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Comment and Controversy

Soon, we will have only two options for delivery

August 2008 · Vol. 20, No. 08
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Dr. Barbieri touches on a topic that is as fascinating as it is frustrating. On one hand, we keep asking ourselves what is the optimal cesarean delivery rate and aim, insatiably, to make it as low as we can safely achieve. On the other hand, we have neglected to offer residents basic obstetric tools. I have seen young colleagues unable even to rotate a presentation from occipital-posterior to occipital-anterior to ease the delivery.

We have abandoned almost completely the teaching of instrumental deliveries (except, perhaps, for outlet vacuum extraction) and breech deliveries, leaving young obstetricians with only two options, as some of my residents used to put it: an easy cesarean section or an easy vaginal delivery.

Add to this the rising demand for elective cesarean delivery and I have no doubt that, in the next few years, our C-section rate will be closer to 50%, if not higher. Ironically, it will be the “right” rate because new obstetricians will lack the ability to deal with difficult deliveries.

Tomas A. Hernandez, MD
Pasco, Wash

Midwife-attended births have lower C-section rate

In our practice for 30 years, about 85% of our private-pay patients have been cared for by midwives, and our primary cesarean rate has remained unchanged at 9%; this includes women who have gestational diabetes. Our total rate is 17%, with exemplary outcomes for both mothers and babes.

Lynn Schimmel, MS, NP
Sutter West Medical Group
Women’s Health
Davis, Calif

Dr. Barbieri responds: 5 ways to reduce the C-section rate

I appreciate Dr. Hernandez’s and Ms. Schimmel’s comments and agree that there are approaches that would likely lower the cesarean delivery rate in the United States. As mentioned in my editorial, five interventions that might lower the cesarean delivery rate are:

  • when counseling pregnant women, highlight the risks of cesarean delivery and encourage vaginal birth
  • reduce the rate of elective induction in uncomplicated pregnancy
  • encourage a trial of labor after cesarean delivery
  • reduce the rate of elective primary cesarean delivery
  • prioritize the teaching of operative delivery during residency.

A major point of my editorial is that, in the United States, the C-section rate is at an historic high, but still comparable to that in many European countries that rely heavily on midwifery care. The US rate is below the rate in China, Mexico, Brazil, Italy, and, surprisingly, Cuba.

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