Sunday, November 16, 2008

The Pitfalls of Impatience

A new study published in the November, 2008 issue of Obstetrics and Gynecology, conducted by researchers at the University of California, San Francisco, found that over 130,000 cesareans could be avoided each year by simply waiting an extra two hours for labor to progress normally.

The study focused on the all-too-common "failure to progress" c-section. The study was longitudinal over 1991-2001 and examined outcomes for 1,014 women having their first child at the UCSF.

Current ACOG guidelines state that physicians should wait two hours once an active labor arrest, or a period of time when dilation and effacement have ceased, before moving to a c-section. However, the article states that while this is the standard of care, many physicians currently ignore the guideline and move straight to an avoidable, unnecesarean.

Currently, 1/3 of all c-sections performed each year are for "failure to progress".

The study also highlights the dangers of a primary c-section, which are so often overlooked and were well outlined by the head author:

"Cesarean delivery is associated with significantly increased risk of maternal hemorrhage, requiring a blood transfusion, and postpartum infection," Caughey said. "After a cesarean, women also have a higher risk in future pregnancies of experiencing abnormal placental location, surgical complications, and uterine rupture."

Results of the study also found that women who had c-sections had increased rates of postpartum hemorrhage, chorioamnionitis infections and endomyometritis infections.

However, no significant difference in the health outcomes of the infants was found.

The most refreshing factor about this study is that ultimately, it highlights the dangers of primary and repeat c-sections as well as highlighting the role of physician non-compliance with the outlined standard of care.

Ultimately, the study shows that if physicians follow evidence-based guidelines in their practice, maternal outcomes are improved.

Despite the fact that this is a new study, this is not new information. The two hour wait time was already the standard of care when this study was undertaken. The real issue is getting physicians to respect the evidence and stop rushing to a c-section at the earliest convenience.

I have to wonder what will have to happen before physicians start using evidence-based practice in maternity care.

Despite study after study extolling the pitfalls of procedures such as episiotomy, lithotomy position, EFM, failure to progress c-section, restricted movement and arbitrary time limits on labor, these harmful practices are still standard across much of the US.

Perhaps a punitive approach would work: fine physicians for each non evidence-based procedure: $500 for an episiotomy, $1000 for EFM, $3000 for each unnecesarean.

That, I think, would be an effective approach at gaining adherence to evidence-based medicine and focus on maximizing reimbursement for quality care, not convenience.


A Much Better Way said...

The fines would work as would insurance companies refusal to pay for these unnecessary and damaging procedures.

I am generally not litigious but I cannot comprehend why a woman cannot sue (and press charges) against a doctor who performs an unwanted and unnecessary episiotomy. It is sexual assault if you ask me. I think that would stop the procedures pretty fast too.

Catherine said...


Ugh, episiotomy is a nightmare unto itself.

Did you know that interns are required to perform a certain number of episiotomies during their rotation or fail to meet their program requirements?

This means that despite all the evidence that episiotomy is harmful and rarely necessary, women will be callously treated as guinea pigs and given unnecessary episotomies to fulfill an arbitrary and non evidence-based program requirement.

I fail to see where this falls under the umbrella of "Do No Harm".

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