Slowing Down The Cesarean Section Assembly Line, What Can You Do?

Charlotte Moody Russell and My Facebook Friends,

My patients are more educated now than at any time in my 14 years in private practice. Yet every day at least one patient comes to my office saying, “if I only knew then what I know now, I would never have agreed to a C/S.” Our job is to educate the patients who come for preconception counseling, to speak in the community and let patients know they always have a choice and create a physician-patient relationship where the patient is not afraid to question their doctor. One of the most valuable sources of advice and education at the time when C/S is mentioned is your nurse. One thing that needs to change is that if asked about a particular situation, a nurse should have the right to give their opinion when asked. On almost a daily basis my wife, an L&D nurse or one of her colleagues has to “bite their tongue,” when asked, “do I really need a C/S or “is my doctor doing the right thing?” Nurses have a unique perspective in Obstetrics because they see doctors doing things differently on a daily basis. Yet if a nurse speaks up for a patient, they are often reported to their superior as being a “trouble maker or insubordinate.”

I learned a long time ago that nurses can be your most valuable asset and that if you allow them to speak to you they very often can teach you something new. Unfortunately, many physicians are not willing to take the advice of someone they may consider “inferior.” When you leave residency what you know is all that you will know unless you have the opportunity to work with other physicians or nurses who trained somewhere other than where you came from. For many physicians additional learning is strictly didactic, completing necessary CME to stay board certified but never learning anything that maybe clinically useful.

Charlotte GIVE A TALK IN YOUR COMMUNITY about how to avoid a C/S, what are the indications for a C/S, what are the risks of a C/S vs. a vaginal delivery, etc. On a more nationwide scale the AMA, ACOG and the Insurers need to reward quality care not convenience care. Right now a C/S pays significantly more than a vaginal delivery; in addition, a vaginal delivery patient goes home 2 days earlier and recovers quicker leading to better bonding, maternal well-being and greater success with breast feeding. This makes no financial sense at all. If a vaginal delivery paid more to a physician the cost savings to the entire health care system would be staggering. Not all doctors are in it for the money but OB, like many medical specialties, can be stressful and of course every patient expects a perfect baby, so sometimes the pressure of doing the right thing is overwhelmed by the desire to do the least stressful and usually the quickest thing, which in this case is a C/S.

On a final note, I received a gift in the mail two weeks ago from a physician in the Netherlands who found me on the internet. He wrote a book called Proactive Support of Labor (www.proactivesupportoflabor.com) it talks all about the over medicalization of childbirth. Sadly he asked me to give him the names of national leaders who have similar opinions but I do not know any. Residents are being taught by professors and other national leaders in the field of OB/GYN who have no clue as to what is going on in the real world. ACOG publications write about getting the C/S rate down to a manageable 10-15% as recommended by the World Health Organization. Yet residents are sent out with the message “you need to intervene if labor does not follow the Friedman Curve (14 hours for the 1st four centimeters of labor then 1.2 cm per hour dilation for 1st time mom’s and 1 cm an hour for multiparous patients). Of course, let us not forget the golden rule of Stage 2 of labor (once 10 cm is reached, 1st baby 3 hours maximum to deliver with epidural, 2 hours with no epidural; future children 2 hours to deliver with epidural and 1 hour to deliver naturally. I guess my patient that VBAC’ed* a 9#12oz baby 5 hours after she was completely dilated forgot to read the manual.

Have a great night and thanks for all the support.

Dr. Weinstein

* Dr. Weinstein is no longer taking new VBAC patients.

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