAC w/o an attending OB in the building.

Who cares about the risk/benefit for the patient. JACHO has decided that VBAC's are evil, and therefore they are not done w/o a tramu setting -- thus massively increasing c/s rates.
 

Welcome to JACHO -- the decision is out of the hands of many (esp rural) physicians.

In my area, we have some OB's, some FP's that do OB, and some CRNA's. Very few to no 24 hour anesthesia within 150 miles. VBAC is now big city medicine -- and even then only at teaching hospitals or tramu centers. Even many of them won't perform a VBAC w/o an attending OB in the building.

Who cares about the risk/benefit for the patient. JACHO has decided that VBAC's are evil, and therefore they are not done w/o a tramu setting -- thus massively increasing c/s rates.
 

I am a Certified Professional in Healthcare Quality with 23 years experience in the field - all in acute care hospitals. I was part of the move to more VBACs in the early to middle 90s, by providing the OB/Gyn department comparative information on rates and reasons.

After a fairly successful increase n our VBAC rates, we had two uterine abruptions in a 12 month period. They were both in the daytime, both doctors happened to be at the bedside. Anesthesia was available for one of the cases. Both babies were delivered within 15-18 minutes from the decision to cut.

The baby on the case for which anesthesia was available, did not survive. The baby on the case without anesthesia did survive, as the OB/Gyn doc knew how to do fast local infusion to reach the baby. Anesthesia made it in time for the doc to close the mother's incision. These two cases had a chilling effect on all the docs doing VBACs and our rates fell a bit, for a while.

If I remember correctly, somewhere around 1997 the American College of OB/Gyn and the American Society of Anesthesia led the charge to require both the OB doc, the Anesthesisa provider, and the surgical team to be in the hospital during the VBAC trial of labor. Only THEN did the JCAHO made it a requirement. In fact if you want to blame someone it would have to be the ACOG and the ASA.

I am now at a small rural hospital, sole community provider, with one OB doc on staff and no Anesthesia/surgical team in house 24/7. We have a Zero VBAC rate because it isn't safe with our set up.

I share the concern of those who think America's C/Section rates are too high. Our hospital rates are too high and we are agressively trying to figure out why and what to do about.

We all may have to wait until Beverly Crusher can just beam the baby out of the Mom to have lower rates of surgical intervention!