I wrote this response a week ago but I was away and could not send it thru
my usual email server then egroups would not add any other email address.
Sorry it took so long to respond to this.
Let me say that there has been a problem with too high a rate of C sections in
the US for a long time. About 25 years ago, a concerted effort was undertaken
to reduce the rate after doctors realized the rate should not be at the 35%
rate it had been.
The American College of Obstetrics and Gynecology has defined absolute and
relative indications for C section. When hospitals are credentialed by the
Joint Commission on Accreditation of Healthcare Organizations (JCAHO) they must
demonstrate that they are within the accepted range for C sections or risk
credentialing. Loss of credentialing can affect the willingness of insurance
companies to contract for services.
Here is a table of how the decision is made for a Caesarean delivery. This is
not black and white; decisions are often judgment calls, not based on hard
science.
TABLE 19-6 -- Commonly Reported Indications for Cesarean Delivery
Indications
Selective
Subjective
Controversial a
Universally Accepted b
Fetal
Nonreassuring FHR c
Breech, frank
Breech, nonfrank
Breech, preterm
Very low birth weight (< 1,500 g)
Herpes simplex virus
Immune thrombocytopenic purpura
Congenital anomalies, major
Maternal-fetal
Cephalopelvic disproportion (relative)
Cephalopelvic disproportion (absolute)
Failure to progress
Placental abruption
Placenta previa
Maternal
Obstructive benign and malignant tumors
Large vulvar condyloma
Cervical cerclage (abdominal)
Prior vaginal colporrhaphy
Conjoined twins
a Controversy regarding need for universal application.
b Universally accepted if selective/subjective criteria present.
c Of a critical degree commonly associated with change in FHR variability.
Gabbe: Obstetrics - Normal and Problem Pregnancies, Third Edition
--------------------------------------------------------------------------------
Most doctors who deliver babies want to deliver in the safest, most
appropriate way for mother and child. Some less than competent or ethical
doctors might push to have a C section for inappropriate reasons. There are a
few less than competent and frankly incompetent people in all walks of life
from doctors to voice teachers. What to do about the bad doctors is a problem
and too complicated for this venue.
It is certainly true that childbirth is a natural event and most of the time,
things go fine. When all goes well, even a taxi driver can deliver a baby. In
fact, if all goes well, the baby delivers itself. The reason for another
person being involved is for the support of the mother and for those occasions
when things do not go well.
In the US, if we were socialized to have mothers and sisters and other family
and friends there for the delivery, one of the reasons for an assistant would
go away. When medicine became more technical after WW II, we lost touch with
the personal care in obstetrics. Now we have birthing centers where anyone the
mother wants present can be in the room while labor and delivery progress.
Something else we have in the US is a lot of lawyers. Here our population
expects every baby to be 100% healthy. If anything happens, the doctor is
blamed. About 70% of OB's are sued at some point in their careers. Is that
because most OB's in the US are incompetent? It's because they are blamed for
bad outcomes. If a fetus has a heart problem and has cerebral palsy, the
doctor has for decades been blamed and often sued for not operating sooner. We
now know that CP develops very early in pregnancy and has nothing to do with
birth asphyxia. But tell that to the sued doctors. Also, a small percentage
of US women do not want to deal with the discomfort of delivery. Plus in the
US, over 50% of the population is overweight. This increases the size of the
babies, making failure to progress more common.
We have a very heterogeneous population compared to some countries, such as,
Japan where the population is mostly Asian. This heterogeneity increases the
occurrence of problems in all aspects of medicine.
The real truth is that most doctors are doing a great job, many are doing a
good job and a few are bad. There is no conspiracy by doctors, HMO's or anyone
else to cut women open for any reason. For the individual woman, pick a doctor
you trust and work with him/her to get the care you deserve.
John
John J. Messmer, M.D.
Assistant Professor, Family & Community Medicine
Penn State College of Medicine
|
|
|  |
