The cesarean conundrum
I really enjoy your journal. It focuses on clinically meaningful topics. Of course Dr Lockwood’s monthly contribution are always highly insightful and not to be missed. Something occurred to me and struck me as funny after reading the January issue of Contemporary OB/GYN. While we are struggling nationally to reduce the primary cesarean section rate the back of the issue of Contemporary OB/GYN was filled with malpractice cases that would have been avoided if cesarean sections were performed. I would like to see if Dr Lockwood would comment on the conundrum that our specialty faces.
SMFM/ACOG have redefined active labor and have extended the limit to the second stage of labor. We are under additional pressures to avoid cesarean section. In this environment there are going to be obstetricians who are going to get lost in the fervor, reducing their section number but at the cost of maternal and perinatal morbidity and mortality. The obstetrician is put in such a bad spot. The cover article “We’re only human” makes the point.
Genevieve B Sicuranza, MD, FACOG
Thanks for sharing your thoughts. The relationship between cesarean delivery rates and defensive medicine is certainly embedded in conventional wisdom though hard to prove statistically.
In my opinion, ob/gyns working in states without meaningful tort reform, where there is a superabundance of unscrupulous trial lawyers who perpetually bombard the media with their ads and where patient safety initiatives are impeded by the resultant culture of secrecy and lack of transparency, are far more likely to engage in defensive medical practices and thus, have higher cesarean rates. Conversely, I would opine that those working in states with just and equitable professional liability laws, fewer and more ethical trial lawyers and a culture of transparency and pro-active approaches to patient safety will likely have lower caesarean delivery rates. But these are opinions, no one could argue that we should all toil ceaselessly to create to try and create that better environment. That means getting involved with local ACOG districts and state and county medical associations to support tort reform while working to create strong patient safety cultures in our practices and hospitals. The latter includes employing evidenced-based approaches to care, implementing proven patient safety measures (eg, team training, structured hand-offs, checklists, clinical guidelines, FHR certification, etc.), keeping our medical knowledge current and our surgical skills honed.
Charles J Lockwood, MD, MHCM