Reducing cesarean sections at a teaching hospital

Reducing cesarean sections at a teaching hospital Luis Sanchez-Ramos, MD: Andrew M. Kaunitz, MD: Herbert B. Peterson, MD,' Beverly Martinez-Schnell, PhD,' and Robert J. Thompson, MD" Jacksonville, Florida, and Atlanta, Georgia A department-wide effort to reduce the cesarean section rate at the University Medical Center of Jacksonville (Florida) began in 1987. University Medical Center, a teaching hospital with approximately 4500 annual deliveries, serves an almost exclusively indigent obstetric population. Overall, the cesarean section rate declined from 28 per 100 deliveries in 1986 to 11 per 100 in 1989. Decreasing the number of repeat cesarean sections played an important role in reducing total cesarean deliveries. In 1986 32% of women with prior cesarean sections underwent a trial of labor. By 1989 this proportion had increased to 84%. In 1986 65% of women undergoing a trial of labor were delivered vaginally. By 1989 this proportion had increased to 83%. For these reasons the proportion of patients who had repeat cesarean sections dropped from 8% in 1986 to 3% in 1989. Changing approaches to the evaluation and management of dystocia and fetal distress also helped to lower the overall cesarean section rate. In 1986 cesarean sections for at least one of these two indications accounted for 14% of all deliveries. By 1989 this percentage had dropped to 4%. Because selective criteria for vaginal delivery of fetuses in breech presentation were maintained, incremental increased rates of vaginal breech delivery had only a minimal impact on lower overall cesarean section rates. The reduction in the number of cesarean sections was accomplished without compromising neonatal outcomes. In fact, during this 4-year period neonatal mortality rates actually decreased; neonatal morbidity rates remained stable. Our experience suggests that cesarean section rates can be substantially reduced without compromising the newborn. (AM J OBSTET GVNECOL 1990;163:1081-8.)

Key words: Cesarean section, perinatal outcome, trial of labor

In the United States the rate of cesarean sections has quintupled from 5% of obstetric deliveries in 1964 to greater than 25% in 1988.' Some have suggested that this increase in cesarean deliveries has played a major role in lowering neonatal mortality. 2 Others note the negative impact high cesarean rates have on maternal health'· 4 and obstetric care costS.5 Although a broad consensus agrees that current rates of cesarean section are excessive, the number of such deliveries remains high. This article describes efforts to reduce cesarean sections at a teaching hospital.

Material and methods University Medical Center of Jacksonville, one of 10 regional perinatal centers in Florida, serves a largely

From the Department of Obstetrics and Gynecology, University of Florida Health Science Center,' and the Centers for Disease Control, b Public Health Service, United States Department of Health and Human Services. Presented as Invited Guest at the Fifty-second Annual Meeting of the South Atlantic Association of Obstetricians and Gynecologists, Palm Beach, Florida, january 28-31, 1990. Reprint requests: Luis Sanchez-Ramos, MD, Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Florida Health Science Center, 655 West 8th St., jacksonville, FL 32209. 6/6/22008

high-risk, low-income obstetric population. All obstetric patients are cared for by resident physicians in obstetrics and gynecology and nurse-midwives supervised by full time faculty members. Beginning on July 1, 1987, a recently hired faculty perinatologist (L.S.R.) introduced new guidelines regarding intrapartum management of women with prior cesarean sections. Patients with one or two previous cesarean sections were counseled regarding the benefits oftrial oflabor. Patients with low transverse and vertical scars not extending into the uterine corpus were considered candidates for trial oflabor. Patients with either a previous classic cesarean section, myomectomy in which the uterine cavity had been entered, or previous uterine incisions of unknown type were not considered candidates for vaginal delivery. The option of electing a repeat cesarean section was not routinely offered to patients who otherwise were appropriate candidates for trial oflabor. Patients with priot cesarean section(s) who requested postpartum sterilization likewise were not routinely offered a cesarean section. The intrapartum management of the patients undergoing a trial of labor included continuous electronic fetal monitoring. After rupture of membranes an intrauterine pressure catheter and fetal scalp electrode were applied. As for other intrapartum patients, oxy-

1081

1082 Sanchez-Ramos et al.

September 1990 Am J Obstet Gynecol

Table I. Cesarean sections among total deliveries at University Medical Center, Jacksonville, 1986 to 1989 (N Cesarean sections

No.

Primary Repeat TOTAL

1986

= 4350)

I

(N

%

No.

849 349

19.5 8.0

1198

27.5

1987 = 4285)

I

(N

%

No.

643

15.0

952

22.4

319

7.4

tocin for induction and augmentation or both and epidural anesthesia were used. New guidelines for performing primary cesarean section were also established in July, 1987; these considered dystocia, fetal distress, and fetal malposition as potential indications. Dystocia was diagnosed according to the criteria outlined by Friedman. 6 Cesarean delivery for arrested dilatation was performed after no further dilatation was noted with more than 2 hours of regular uterine contractions (2! 150 Montevideo units), whether contractions occurred spontaneously or as a result of oxytocin augmentation. Other diagnoses classified as arrest disorders were prolonged deceleration phase (>3 hours for nulliparous women and 2!1 hour for multiparous patients), and arrest of descent (no progression in descent for more than 1 hour for nulliparous women or for more than 30 minutes for multiparous women) during the second stage of labor.' In cases of arrest of dilatation as a result of a hypocontractile pattern, cesarean section was performed only if at least 4 hours of contractions achieved with oxytocin failed to progress labor. Medically indicated induction of labor in patients with unfavorable cervices was preceded by cervical ripening with either prostaglandin gel (4 mg of Prostin E2 , The Upjohn Co., Kalamazoo, in 6 ml of sterile lubricant) or Hypan (Dilapan, Gynotech Inc., Lebanon, N.J.) osmotic dilators. s. g Fetal distress suggested by electronic fetal monitoring was confirmed by scalp pH sampling. When the extent of cervical dilatation did not permit scalp sampling, fetal acoustic stimulation was performed. IO A rise of 15 beats/min above the fetal heart rate baseline for a duration of at least 15 seconds was considered reassuring. Vaginal delivery of breech fetuses was performed only if the following criteria were met: (1) frank or complete breech presentation; (2) adequate x-ray pelvimetry without hyperextension of the fetal head; (3) ultrasonographically estimated fetal weight between 2500 and 4000 gm; and (4) presence of an obstetrician with experience in breech deliveries. For patients with singleton gestations between 36 and 39 weeks in which the breech presentation was identified antepartum, external cephalic version was attempted. Twin pregnan-

1988 = 4493)

I

(N

%

No.

424

9.4

3.9

598

13.3

174

1989 = 5163)

I

Difference, 1989-1986

I

p Value

%

%

374 168

7.2 3.3

-12.3

-4.7

p < 0.0001 P < 0.0001

542

10.5

-17.0

P < 0.0001

cies with a nonvertex second twin were managed according to the criteria of Chervenak et al. 11 After the birth of the first twin, external cephalic version was attempted if the second twin was not vertex. If the version was not successful and the estimated fetal weight was 2!2000 gm, a cesarean section was performed after failed version. At weekly conferences, departmental resident and obstetric faculty physicians reviewed each cesarean section and focused on indications for abdominal delivery. Particular attention was paid to electronic fetal monitoring records, umbilical cord gas results, and Apgar scores. In autumn of 1989 a sustained decline in the overall cesarean section rate was noted by the faculty at University Medical Center. For this reason it was decided to scrutinize neonatal morbidity and mortality while continuing to monitor cesarean section trends. This article documents the impact of changing clinical intrapartum management policies. We computed annual proportions of primary and repeat cesarean sections from 1986 to 1989. For each year, primary sections were classified by indication. We tested the difference between the proportions in 1986 and 1989 for statistical significance. 12 Similar tests for difference were performed for the proportion of trial of labor among women with prior cesarean section, the proportion of vaginal birth among women undergoing a trial of labor, the neonatal and perinatal mortality rates, and adverse neonatal outcome rates. During the same years (1986 to 1989), cesarean section rates, neonatal intensive care unit admission rates, and neonatal mortality rates were tested for difference in each of five birth weight categories. Results

Cesarean sections. The overall cesarean rate decreased steadily from 27.5% of deliveries in 1986 to 10.5% in 1989 (P < 0.0001) (Table I). Decreased rates of cesarean section occurred among women who had infants in all birth weight categories; these decreases were statistically significant for all categories except for women who had infants weighing >4500 gm (Fig. I). The rates of primary cesarean sections fell from 19.5%

Reducing cesarean sections

Volume 163 Number 3

1083

60

• •

50

8

40

% Deliveries

1986

12] 1987 1988 1989

30

20

10

o 501·1500

1I01·2S00

2501·3500

3501·4500

.4500

Birthweight Category (grams) Fig. 1. Birth-weight-specific cesarean section rates, 1986 to 1989.

Table II. Deliveries of women with prior cesarean section, University Medical Center, Jacksonville, 1986 to 1989 1986

%

No.

139 90

31.7 64.7

90

20.5

No.

TOL Proportion of women undergoing TOL with subsequent vaginal birth Proportion of all women delivered after prior cesarean with subsequent vaginal birth

I

1987

I

1988

%

No.

193 142

41.9 73.6

142

30.8

I

Difference

1989

%

No.

381 342

76.5 85.0

342

65.1

I

(1989-1986)

I

p Value

%

%

487 403

83.9 82.7

52.2 18.0

P < 0.0001 P < 0.0001

403

69.4

48.9

P < 0.0001

TOL, Trial of labor among women with prior cesarean sections.

to 7.2% (P < 0.0001), whereas repeat cesarean sections declined from 8.0% to 3.3% (P < 0.0001). While rates of cesarean sections decreased, operative vaginal deliveries (forceps and vacuum) remained stable (16.2% of all vaginal deliveries in 1986 versus 18.5% in 1989). Decreased repeat cesarean sections played a key role in the overall reduction in cesarean deliveries. From 1986 to 1989 the proportion of patients with prior cesarean deliveries who underwent a trial of labor increased from 32% to 84% (P < 0.0001). During these same years the proportion of women undergoing a trial

of labor who had subsequent vaginal births increased from 65% to 83% (P < 0.0001). Among all women who were delivered after a previous cesarean section, the percentage who had a subsequent vaginal birth increased from 20.5% to 69.4% (P < 0.0001) (Table II). Decreased rates of cesarean section for dystocia and fetal distress also contributed to overall reduction in cesarean delivery. From 1986 to 1989 rates of primary cesarean section for dystocia declined from 7.2% to 2.9% (P < 0.0001) and for fetal distress from 6.7% to 1.5% (P < 0.0001) of all deliveries (Table III). Cesarean

1084 Sanchez-Ramos et al.

September 1990 Am J Obstet Gynecol

Table III. Primary indications for cesarean sections among total deliveries, University Medical Center, Jacksonville, 1986 to 1989 1986

(N = 4350)

I

1987

(N = 4285)

%

No.

313 291 130 ll5

7.2 6.7 3.0 2.6

849

19.5

Indication

No.

Dystocia Fetal distress Malpresentation Other Total primary cesarean sections

I

1988

(N = 4493)

%

No.

233 225 108 77

5.4 5.3 2.5 1.8

643

15.0

I

1989

(N = 5163)

%

No.

140 llO 108 66

3.1 2.4 2.4 1.5

424

9.4

I

Difference, 1989-1986

%

%

150 79 106 39

2.9 1.5 2.1 0.8

-4.3 -5.2 -0.9 -1.8

374

7.2

-12.3

1

p Value P< P< P< P<

0.0001 0.0001 0.01 0.0001

Table IV. Perinatal and neonatal mortality, University Medical Center, Jacksonville, 1986 to 1989 Difference, 1989-1986

Neonatal deaths Fetal deaths Live births (denominator) Neonatal mortality rate* Perinatal mortality ratet

1986

1987

1988

1989

%

71 67 4336 16.4 31.8

41 43 4270 9.6 19.7

35 43 4470 7.8 17.4

33 44 5157 6.4 14.9

-10.0 -17.4

J

p Value

P< P<

0.001 0.0001

*Based on deaths occurring at <28 days of life per 1000 live births. tFetal deaths plus neonatal deaths per 1000 births.

section for breech and other fetal mal presentations decreased from 3.0% to 2.1 % of deliveries during the years 1986 through 1989, which represented a small but statistically significant change. Perinatal outcome. Overall, the perinatal mortality rate decreased from 31.8 in 1986 to 14.9 in 1989 (P < 0.000l), whereas the neonatal mortality rate decreased from 16.4 to 6.4 (P < 0.0001) (Table IV). Birthweight-specific neonatal mortality declined in infants weighing <2500 gm, and rates remained stable in higher-birth-weight categories (Fig. 2). Because the number of neonatal deaths in each category was small, the decrease was not statistically significant. The incidence of low 1- and 5-minute Apgar scores and neonatal seizures remained stable over the 3-year study period. During these years no consistent trends were observed in either incidence of neonatal intensive care unit admissions or length of neonatal intensive care unit stay. In 1989 there was a statistically significant reduction in the proportion of newborns admitted to the neonatal intensive care unit (Table V, Fig. 3).

Comment Elimination of elective repeat cesareans, active management of dystocia, and an approach to suspected fetal distress that emphasized intrapartum confirmation

contributed to the reduction of overall cesarean sections at University Medical Center from 1986 to 1989. Of all women who were delivered after a previous cesarean section, 69% had subsequent vaginal births in 1989; the comparable U.S. national estimate for 1987 was 9.8%.13 Our approach to trial of labor after prior cesarean is based on two assumptions. First, trial of labor after one or two prior cesarean sections in which uterine incision(s) involved only the lower segment is safe. I •• 15 Second, higher morbidity and health care costs I of elective repeat cesarean section outweigh the advantages that individual patients or their obstetricians may perceive. Active management of dystocia, as described earlier in this report, also played an important role in reducing the number of cesarean sections at our institution. Similar intrapartum protocols have resulted in lower rates of cesarean section for dystocia in other institutions. Myers and Gleicher l6 were able to reduce their cesarean section rate from 17.5% to 11.5%. Porreco l7 demonstrated that a low cesarean section rate (6%) can be achieved without compromising neonatal outcome. Similarly, reports from Ireland l8 have consistently documented a very low cesarean section rate (4% to 6%) without undue perinatal morbidity or mortality.

Reducing cesarean sections

Volume 163 Number 3

1085

400 CD It)

N (')

CD

300

Neonatal Deaths per ',000 Livebirths

•r.a • 9

200

1986 1987 1988 1989

100 01 N Nil) 01 0

It)~

,...,...,...,...

N(,)OO

0000

2501·3500

3501·4500

.4500

0 501·1500

1501·2500

Birthweight Category (grams) Fig. 2. Birth.weight-specific neonatal mortality rates, 1986 to 1989.

Table V. Adverse neonatal outcomes among total live births, University Medical Center, Jacksonville, 1986 to 1989 (N Outcome

Apgar score < 7 I min 5 min NICU admission NICU LOS (days) Mean Mode Median Neonatal seizures

No.

457

79

447

19 2 6 108

1986 = 4336)

I

(N

%

No.

10.5

357

1.8

10.3

65

420

1987

= 4270)

I

%

No.

8.4 1.5 9.8

476

2.5

120

83

432

1988 = 4470)

I

2.8

3 5

116

(N

%

No.

10.6

571

1.9

9.7

15

15

3 4

(N

2.6

90

453

16 3 5

114

1989 = 5157)

T

Difference, 1989-1986

Tp

%

%

11.0 1.7

-0.1

- 1.5

p> 0.40 p> 0.80 P < 0.05

2.2

-0.3

p > 0.40

8.8

+0.5

Value

NICU, Neonatal intensive care unit; LOS, length of stay.

Our approach to cesarean section for fetal distress emphasized fetal scalp pH testing when feasible to improve the precision of this diagnosis. This strategy acknowledges the low positive predictive value of electronic fetal monitoring as a sole indicator of fetal distress. I9 Because selective criteria for vaginal delivery of fetuses in breech presentation were maintained, incremental increased rates of vaginal breech delivery had

only a minimal impact on lowering overall cesarean section rates at University Medical Center. In a report of another program to lower the number of cesarean sections, a liberalized approach to vaginal breech delivery was associated with three neonatal deaths among breech presentation fetuses. I6 Some authorities have criticized this liberalized approach to vaginal breech delivery.2o.21 We support maintenance of selective criteria for vaginal delivery of breech presentation fetuses,

1086 Sanchez-Ramos et al.

September 1990 Am J Obstet Gyneco1

120

100

• •

80

% of Liveborns 60 Admitted to NICU

r2J

1986 1987 1988

1.3

1989

40

20

o 501-1500

1501·2500

2501·3500

3501·4500

.4500

Birthweight Category (grams) Fig. 3. Birth-weight-specific neonatal intensive care unit admissions, 1986 to 1989.

and also underscore that the number of cesarean sections can be substantially reduced without major alterations in managing obstetric mal presentations. Our finding that perinatal and neonatal mortality rates decreased concurrently as the number of deliveries decreased should not be overinterpreted. These declines in mortality rates could well be attributable to factors other than method of delivery. Data from the National Infant Surveillance project (unpublished) found higher mortality rates for those infants weighing ~ 1000 gm delivered by cesarean section. Although we believe our data strongly suggest that reductions in cesarean section can be accomplished without increasing risk to infants, only a randomized clinical trial could test that hypothesis. Our success in lowering cesarean section rates is largely attributable to our centralized approach to intrapartum decision making. Although others have used such a centralized approach successfully,18 it contrasts with other approaches many obstetric units in this country use, in which cesarean section rates for individual obstetricians may vary markedly. Goyert et al. 22 noted that rates of cesarean delivery for different physicians at a community hospital serving an affluent population ranged from 19% to 42%. Their analysis suggested that the individual clinician's practice style itself was a major determinant of the wide variations in rates of cesarean section. Implementing standardized protocols regarding repeat cesarean sections, dystocia, and fetal distress

requires substantial commitment and effort from obstetricians and others who care for obstetric patients. However, our experience suggests that such an effort can substantially reduce rates of cesarean delivery without compromising the newborn. Addendum

During the first 6 months of 1990, the overall cesarean section rate has continued to decrease (8.6%), without an evident increase in perinatal morbidity and mortality. REFERENCES 1. Placek P], Taffe! SM. Recent patterns in cesarean delivery in the United States. Obstet Gynecol Clin North Am 1988;15:607-27. 2. Williams RL, Peter MC. Identifying the sources of the recent decline in perinatal mortality rates in California. N Engl] Med 1982;306:207-14. 3. Rubin GL, Peterson HB, Rochat RW, McCarthy B], Terry ]S. Maternal death after cesarean section in Georgia. AM ] OBSTET GVNECOL 1981;139:681-5. 4. Evrard ]R, Gold EM. Cesarean section and maternal mortality in Rhode Island-incidence and risk factors, 19651975. Obstet Gynecol 1977;50:594-7. 5. lams ]D, Chawla A. Patient costs in the prevention and treatment of post-cesarean section infection. AM] OBSTET GVNECOL 1984; 149:363-6. 6. Friedman EA. Labor: clinical evaluation and management. 2nd ed. New York: Appleton-Century-Crofts, 1978: 102-23. 7. Bottoms SF, Hirsch V], Sokol RJ. Medical management of arrest disorders of labor: a current overview. AM ] OBSTET GVNECOL 1987;156:935-9.

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8. Johnson IR, Macpherson MBA, WeIch CC, Filshie GM. A comparison of Lamicel and prostaglandin E2 vaginal gel for cervical ripening before induction of labor. AM J OBSTET GYNECOL 1985;151:604-7. 9. Chvapil M, Droegemueller W, Meyer T, Macsalka R, Stoy V, Suciu T. New synthetic laminaria. Obstet Gynecol 1982;60:729-33. 10. Edersheim TG, Hutson JM, Druzin ML, Kogut EA. Fetal heart rate response to vibratory acoustic stimulation predicts fetal pH in labor. AM J OBSTET GYNECOL 1987; 157:1557-60. 11. Chervenak FA, Johnson RE, Berkowitz RL, Hobbins Jc. Intrapartum external version of the second twin. Obstet Gynecol 1983;62: 160-5. 12. Fleiss JL. Statistical methods for rates and proportions. 2nd ed. New York: John Wiley & Sons, 1981:23-4. 13. Taffel SM, Placek PJ, Moien M. 1988 US cesarean section rate at 24.7 per 100 births: a plateau? N Engl J Med 1990;323: 199-200. 14. Flamm BI. Vaginal birth after cesarean section: controversies old and new. Clin Obstet Gynecol 1985;28:735-44. 15. Shiono PH, Fielden JG, McNellis D, Rhoads GG, Pearse WHo Recent trends in cesarean birth and trial of labor rates in the United States. JAMA 1987;257:494-7. 16. Myers SA, Gleicher N. A successful program to lower cesarean-section rates. N Engl J Med 1988;319: 1511-6. 17. Porreco RP. High cesarean rate: a new perspective. Obstet Gynecol 1985;65:307-11. 18. O'Driscoll K, Foley M. Correlation of decrease in perinatal mortality and increase in cesarean section rates. Obstet GynecoI1983;61:1-5. 19. Thacker SB, Berkelman RL. Assessing the diagnostic accuracy and efficacy of selected antepartum fetal surveillance techniques. Obstet Gynecol Survey 1986;41: 121-36. 20. Battaglia FC. Reducing the cesarean-section rate safely [Editorial]. N EnglJ Med 1988;219:1540-1. 21. Sachs BP. A program to lower cesarean-section rates [Letter]. N Engl J Med 1989;320: 1693. 22. Goyert GL, Bottoms SF, Treadwell MC, Nehra PC. The physician factor in cesarean birth rates. N Engl J Med 1989;320:706-9.

Editors' note: This manuscript was revised after these

discussions were presented. Discussion

DR. ROBERTG. BRAME, Greensboro, North Carolina. This article covers an obviously timely topic. Despite much that has already been written, the continuing appropriateness of the topic results from the great disparity that persists in actual practice compared with a now abundant literature that suggests that the cesarean section rate is too high. This report documents the achievement of a very low cesarean section rate in an indigent and high-risk population, with a reduction in the combined section rate from 27% in 1986 to 11 % in 1989, with an attendant reduction in perinatal and neonatal mortality rates; this is principal point of the article. The authors demonstrate quite clearly that a dedicated (and if I may read between the lines) intense effort to reduce the cesarean section rate can be successful. By the standard measures we use perinatal morbidity seems to certainly be no worse, but this is obviously a much more difficult assessment to make. I commend the authors for this excellent work but I do have some questions. Although you emphasize that elimination of elective "repeat cesarean sections played a key role in the overall

Reducing cesarean sections

1087

reduction in cesarean deliveries," I note that, according to Table I, the reduction in primary cesarean section almost exactly duplicated the reduction in repeat sections; I am a bit puzzled by this emphasis. Since you do not give patients with previous cesarean sections the option of a repeat cesarean delivery, I would like to know what you tell them. Do you have patients who demand a repeat cesarean section, and what do you do with them? I suspect my patients are similar to yours, and I have some patients for whom no amount of education or paternalism will convince the patient that she should be delivered vaginally. In addition, I have problems dealing with unfavorable and unengaged postdate pregnancies, labor in patients with previous section with unengaged fetal parts, and excessively large fetuses that are unengaged; these situations balloon my cesarean section rates. I wonder if you have ways of dealing with these circumstances that might help us. Finally, although the last word on this topic has obviously not been written, cesarean section rates can be reduced, but to what degree this is really in the best interest of patients is not quite so clear. I spent most of my adult life adjusting to a belief that cesarean section was all right, and now I am trying to adjust to your implied suggestion that I may be performing too many cesarean sections. I do not know what the section rate ought to be. I do know, as a practitioner, that the decision to perform or not perform a section, particularly in a private, well-educated population, is rarely a simple matter of strict medical indication. In conclusion, we obviously can reduce the cesarean section rate, and the best scientific information suggests we can do that safely and that we ought to try. This presentation is an excellent documentation that a reduction can be achieved and I congratulate the authors on this effort. Yet to be answered, however, is the question encompassing all of those other considerations that enter into a decision: our legal climate, patient autonomy versus medical paternalism, and desire by patients and doctors to control events and their timing by surgical delivery. DR. WILLIAM KIRKLEY, Fort Lauderdale, Florida. I have several questions. Did you have any patients with ruptured uteri? I presume you did not since you did not mention it. Second, when I was practicing obstetrics and the fetal heart monitor strip would be slightly abnormal or moderately abnormal, I would rush to do a cesarean section. I am sure you have had similar cases in your hospital. Do you rely solely on the fetal scalp pH? Third, do you have any potential lawsuits regarding these cases? If you have a monitoring problem during labor, you will be sued if you do not take action immediately. DR. WILLIAM S. GRIZZARD, JR., Petersburg, Virginia. Do you allow patients with either twin pregnancy or breech presentation to undergo a trial of labor? DR. HUGH RANDALL, Atlanta, Georgia. This article suggests the need for an individual, if not a committee, within the hospital to scrutinize cesarean sections. I know that in our community cesarean section rates around 35% are common. When there are individuals

1088 Sanchez-Ramos et al.

like Dr. Sanchez-Ramos to study these services and to perform the type of peer review that was done at this institution, I think we will really be able to reduce the cesarean section rate. In many cases his review perhaps made him an unpopular individual. I would ask Dr. Sanchez-Ramos how many times he or his committee had to point out to a physician that he had not met the criteria for doing the cesarean section, for example, for dystocia? DR. SAMIR BEYDOUN, Miami, Florida. You empha­ sized that there is no increase in the neonatal morbidity and mortality. I would like to ask Dr. Sanchez-Ramos to compare the maternal morbidity in cases with failed trials of labor that ultimately needed a repeat cesarean section and those with elective repeat cesarean section. DR. GENE BURKETT, Miami, Florida. In Miami we have a large migrant population. How do you handle cases with unknown scars? DR. SANCHEZ-RAMOS (Closing). First, I will address Dr. Brame's concern about not giving our patients a choice between repeat cesarean sections and a trial of labor. In accord with recommendations of the Ameri­ can College of Obstetricians and Gynecologists, we do not routinely perform elective repeat cesarean sections. We believe that vaginal birth after cesarean section is a much safer procedure than a repeat cesarean section. There are currently no reports in the literature of ma­ ternal deaths directly attributable to vaginal births after cesarean sections. In contrast, maternal deaths as a re­ sult of repeat cesarean sections do occur. Dr. Kirkley had a question regarding ruptured uteri. I am not aware of a true ruptured uterus occurring in a patient with a previous cesarean section undergoing a trial of labor. Occasionally we have noted "windows" or dehiscences. The most serious dehiscence that I re­ call was in a patient with a previous low vertical scar who was undergoing an elective repeat cesarean. With regard to the use of scalp pH sampling and electronic fetal monitoring, we use the former to com­ plement the latter. Rather than rely solely on scalp pH results or alterations in the fetal monitoring tracing, we use both modalities together.

September 1990 Am J Obstet Gynecol

I am unaware of any lawsuits directly related to our management protocol for cesarean sections. With regard to management of twins we currently allow patients with twins and previous cesarean sections a trial of labor. Peer review has been one of the most important fac­ tors contributing to the reduction of cesarean sections at our hospital. All our practicing obstetricans are full­ time faculty members. We do not have private practi­ tioners. All the cases discussed at our cesarean section review meetings are those performed by the residents under faculty supervision; critiquing of individual cases is therefore facilitated. I may occasionally become un­ popular if a resident feels he or she is not performing enough cesarean sections. However, the peer review process itself has not generated hard feelings. I am popular with the pediatric physician and nursing staff because our intrapartum policies have markedly re­ duced their visits to the operating room. We did not address maternal morbidity in our study. However, it is well accepted that less morbidity occurs in patients who are delivered vaginally compared with those delivered by cesarean sections. Because of the reduction of almost 2000 cesarean sections during the past 3 years, we think that the decrease in post­ cesarean section endomyometritis has substantially re­ duced overall maternal morbidity. What do we do with patients with unknown scars? We have had patients from as far away as Nigeria whose medical records were more available that those of our local patients. It is embarrassing to note that the most difficult records to find are those from our own insti­ tution. When we first started with an aggressive ap­ proach to vaginal birth after cesarean section, patients with unknown scars were not allowed a trial of labor. Currently, we try to individualize management in these cases. We try to obtain a history as to the indication for the previous section. If the indication appeared to be an arrest of dilation at 8 cm (for example), then we conclude that the patient probably had a low transverse incision and therefore may proceed with a trial of labor.

Make researching easier with the Ten-Year Cumulative Index (1978-1987) to the AMER­ ICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY The Ten-Year Cumulative Index is a complete guide to more than 30,000 pages of original articles, case reports, letters, and editorials published in the AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY from 1978 through 1987 (volumes 130 to 157). Num­ bering more than 800 pages, the Cumulative Index includes both a subject and an author index. This hard-cover volume is $64.50 ($69.00 international). Prices include shipping. Payment must accompany all orders and must be in U.S. funds, drawn on a U.S. bank. Contact Mosby-Year Book, Inc., Circulation Department, 11830 Westline Industrial Drive, St. Louis, Missouri 63146-3318 USA; phone (314) 872-8370, ext. 7394. In the U.S., call toll-free: 1-800-325-4177, ext. 7394. Please allow six weeks for delivery.