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A Doctor's Rx for Curbing Unnecessary Cesareans

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This year about 600,000 American babies—one of every six delivered—will be born by cesarean. With the cesarean rate now three times as high as a decade ago (it has become the 10th most common surgical procedure in the U.S.), physicians and patients alike are wondering whether some of their attitudes about it may themselves need major surgery. Under special scrutiny these days is a dictum prevalent in American obstetrics for more than 50 years: “Once a cesarean, always a cesarean.” In current medical practice, 99 percent of all women who have cesareans do so again for their subsequent babies, which translates into nearly 150,000 such operations in 1982. Of course, the main desire of every physician is to deliver a healthy newborn, but the repeat cesarean may often be the unkindest cut of all, believes Dr. Mortimer Rosen, a featured speaker at the Tenth World Congress of Gynecology and Obstetrics, meeting this month in San Francisco. “We already have data that say the risk for vaginal delivery after a cesarean is so low to both mother and baby that the choice should be available,” comments Rosen, 50, who headed a 1980 National Institutes of Health task force on cesareans. Earlier this year, in line with the task force’s recommendations, the American College of Obstetricians and Gynecologists issued new guidelines about vaginal delivery after cesarean birth. Rosen teaches at Case Western Reserve Medical School and directs the ob-gyn department at Cleveland Metropolitan General Hospital. He and his wife, Lynn, a former dean at Cuyahoga Community College in Cleveland, have two sons, neither by cesarean: Robert, founder of an educational computer firm in Chicago, and Bradley, who works at a community theater in Grove City, Ohio. Rosen gave his prescription for cutting cesareans to Giovanna Breu of PEOPLE.

Should a woman think twice before agreeing to a repeat cesarean?

Yes. The patient should know that she has a choice. It’s clear that nature made women to deliver vaginally and not by cesarean. A cesarean is only an alternative.

How would you lower the cesarean rate?

Two areas in particular need reform—the overdiagnosis of difficult labor, and the automatic repeat cesarean. In the latter, the mother has a choice because the reasons for a cesarean often don’t occur the second time: She may have better labor, say, or the baby may not show fetal distress. Most studies show that if you give people the choice, in an adequate environment somewhere between 60 and 80 percent will deliver vaginally the next time.

Do most physicians agree with you?

I haven’t counted them, but the doctors I’ve heard from or visited at places where I’ve lectured are generally very positive about the need for change.

What’s safest for the baby?

It’s almost always safer for the baby to be born vaginally. The baby’s major risk in a cesarean is being born too soon, and the baby may have some respiratory distress. No matter how sure you are that a person is near term, we make errors in calculating the date.

Are there special precautions for a vaginal delivery after a cesarean?

I don’t urge them in women who’ve already had more than one cesarean. Also, such births should be limited to babies of average size. Mother and baby should be carefully monitored throughout labor. A woman needs to be able to get to an operating room within 15 minutes if her scar starts to separate or cause pain.

How likely is such difficulty?

Rupture or separation of tissues is very uncommon in the low transverse cut—the cut that goes from side to side in the uterus, not the scar you see on your skin. Of all cesareans these days, 90 percent are low side-to-side cuts and are very safe for vaginal delivery in the next pregnancy, and that’s what we’re trying to encourage.

What happens if a scar does rupture?

Scars that rupture rarely do so completely, which means that if they do the baby can still be safely delivered by cesarean. Maybe one in 100 patients will have a partial separation of these scars. The risk of mortality to the mother in these cases is extremely low. In repeat cesareans the death rate is about 20 in 100,000 women, at least twice as high as for vaginal deliveries.

What else makes cesareans risky?

They’re less than an acceptable choice in many cases: You hurt, you’ve lost three times as much blood as your neighbor with a normal delivery, and you’re more susceptible to infection. You’re usually in the hospital several days longer, and you convalesce more slowly. Besides, you end up with a big scar on your abdomen.

What are the major reasons for cesareans?

Difficult labor, or dystocia, where either the cervix doesn’t dilate well or the baby’s head doesn’t descend well. Fetal distress, where the baby’s heartbeat shows a change, which is cause for concern. Remember, there’s a life hanging out there. Another major reason is breech birth, where the baby comes out backwards. I’m not going to fight you on breech birth. I don’t have an answer for it. The last major reason is, of course, a previous cesarean.

Why has the cesarean rate risen so dramatically?

Not because babies are significantly larger, or women’s hips smaller. For one thing the diagnosis of dystocia has gone way up during the last 20 years. Meanwhile it’s become easier to perform a cesarean successfully. Almost a third of the rise in the cesarean rate can be attributed to repeat cesareans.

Doesn’t a physician earn more for a cesarean than for a vaginal delivery?

As a matter of fact, my fees for both are the same. I don’t think money’s an issue in the high incidence of cesareans, because in general at military hospitals and some county hospitals, where no fees are charged for the individual operation, the cesarean birth rate is also high. Though a cesarean might take less time than a vaginal delivery, the care afterward can take more.

Has the threat of malpractice affected the number of cesareans?

Malpractice hides in the background of the cesarean controversy. Some people have suggested that if you do a cesarean you’re less likely to be sued, but it may be only a matter of time before the fears that have pushed people in one direction may push them in another—that they also may be sued for an unnecessary cesarean.

Do you have any evidence of a reversal in the trend toward more cesareans?

A preliminary look at data from 1981 suggests there was no further rise in the cesarean birth rate—the first time that’s happened in years—and I’m optimistic that we’ll soon see it fall.

What do you advise a pregnant woman nowadays?

Speak out and let your doctor know what you want. At the beginning of the pregnancy ask what hospital facilities are available. Can you have a vaginal delivery after a cesarean? Will your husband be allowed to be with you? If the patient is in a big city, she should know she has a choice of hospitals, and if she doesn’t like the situation at one place she can go elsewhere.

Will physicians let their patients prescribe to them?

Apparently so. While some of the re-form about cesareans is coming from the physicians, it is the patient population that effects change. We respond to what they want to do. It is a woman’s body—and a patient’s right to participate in the decision.