The total cesarean section rate in the United States. Effect of Peer Review and Trial of Labor on Lowering Cesarean Section Rates.

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1 Original Article J Chin Med Assoc 2004;67: Wei-Hsing Liang Chiou-Chung Yuan Jeng-Hsiu Hung Man-Li Yang Ming-Jie Yang Yi-Jen Chen Tzay-Shing Yang Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, and National Yang-Ming University, School of Medicine, Taipei, Taiwan, R.O.C. Key Words cesarean section; peer review; trial of labor Effect of Peer Review and Trial of Labor on Lowering Cesarean Section Rates Background. In an attempt to lower cesarean section rates, a cesarean surveillance system and a selective trial of labor were introduced in a tertiary hospital in Taiwan. Methods. From 1997 to 2000, 2 physicians were appointed as consultants for the pre-cesarean surveillance, and a trial of labor after a cesarean section was employed concurrently. We organized a weekly departmental Cesarean Indication Conference on Mondays. Comparisons of the cesarean rates between and were made using the chi-square test. Comparisons of the proportion of overall cesarean sections contributed by each indication for both 1993 and 2000 were also made by chi-square test. Results. A comparison of the 4-year periods before and after 1997 showed that the total cesarean rate had decreased from 37.0 to 30.7% (p < 0.001), primary cesarean rate from 21.3 to 17.8% (p < 0.001), and repeat cesarean rate from 15.7 to 12.9% (p < 0.001). No uterine rupture occurred. Among the 54 indications for primary cesareans, compared between 1993 and 2000, the proportion rates for dystocia, fetal distress, preeclampsia, induction failure, gestational diabetes, and elderly primigravidahad decreased substantially. Conclusions. The efficient way to lower the repeat cesarean rate is trial of labor, and the way to reduce the number of primary cesareans is in practicing of the guidelines for various indications. The cesarean surveillance system can solidify these guidelines, leading to a lower cesarean rate and an avoidance of inappropriate indications. The total cesarean section rate in the United States increased steadily during the period of the 1960s-1980s, reaching in 1988 a peak rate of 24.7%; at the same time, the rates in the European countries were below 14%, and as high as 34% was reached in Taiwan (Fig. 1). 1,2 There was a growing consensus in the 1980s that the risks of cesarean section had probably exceeded the benefits of improving perinatal mortality, and that a reduction in the rate could be achieved without compromising the improved mortality statistics for neonates. 3,4 Besides, there were strong economic arguments for the reduction of the cesarean rate. 5 At least 13 strategies have been employed or proposed to reduce cesarean section use, including: vaginal birth after prior cesarean (VBAC), peer review, external audit, active management of labor, operative vaginal delivery, supportive companion (doula), changing hospital reimbursement, etc. 2,6-9 In January, 1997, Taipei Veterans General Hospital (TVGH) instituted some remodeling efforts to lower the cesarean rate, including: a cesarean Fig. 1. Annual cesarean section rates for Taipei Veterans General Hospital, Taiwan, the United States, Norway, and England. The Taiwan data consists of the hospitals enrolled each year in the Health and Vital Statistics Annual Report, Department of Health, Republic of China. No formal data were available before Received: September 26, Accepted: May 12, Correspondence to: Tzay-Shing Yang, MD, Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, 201, Sec. 2, Shih-Pai Road, Taipei 112, Taiwan. Tel: ; Fax: ; 281

2 Wei-Hsing Liang et al. Journal of the Chinese Medical Association Vol. 67, No. 6 surveillance system, trial of labor after one cesarean section, encouraging instrumental delivery in VBAC trials, staff education, calculation of the physician s cesarean section rate, press conferences, and calling for an increased national health insurance reimbursement for VBAC. MATERIALS AND METHODS The peer review included pre-cesarean consultation and post-cesarean surveillance. We organized a weekly departmental Cesarean Indication Conference on Mondays. Two board-certified obstetricians were appointed consultants. A second opinion by a consultant was required for all cesarean sections. The guidelines for dystocia, fetal distress, and breech remained unchanged from 1993 through The diagnosis of dystocia was accepted after no labor progress had been observed in more than 2 hours of appropriate uterine contractions, which was defined as more than 200 Montevideo units in a 10-minute period in the active phase of labor. The diagnosis of fetal distress was based on the following results of a monitoring of the fetal heart rate: persistent bradycardia < 120 or tachycardia > 180 beats/min; any baseline heart rate with late decelerations; and meconium with severe variable decelerations. Every cesarean case were supposed to be presented in the departmental conference by the chief resident on the following Monday. The tracing records of the tocodynamometry and fetal heart rate, and other related information, e.g., the ph values of the umbilical vessels, or the operative findings, would be discussed and defended by the patient s attending physician. All physicians cesarean section rates were presented at the conference, but not disseminated to the press or on the Internet. The selection criteria for a selective trial of labor were: (1) one low transverse uterine scar; (2) a singleton pregnancy without suspected macrosomia (> 4,000 gm); (3) a vertex presentation; (4) no medical or surgical illness; and (5) patient consent. For pregnancies of more than 37 weeks, an assessment of the thickness of the uterine scar and an estimation of the fetal weight by ultrasound were performed routinely. Induction of labor was not recommended. Continuous electronic fetal monitoring was set-up after intravenous fluid had been started with a transfusion catheter emplaced when the patient came to delivery room. No food or drink was allowed until the baby was born. Only one indication was recorded for each cesarean section in the analysis of the distribution and attribution of the cesarean section rate based on cesarean causes. The decision rules for assigning multiple-diagnosis deliveries to a single clinically reasonable diagnostic class were modified from the method described previously by Anderson and Lomas. 10 A total of 1,112 records in 1993 and 665 records in 2000 were classified. The data were analyzed in 2 stages. First, the overall cesarean birth rate, regardless of diagnosis, was calculated for each year. Comparisons of the cesarean rates between and were made using chi-square test. Secondly, the data were analyzed for each indication for both 1993 and Comparisons of the proportion of overall cesarean sections contributed by each indication were also made by chi-square test. RESULTS Fig. 1 depicts the annual cesarean section rates at TVGH paralleled with those of the United States from 1975 through The rate at TVGH exceeded the latter in 1989, and that of Taiwan in The cesarean section rate declined from 36.7 (1996) to 30.2% (1997), which was lower than the rate for Taiwan as a whole (32.7%) in The cesarean section rates of Norway and England shown in the figure served as good references for the 1980s. Table 1 shows the numbers and percentages of women who received selective VBAC from 1997 through Totally, among 1,169 women with prior cesareans, 188 (16.1%) elected a trial of labor and 145 (12.4%) achieved a vaginal delivery. The VBAC success rate was 77.1%. No uterine rupture occurred; however, 2 women received a hysterectomy due to a postpartum hemorrhage caused by placenta accreta, and one abruptio placentae occurred. No maternal or perinatal mortality ever occurred in 188 episodes of trial of labor. Only 2 neonates were born with a low Apgar score (< 7) at the 5-minute 282

3 June 2004 Peer Review and Trial of Labor stage: one was scored as 7/4/9 at 1-, 5-, and 10-minute periods after a low-forceps delivery; the other was delivered by emergency cesarean section due to abruptio placentae. The babies were followed-up by pediatricians, and are in fair condition. Thirty-two vacuum-assisted and 5 low-forceps deliveries were performed in 145 successful VBAC cases, with an operative vaginal birth rate of 25.5%. The reasons for the 43 failed trials of labor were: 19 (44.2%) dystocia, 13 (30.2%) intrapartum laboring pain, 10 (23.2%) fetal distress, and 1 (2.3%) abruptio placentae. As shown in Table 2, a comparison of the 4-year periods before and after 1997 at TVGH showed a significant reduction in all 3 categories, rated: p < for total cesareans; p < for primary cesareans; and p < for repeat cesareans. At the same time in Taiwan, conversely, significant increases occurred in the total cesarean section rate during the periods and (p < 0.001). Stage 2 of this study was designed to detect the effectiveness of VGH-T sremodeling efforts by revealing the proportional changes in the overall cesarean birth Table 1. Vaginal birth after prior cesarean (VBAC) rate, VBAC success rate, and the major complications of VBAC at Taipei Veterans General Hospital Year VBAC Prior cesarean VBAC rate* VBAC trial VBAC success rate Major complications n n % n % hysterectomies nil nil abruptio * VBAC rate = number of VBAC/ number of women with prior cesarean section. VBAC success rate = number of VBAC/number of VBAC trials. Pathology-proved placenta accreta. Table 2. Summary of cesarean section data from Taipei Veterans General Hospital and in Taiwan, 1993 through 2000 Taipei Veterans General Hospital Taiwan Year Total deliveries Cesarean sections Total deliveries Total cesarean sections Total Primary Repeat n n(%) n n(%) (40.7) 711 (26.0) 401 (14.7) (32.2) (36.4) 507 (20.5) 394 (15.9) (33.1) (33.8) 449 (17.5) 416 (16.3) (33.7) (36.7) 432 (20.6) 337 (16.1) (32.7) (37.0)* 2099 (21.3) 1548 (15.7) (32.9) (30.2) 344 (16.5) 285 (13.7) (32.7) (32.5) 334 (18.8) 244 (13.7) (33.1) (29.2) 326 (16.9) 238 (12.3) (34.0) (30.9) 408 (18.9) 257 (11.9) (34.5) (30.7)* 1412 (17.8) 1024 (12.9) (33.5) * Reduction of total cesarean section rate at VGH-T, comparing the periods of and using chi-square test, p < 0.001; 95% Confidence Interval (CI) for 37.0%: ; 30.7%: Reduction of primary cesarean section rate at VGH-T, comparing the periods of and , p < 0.001; 95% CI: 21.3%: ; 17.8%: Reduction of repeat cesarean section rate at VGH-T, comparing the periods of and , p < 0.001; 95% CI: 15.7%: ; 12.9%: Increase of total cesarean rate in Taiwan, comparing the periods of and , p < 0.001; 95% CI: 32.9%: ; 33.5%:

4 Wei-Hsing Liang et al. Journal of the Chinese Medical Association Vol. 67, No. 6 rate attributed to each indication. In 1993, 43 indications were employed as reasons for cesarean sections, whereas 35 indications were used in 2000 (Table 3). Table 4 shows the comparison of the proportions attributed to 15 leading indications in 1993 and 2000: 9 indications declined, 5 inclined, and 1 remained unchanged. The reductions were substantial in the major indications, including prior cesarean (-25.2%), dystocia (-38.4%), and fetal distress (-48.4%). Comparing the proportions attributed to 5 indications in 1993 and 2000, there were significant reductions in prior cesareans (p < 0.001), dystocia (p < 0.001), and fetal distress (p = 0.001), but no significant differences were found in breech (p = 0.621) and other (p = 0.360). The contribution of each major indication to the decline of the total cesarean rate can be estimated: 36.7% by reduced prior cesarean use, 37.8% by dystocia; 3.1% by breech presentation, 15.3% by fetal distress, and 8.2% by other. Table 3. Distribution of conditions employed as the indications for cesarean deliveries at Taipei Veterans General Hospital in 1993 and 2000 Characteristic Total cesarean deliveries in 1993 Total cesarean deliveries in 2000 n (%) n (%) Prior cesarean* 391 (35.2) 231 (34.7) Dystocia 270 (24.3) 132 (19.9) Nonvertex 114 (10.3) 84 (12.6) Fetal distress 84 (7.6) 35 (5.3) Other 253 (22.8) 183 (27.5) Total 1112 (100.0) 665 (100.0) * There were 401 and 257 prior cesareans in 1993 and 2000, respectively; the reductions in number were attributed to various conditions, including antepartum hemorrhages, VBAC failure due to dystocia or fetal distress, maternal medical conditions, or fetal disorders. Breech: 111 cases in 1993, 79 in 2000; transverse lie: 2 in 1993, 4 in 2000; compound presentation: 1 in 1993, 1 in minor indications in 1993, 31 minor indications in With a rounding error of 0.2 in the total. Table 4. The proportions of 15 leading indications for cesarean section in 1993 and 2000 Characteristic 1993 (%) 2000 (%) Change* (%) p Prior cesarean < Dystocia < Nonvertex Fetal distress Other Multifetal pregnancy PIH and Preeclampsia Induction failure Placenta previa Abruptio placentae Prior myomectomy Elderly primigravida GDM Macrosomia Myoma Elective primary cesarean Total * Change = (percent in percent in 1993)/ percent in Consists of 51 indications, accounting for 22.8% of the overall cesarean section rate in 1993 and 27.5% in The top 11 indications appear in this table. PIH, pregnancy-induced hypertension; GDM, gestational diabetes mellitus. 284

5 June 2004 Peer Review and Trial of Labor DISCUSSION This study was the first trial to employ VBAC systematically in Taiwan. The authors chose almost perfect candidates for trial of labor. Labor induction or augmentation by oxytocin or prostaglandins was not recommended. 11 The VBAC rate at TVGH has been 12.4% in the most recent 4 years. We plan a 37 percent VBAC rate in the next 5 years, the same percentage as recommended by the American College of Obstetricians and Gynecologists (ACOG) Task Force on Cesarean Delivery Rate for the United States for the year 2010 a gradual increase starting from the 27.4% of 1997 and the 26.3% of VBAC was accepted and encouraged during the 1980s. 13 Accumulated experience showed that trial of labor might be associated with higher maternal morbidity and perinatal complications, but most of these adverse effects were attributable to uterine rupture. 14 The rate of cesarean delivery in the United States increased after 1996, and the rate of VBAC decreased at the same time. Nonetheless, more recent reports dealing with the detailed mechanisms of VBAC are optimistic. 15,16 Although VBAC does pose a lower level of fetal risk, and probably had higher major maternal complications according to the definition of McMahon et al, significant neonatal morbidity could be avoided if prompt delivery, within 17 minutes, is undertaken for women with severe, repetitive late decelerations. 14,17 Active management of labor and external audit were ineffective in reducing cesarean section use. 18 However, the combined efforts of review committees, operative vaginal delivery, and 24-hour physician staffing in hospitals could lead to reduced numbers of convenience cesarean sections occurring during evening hours. 7,8 The contribution of dystocia to the overall cesarean rate per 100 total deliveries in Norway, Scotland, and Sweden was 1.7% to 4.0% in We have lowered the dystocia percentage of the total births from 9.9% (1993) to 6.2% (2000). The potential contribution of breech to the decline in the cesarean rate at our hospital is small because a liberal approach to breech delivery was agreed upon. Nevertheless, the external cephalic version was able to effectively decrease both the breech delivery and cesarean rates. 19 Vaginal delivery for multiparous breeches and external cephalic versions would be a feasible way to lower the breech portion of the cesarean rate. The introduction of electronic fetal monitoring contributed to an increased cesarean section rate in the 1970s. A better understanding and interpretation of fetal heart rate tracings led to a reduction in cesarean section use compared with an initial rise at the beginning of the routine use of monitors. 4,8 At TVGH, the cesarean surveillance system worked well in this category by reducing the fetal distress proportion rate from 3.1% in 1993 to 1.6% in The authors hope to reduce it to 1.1%, a percentage recommended by Myers and Gleicher. 8 It is obviously not sufficient to analyze the four leading indications, which accounted for 85% in Western industrialized countries and 75% at TVGH, in terms of their contribution to all cesarean deliveries. 12 Comparing dozens of minor indications at TVGH for 1993 and 2000, several findings are worth noting: (1) the incidence of multifetal pregnancy with malpresentation exceeded that of fetal distress; (2) the indications for placenta previa and abruptio increased; (3) a new indication referred to as elective primary cesarean (self-pay) appeared a kind of socioeconomic factor influencing the physician s decision-making; (4) inappropriate indications employed in 1993, such as Gestational diabetes mellitus (GDM), induction failure, gum bleeding, or elderly primigravida, were reduced or abandoned in use; (5) the number of conditions inevitably leading to a cesarean section, e.g., total placenta previa, spine/pelvis disorders, gynecological cancers, diaphragmatic hernia, and fetal congenital heart disorders, was high at TVGH as a tertiary center, contributing an approximately 3 percent proportion to the total cesarean rate; and (6) more advanced guidelines for the category other, which accounts for 25% of total cesarean deliveries, is crucial, and this shall be an area of attack for lowering the high cesarean delivery rate at this hospital. In 1990, there were 4 articles published concerning ways to reduce the cesarean rate. One which employed the educational approach alone failed to lower the cesarean rate over a short period. 20 The other three, employing stringent guidelines for prior cesarean, dystocia, fetal distress, and/or breech presentation, lowered the cesarean rate. 12,21 Up to now, the most efficient way to lower the repeat cesarean rate is VBAC, and an efficient way to 285

6 Wei-Hsing Liang et al. Journal of the Chinese Medical Association Vol. 67, No. 6 reduce the primary cesarean rate would be the practice of stringent guidelines for dystocia, fetal distress, and other indications. In this study, we found that the cesarean surveillance system, together with some supportive procedures, could solidify these guidelines. Trial of labor after cesarean section is an issue of medical, economic, and ethical concern. 22,23 Nevertheless, primary cesareans are the origin of this dispute, offering a continuous resource for the debate. Thus, the prevention of primary cesareans is fundamental. In this article, strategies for each category of lowering cesarean section rate have been analyzed, and based on this, the cesarean surveillance system would be a feasible way to double-check the indications before and after a cesarean delivery. REFERENCES 1. Notzon FC, Cnattingius S, Bergsjo P, Cole S, Taffel S, Irgens L, et al. Cesarean section delivery in the 1980s: international comparison by indication. Am J Obstet Gynecol 1994;170: Macfarlane A. At last - maternity statistics for England. BMJ 1998;316: Evrard JR, Gold EM. Cesarean section and maternal mortality in Rhode Island: incidence and risk factors, Obstet Gynecol 1977;50: Gilstrap LC III, Hauth JC, Toussaint S. Cesarean section: changing incidence and indications. Obstet Gynecol 1984;63: Shy KK, LoGerfo JP, Karp LE. Evaluation of elective repeat cesarean section as a standard of care: an application of decision analysis. Am J Obstet Gynecol 1981;139: Douglas RG, Birnbaum SJ, MacDonald FA. Pregnancy and labor following cesarean section. Am J Obstet Gynecol 1963;86: Sachs BP, Kobelin C, Castro MA, Frigoletto F. The risks of lowering the cesarean delivery rate. N Engl J Med 1999; 340: Myers SA, Gleicher N. A successful program to lower cesarean section rates. N Engl J Med 1988; 319: Stafford RS. Alternative strategies for controlling rising cesarean section rates. JAMA 1990;263: Anderson GM, Lomas J. Determinants of the increasing cesarean birth rate. N Engl J Med 1984;311: Lydon-Rochelle M, Holt VL, Easterling TR, Martin DP. Risk of uterine rupture during labor among women with a prior cesarean delivery. N Engl J Med 2001;345: Cesarean delivery and postpartum hysterectomy. In: Cunningham FG, Gant NF, Leveno KJ, Gilstrap LC III, Hauth JC, Wenstrom KD, eds. Williams obstetrics. 21 st edition. New York: McGraw-Hill, 2001; Martin JN, Harris BA, Huddleston JF, Huddleston JF, Morrison JC, Propst MG, et al. Vaginal delivery following previous cesarean birth. Am J Obstet Gynecol 1983;146: McMahon MJ, Luther ER, Bowes WA, Olshan AF. Comparison of a trial of labor with an elective second cesarean section. N Engl J Med 1996;335: Zelop CM, Shipp TD, Repke JT, Cohen A, Lieberman E. Effect of previous vaginal delivery on the risk of uterine rupture during a subsequent trial of labor. Am J Obstet Gynecol 2000;183: Bretelle F, Cravello L, Shojai R, Roger V, D ercole C, Blanc B. Vaginal birth following two previous cesarean sections. Eur J Obstet Gynecol Reprod Biol 2001;94: Leung AS, Leung E, Paul RH. Uterine rupture after previous cesarean delivery: maternal and fetal consequences. Am J Obstet Gynecol 1993;169: Frigoletto FD Jr, Lieberman E, Lang JM, Cohen A, Barss V, Ringer S, et al. A clinical trial of active management of labor. N Engl J Med 1995;333: Zhang J, Bowes WA Jr, Fortney JA. Efficiency of external cephalic version: a review. Obstet Gynecol 1993;82: Porreco RP. Meeting the challenge of the rising cesarean birth rate. Obstet Gynecol 1990;75: Sanchez-Ramos L, Kaunitz AM, Peterson HB, Martinez-Schnell B, Thompson RJ. Reducing cesarean sections at a teaching hospital. Am J Obstet Gynecol 1990;163: Clark SL, Scott JR, Porter TF, Schlappy DA, McClellan V, Burton DA. Is vaginal birth after cesarean less expensive than repeat cesarean delivery? Am J Obstet Gynecol 2000;182: Greene MF. Vaginal delivery after cesarean section: Is the risk acceptable? N Engl J Med 2001;345:

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