Are unnecessary c-sections on the rise?

SmilingBluEyes · Apr 25, 2005

"MORE THAN HALF"??? Really? That is scary, and thankfully, not true where I practice.

At my hospital, the rate is more like 23%. I do believe there is a real increase in csection rates, and part of it can be directly correlated with rising INDUCTION OF LABOR rates. (among other things I will address in a few minutes).

Many women, I believe, are induced for labor before their bodies are "ripe". Why? Well for convenience, very often. Most often women will badger our physicians "to get it over with" They are tired of being pregnant, very tired of the discomforts and sleepless nights. But physician convenience strongly comes into play here, too. You will VERY often see a physician induce labor when he/she is on-call for a given period of 24 hours or scheduled to go out of town, or some other such thing. But it comes down to this fact: If the body is NOT ready to give birth, very little we can do in the medical community will truly change that. "failed inductions" and "failure to progress" are seen all the time in my practice.

Another factor: The use of continuous fetal heart monitoring is VERY controversial. Its value in improving outcomes in labor/deliver has been called into question over the years, and it has been postulated by some it does not improve the outcomes. Definately, some health care providers are eager to "jump the gun" when a baby has some questionable or non-reassuring patterns, and "call the section". Anecdotally, I have observed over time, the most experienced OB's tend to "wait it out" a bit longer, as long as there are reassuring aspects to the fetal heart patterns. The newer ones tend to get very excited and eager to go to section.

I also think consumer demand and litigious natures of obstetrics guide the rising rates. People want what they want and they want it NOW in our society! There are women who have actually told me they would prefer a csection to "save my bladder" or not have to endure hours and hours of labor. On our parts as HCP's, we are eager to always have good outcomes, so again, when a baby starts to show distress, the csection is always considered to prevent decreased oxygenation/acidosis later on, of the baby. In some cases, this is warranted. But how many, truly? I have seen 9/9 Apgar scores on countless babies who had truly "crummy strips" while mom was in labor. So, what did we accomplish? Well, some would say the csection was the reason the baby came out ok, saving further stress. Others would say we are "jumping the gun". Again, the practice will always to "err on the side of caution", particularly in obstetrics.

To sum it all up from where I sit (and this is just me, now), I think there are a lot of reasons csections are on the rise:

1. the use of continuous fetal heart monitoring (raises anxieties of both birth family and health care providers)

2. the ever-increasing litigious nature of the society in which we practice and live

3. the increasing rates of induction for purposes that are outside the realm of truly MEDICAL necessity

4. the increased desire to "meet a schedule" of both birthing family and doctor

5. the increasing expectation by the public that everything be "by the book" perfect. less than perfect outcomes (as seen on Baby Story) are not tolerated by anyone, even if they are not truly "bad" (I am putting this poorly, but I lack better words). doctors/midwives are under great pressure to produce the ideal out come on a schedule, I am trying to say.

6. Later bladder and pelvic integrity are being looked at more and more. Labor/birth are being increasingly linked (not necessarily rightfully, IMO), with later incontinence and the rise in hysterectomies and "bladder tucks" is being seen, as well. In my opinion, we are a nation in search of a quick, easy and permanent "fix"---- ("why do all those damn kegals, keep my weight in check, etc., when I can just have my bladder tucked later or avoid all this altogether by having a csection"?)----- our surgery rates reflect it, including csection and later, hystectomy and bladder procedures.

7. One truly legitimate concern: the rise of LGA babies (large for gestational age). I think we are seeing ever-increasing rates of gestational and Type 2 diabetes in the population, and as a result, larger babies are being born. We are becoming fatter and fatter and our eating habits worse and worse, leading to earlier occurences of diabetes, that used to set in more in people in their 50s and beyond. To expand:

Many physicians will do serial size u/s to see how big the baby is, and will induce at anywhere from 36-38 weeks' gestation to avoid the very real and present danger of of dystocia (the baby getting "stuck", particularly at the shoulders). If a baby is measured as truly macrosomic (greater than 4200 grams generally), , particularly in a woman with a pelvis that is measured to be small, a csection is very strongly considered and encouraged to avoid the dangers of dystocia. Diabetes is *EPIDEMIC*, and so we in the obstetric community have to respond in kind---yes by education and prevention, but also by avoiding dystocia of macrosomic fetuses. But make no mistake, diabetes has HUGE and increasing consequences in the birthing community as well as the general population.

Hope all this makes sense. I am not quoting studies, although I have read quite a few from AWHONN and ACOG. I am just giving you what you requested, a perspective from an experienced OB and GYN surgical nurse. Hope I helped you some.

I am sure there are more experienced and better- educated people who can chime in here. I would be eager to read their insights.

RNLaborNurse4U · Apr 25, 2005

Smiling blue eyes -- I agree with everything you have said. My biggest pet peeve, and one of the contributing factors to the ever-rising c/s rate is the "macrosomic/LGA" babies, or even having the history of one. I have worked at 2 different facilities, who have 2 very different guidelines as to what a macrosomic/LGA baby is.

Small community hospital - low c/s rate - macrosomic was any infant over 4000 gms. We *rarely* did a c/s just for macrosomia.

Where I am now, it all depends on the gestational weeks completed. For example:

39 completed weeks - 3600 gms and above is LGA

40 completed weeks - 3700 gms and above is LGA (many times, I've had a baby born at 39w 6d, birth weight above 3600, but below 3700, and they are still considered 39 weeks and LGA)

I've seen too many "CPD" as the reason c/s for 6-7# infants also. Hmph, yeah, really too big of a baby eh? I don't think so.

Some contributing factors I do see for failure to progress/CPD during labor is epidural usage reducing the ability of mom to change positions in labor, so a less than optimal fetal position cannot be changed (acynclitic, posterior).

I do agree with the above poster - STRONGLY - that we are inducing unripe cervixes (ok, I really don't know if that's the plural for cervix, but you know what I mean), and we are forcing labors onto bodies that are just not ready for labor yet. Why do we mess so much with mother nature?? Pt convenience - insistance even - physician convenience, etc. I've seen some very wacked out reasons for inductions. I quite honestly believe that many physicians today would rather just schedule as many c/s deliveries as possible, since they have a regular schedule for deliveries, and not have to be on call for those *horrendous* :rolleyes: naturally occuring labors.

Jen

L&D RN

JaneyW · Apr 25, 2005

What they said, and how!!! :uhoh3: I have seen all of this. We have also had a lot of almost pre-eclamptic 34-37 weekers that are being amnioed for lung maturity weekly so they can be delivered at our small community hospital with no NICU. I fully realize how dangerous pre-eclampsia can be and how quickly it can progress but a few high BPs here and there and some labs that are trending but not even out of limits yet? I wouldn't let someone stick that needle into my belly without a better reason. I would also want to be delivering at a higher level hospital regardless of the inconvenience to my OB. You can bet if you pit a 34 weeker primip that you will have a c/s.

tntrn, ASN, RN · Apr 25, 2005

What they all said, I agree with completely. At our place, an unripe cervix is gelled the night before, and early in the morning, pit is started. I don't work those hours, so I don't know how truly "ripe" they are by 0500. I do know that we do lots of 1700 sections "because you're just not progressing."

Then there are those with SROM who are 1 cm and thick. They are given a few hours (3 or 4 on pit) and when they haven't progressed, they'll get the Bard-Parker bypass because it's been "so long since your membranes ruptured."

Lots of 34 to 36 weekers in our NICU right now, due to all of the above. You have to wonder if Doctors read their own guideline books and journal articles and procedure manuals.

We just had a new nurse, who seemed to really know her stuff, quit because our docs insist on pitting to excess. She has cited "unsafe practices." And she's right.

Mimi2RN, ASN, RN · Apr 25, 2005

What they said, and how!!! I have seen all of this. We have also had a lot of almost pre-eclamptic 34-37 weekers that are being amnioed for lung maturity weekly so they can be delivered at our small community hospital with no NICU. I fully realize how dangerous pre-eclampsia can be and how quickly it can progress but a few high BPs here and there and some labs that are trending but not even out of limits yet? I wouldn't let someone stick that needle into my belly without a better reason. I would also want to be delivering at a higher level hospital regardless of the inconvenience to my OB. You can bet if you pit a 34 weeker primip that you will have a c/s.

We've been waiting for one of those all weekend. Mom has been a cervidil induction for PIH, she was 1cm last night. Baby is 34 weeks (will be 35, the rate things are progressing). We are all betting on a c/s, probably today.

Unlike you, we do have a NICU, and mom's don't get repeating amnios. This little one has a good chance of being on a vent, as mom has not been given betamethasone. Just think of this a job security!

hospitalstaph · Apr 25, 2005

Wow! I am not sure if I am happy to hear that nurses agree with my thoughts on the rise in c/s or not. I have some pretty strong feelings about labor and delivery practices and have worried that when I am done with school that I will find it difficult to work in an enviornment when there is so much room for improvement. God bless all of you L & D nurses who can focus on the patient and not let your feelings get the best of you. I am beginning to wonder if I may find postpartum care easier to handle. Of course then there are the breastfeeding issues............

Tracy

Maxs · Apr 25, 2005

My sociology professor said in lecture that "C-sections are increasing because the physicians will charge more money." I don't know if this is true, but he also stated that "70% all c-sections performed are unneccessary."

Maxs

SmilingBluEyes · Apr 25, 2005

My sociology professor said in lecture that "C-sections are increasing because the physicians will charge more money." I don't know if this is true, but he also stated that "70% all c-sections performed are unneccessary."
Maxs

can you quote me the study/report this person used for such a high figure? I am impressed a sociology professor would be so up on such stats and I would love to read the report/study myself. Thanks.

SmilingBluEyes · Apr 25, 2005

Wow! I am not sure if I am happy to hear that nurses agree with my thoughts on the rise in c/s or not. I have some pretty strong feelings about labor and delivery practices and have worried that when I am done with school that I will find it difficult to work in an enviornment when there is so much room for improvement. God bless all of you L & D nurses who can focus on the patient and not let your feelings get the best of you. I am beginning to wonder if I may find postpartum care easier to handle. Of course then there are the breastfeeding issues............
Tracy

I have strong feelings, too, on several fronts. I have seen some bad outcomes, (very bad) that make me shudder today to think about. I can see where, in such a litigious world, people would jump the gun in some cases. It's very scary when things go bad on ya. Birth SHOULD be a natural and healthy process, but in the rare event it does not turn out that way, the allegations fly and FAST.

windsurfr · Apr 26, 2005

My sociology professor said in lecture that "C-sections are increasing because the physicians will charge more money." I don't know if this is true, but he also stated that "70% all c-sections performed are unneccessary."
Maxs

Perfect... medical advice from a sociology professor.

Cesarian sections are done for two reasons:

1. fetal complications

2. maternal complications (decels, 9 lb baby in a 7 lb pelvis, etc)

If a c-section is performed for fetal complications, and there are no maternal complications... a lady partsl delivery can be performed in subsequent deliveries (V-back). The problem is that the LEGAL (not medical) system is mandating that v-backs be performed less and less. It has nothing to do with patient safety because v-backs are safer. It has everything to do with trial lawyers suing a hospital into the ground if complications arise from a v-back. Again, IT IS SAFER TO PERFORM A V-BACK THAN A REPEAT C-SECTION, however we are often not allowed to do so.

But I'm sure your sociology professor knows all of this....

windsurfr · Apr 26, 2005

Arrrggggg... I'm perseverating but it is aggrivating when I hear sweeping generalizations such as the "sociology professor's" comment.

Ask him/her about the huge increase in cephalopelvic disproportion (android pelvis, etc) seen in younger patients these days. This is one of the most common causes of c-sections today. See if the good professor knows about it's increasing incidence. Also ask about the increase in women older than 30 delivering... and potential complications that can arise. Ask about increased (voluntary) utilization of reproductive specialists and the resultant increase in high-risk deliveries. Ask about the increasing incidence of C-sections WORLDWIDE, not just in the US. These countries have completely different reimbursement patterns...

And we've already touched on the legal pressures to decrease VBAC's.

Finally, if anyone wants to do a VBAC, there must be facilities to deliver the baby within 15-20 minutes to avoid neonatal neurological problems. There must therefore always be an obstetrician and an anaethetist present in the labour ward at all times. Because of these requirements and the fear of litigation, the incidence of VBAC is steadily declining. Again, I'm sure your professor has thought this all through before making rediculous comments about physicians.