“A perfect storm of medical, legal and personal choice issues.” More on the record high C-section rates:

The increase in primary C-sections and decrease in VBACs continue a trend established in the mid-1990s, the report noted. In 1996, C-sections accounted for just more than 20% of all U.S. births, with primary C-sections constituting about 13% of the surgeries. At the same time, VBACs rose to about 28% of births to women with a prior C-section. But since 1996, VBACs have declined sharply while C-sections have steadily increased.

The numbers are the result of a “perfect storm” of medical, legal, and personal choice issues, according to Dr. Bruce L. Flamm, area research chairman and a practicing ob.gyn. at the Kaiser Permanente Medical Center in Riverside, Calif. “All the forces are pointing toward higher C-section rates,” he said in an interview.

Increased intrapartum information available through electronic fetal monitoring can combine with malpractice worries to sway some ob.gyns. toward suggesting a C-section. “During labor, most ob.gyns. have in the back of their minds that any of the little blips on the monitoring strip could be used in a legal claim,” Dr. Flamm said. “While scientifically, there’s not much basis for that, it can sound good in a court of law.”

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  • j hubbard md

    I’m surprised at all the stories about patient-choice cesarean popping up in the lay and non-OB medical press and the emotion it engenders. There are a limited number of medical indications for cesarean delivery: baby won’t come out (abnormal labor unresponsive to stimulation, some cases of malposition, some multiple gestations, fetal structural abnormalities); baby intolerant of labor (fetal distress); labor inappropriate (prolapsed cord, other cases of malposition, abruption, placenta previa, certain multiple gestations); and possibly others. But many surgeries are performed without strict indications. Most plastic surgeries, and what about tubal ligation? What’s going on there? The patient chooses! Those who rant and rave that VBAC should be promoted and available within arms reach should direct their attention towards the generation of residents currently graduating without any experience in breech delivery, and little experience in forceps and vacuum deliveries, all in the context of, I think, an inappropriate paranoia regarding their risk of malpractice liability, and an almost complete dependence on electronic fetal monitoring. Those who go off on tangents of lawyer-blame are displaying their ignorance also of true liability risk. Physicians are placed in positions of trust and responsibility and there is a risk of malpractice liability inherent in the profession, but, I believe, not as much as perceived. Cost of malpractice insurance premiums is not the same as risk of tort liability. The bottom line of malpractice liability risk is whether the physician breached a duty of reasonable care regarding that individual patient to which a duty was owed. Not extraordinary or perfect care, but reasonable care. And reasonable care that would be provided by a minimally qualified practitioner providing care within the boundaries established by their profession. How hard can that be? (…instructions to the jury should…emphasize the ordinary reasonable care standard shaped, …by a “due regard for the state of medical science at the time plaintiff was treated.” Nowatske v. Osterloh, 543 N.W.2d 265 [Wis.1996]) OB’s should practice the way they were taught by their faculty in their residencies with due regard to current ACOG published guidelines and meticulous documentation. If after that the malpractice heat is too high, then get out of the kitchen. Some might retort that one cannot control all circumstances and what about the unforseeable disaster? But that’s part of the profession. I once performed a double footling breech delivery with an entrapped aftercoming head with a nuchal arm (causing the entrapment) on a gurney on the ER loading dock with only a bandage scissors, no records and no monitor. Never saw the patient before and I was only incidentally in the ER waiting for my own gyn patient to arrive. Never want to see that situation again. But there was really no liability risk. I acted as a minimally qualified practioner in the context of that individual situation. And I documented for 15 minutes. Fortunately, God takes care of babies and ignorant people.

  • Anonymous

    I think it would be interesting to see the correlation between the rise of STD’s (such as herpes) and C-sections. A woman with a transmittable STD there is always the what if factor and better to error on the side of caution then put a baby at risk.

  • gasman

    We cannot live in the fantasy world where we pretend that the patient, having been ‘informed’ then giving their consent carries any significance in this situation. The patient is never fully informed as to the physician’s state of mind, no to the complete body of medicine that may (or may not) be guiding the physician’s recomendations.

    If a doc says we need to cut in 5 minutes, the patient in in the same position they have always been in, just like the era a few decades before when the informed consent doctrine had not yet been invented. The patient must trust at that moment that this is the best and right thing to do. The physician gets a free pass if the patient makes the (un)informed decision to not accept such advice and has a bad outcome.

    The section rate is going up not because of careful analysis of outcomes data suggesting it is best this way, but because gut reactions of physicians are stearing patients toward this choice.

    Yes, it is the patients choice. But let’s not pretend that it is free from biases of those doing the informing.