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Originally published Sunday, July 27, 2014 at 6:16 AM

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Hospitals resist scheduling cesareans just for convenience

The American College of Obstetricians and Gynecologists says cesarean surgeries are overused and risky. Doctors and hospitals are following suit.


Pittsburgh Post-Gazette

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After a decade of spiking cesarean-birth rates around the turn of the millennium, hospitals in Washington state and beyond are working to increase rates of natural delivery.

According to the Centers for Disease Control and Prevention, the cesarean rate in Washington rose 70 percent from 1996 to 2007 — to a point at which nearly one in three babies were delivered surgically. Since then, hospitals have focused on reversing the trend for low-risk births.

The American College of Obstetricians and Gynecologists says the surgery — riskier in some ways than a vaginal birth — is overused.

In February, the college issued its own guidelines aimed at reducing cesareans. Noting that slow labor is a common reason for a cesarean, the guidelines attempt to change expectations about the amount of time involved.

“Evidence now shows that labor actually progresses slower than we thought in the past, so many women might just need a little more time to labor and deliver vaginally instead of moving to a cesarean delivery,” college member Aaron B. Caughey said when the guidelines were issued.

The guidelines also call for more frequent use of techniques for turning babies who are in the breech position, of using forceps to facilitate vaginal births and of developing better, more standardized methods of fetal heart monitoring. Concerns about the baby’s heart rate are another frequent reason for cesarean deliveries.

The college especially wants to promote vaginal birth among first-time mothers because data show that women who have one cesarean likely will deliver in the same manner a second time.

However, when women who have had a cesarean become pregnant again, doctors and midwives should help them understand their options and calculate the likelihood of a successful vaginal birth, said Hyagriv N. Simhan, vice chairman for obstetrical services at University of Pittsburgh School of Medicine and medical director of obstetrical services at Magee-Womens Hospital of UPMC

“In so doing, a higher proportion of women may choose a vaginal birth after cesarean,” Dr. Simhan said. Magee’s overall cesarean rate was 29 percent last year, he said.

Recently released results from a study on early births provide more caution about cesareans.

The study examined 7.3 million uncomplicated births that occurred from 1995 to 2009 in Pennsylvania, California and Missouri and found that nearly one baby in 25 was delivered earlier than medically necessary through cesarean or induced labor.

“That’s a lot of babies,” said one of the authors, Scott Lorch, a neonatologist at The Children’s Hospital of Philadelphia. Patient and physician preference both seem to play a role, Dr. Lorch said.

The study said early cesareans increased the baby’s chance of respiratory problems, while both types of early-term births increased the infant’s hospital stay.

Doctors say they do face pressure from mothers who want to schedule a birth for convenience, and Jan Mallak, founder of Heart and Hands Doula Service, decried what she called the “too posh to push” culture.

Doulas are hired, often on a private-fee basis, by women seeking an unmedicated, vaginal delivery. Doulas attend their clients at hospitals, birthing centers and in the expectant mom’s home. They offer emotional and physical help to mothers before, during and after delivery.

The college’s new guidelines cite “continuous labor and delivery support” as a way to lower the cesarean rate.

Interest in midwives, who perform vaginal deliveries in hospitals and other settings, also is said to be increasing among women interested in natural births.

Some of the college’s new guidelines — such as allowing more time for labor — reflect doulas’ beliefs.

“As long as the mother and the baby are both stable, there isn’t really a reason to not let it unfold,” said Amy Farr, owner of Armstrong County-based Blessed Arrivals.



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