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Experts say cesarean section rates are headed 'Sky-High'. (Fewer VBACs Cited as One Factor).

VAIL, COLO. -- Cesarean section rates are headed up, up, and away.

"I suspect that the cesarean section rate is probably going to double by the next generation," Dr. Ronald S. Gibbs predicted at a conference on obstetrics and gynecology sponsored by the University of Colorado.

The total cesarean delivery rate has climbed steadily from 20.7% in 1996 to 22.9% in 2000, according to data from the Centers for Disease Control and Prevention in Atlanta.

Dr. Gibbs and other speakers cited multiple contributing factors. A major one is the American College of Obstetricians and Gynecologists' recent recommendation that vaginal birth after cesarean (VBAC) section be attempted only if physicians are "immediately available" to provide emergency care. That's already having a chilling effect.

In addition, the recent ACOG practice bulletin recommending against planned vaginal delivery of singleton breech presentations will cause a bump in C-section rates. However, the effect will be small because three-quarters of such cases are already managed by planned C-section.

A bigger contributor to increased cesareans will be the patient choice issue, with a growing number of women opting for C-section to avoid perineal dysfunction after vaginal delivery, said Dr. Gibbs, the E. Stewart Taylor Chair and professor of ob.gyn. at the university in Denver.

There is no mistaking ACOG's intent in recommending that VBAC be restricted to settings where physicians are "immediately available" for emergent operative delivery, he said. "I don't think 'immediately available' means you're in your office six blocks away or you're at home. I think it means your backside is in the hospital," he emphasized.

"This is an issue that's been resolved. If you are not in the hospital, and you don't have the ability to get a patient immediately to the OR and have someone who's competent give that patient a safe anesthetic, then you shouldn't be doing VBACs--and if you are, you really ought to make sure your quality assurance people are going to back you up," the ob.gyn. advised.

Dr. Harvey Cohen, a Denver ob.gyn. in a four-physician private practice, said that the "immediately available" criterion has put physicians like him in a bind.

"The real issue now is [whether you're] willing to have an obstetrics practice where you're going to devote a person to staying in the hospital all the time. If you don't have a resident staff to help you, and you're a practitioner who's totally in control of your patients all the time and responsible to them, I'm going to predict for you--as I can now see happening in Denver--that the [C-section] rate is going to go sky-high," he said.

Rural obstetricians cited another problem: Even though many of them would like to offer their patients VBAC, they typically can't get an anesthesiologist or nurse anesthetist to stay in the hospital. And that precludes VBAC because of the now-unacceptable medicolegal risk.

According to CDC data, the VBAC rate among women with a previous cesarean dropped from 28.3% in 1996 to 20.6% in 2000.

Turning to the recent change in practice regarding the singleton breech, Dr. Henry L. Galan, another ob.gyn. at the university, cited a highly publicized multi-center study by the Term Breech Trial Collaborative Group as its basis. That trial led to ACOG's recommendation in December against planned vaginal delivery.

In this 2,088-patient study, the combined end point of perinatal or neonatal mortality or serious neonatal morbidity was 1.6% with planned C-section, compared with 5% with planned vaginal birth (Lancet 356[9239]:1375-83, 2000).

The study has flaws rendering it vulnerable to criticism. Nonetheless, speakers agreed that, once it was published, the fate of planned vaginal delivery of the singleton breech was sealed. There had already been increasing concern among ob.gyn. leaders regarding younger American obstetricians' lack of experience with the procedure. Now here was evidence that the procedure is intrinsically less safe than planned surgical delivery.

"People have been doing cesarean deliveries for breeches because they wanted to avoid medicolegal issues. This study was the icing on the cake. It was what everyone was waiting for," Dr. Gibbs said.

Today, a highly motivated woman seeking vaginal breech delivery may with difficulty be able to find an obstetrician experienced in the procedure and willing to take on the medicolegal risk. "I guarantee that in another generation, they're not going to be able find anyone to do it," Dr. Gibbs said.

Congenital Malformation-- Specific Infant Mortality Rates, U.S.,

 1970-1976 1977-1983 1984-1990 1991-1997

Number of Live Births 23,154,676 24,715,275 27,104,323 27,807,720
Number of
 Malformation Deaths 65,866 61,637 57,737 48,115

Source: Obstet. Gynecol. 98(4):620-27, 2001
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Author:Jancin, Bruce
Publication:OB GYN News
Date:Apr 1, 2002
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