C-section rates are the topic of many conversations. In the United States, roughly one third of all deliveries are operative (C-section).The rates are reported and publicly available. Pregnant women want to find a doctor with a low rate. Hospitals are trying to reduce their operative delivery rates. Insurance companies don’t want to pay out for the more expensive delivery method. Why is the C-section rate so high, and who is responsible? Click To Tweet
I recently saw a video by Dr. Neel Shah that made me question the role of the nurse and C-section rates. Dr Shah and his team of researchers are considering hospitals as a factor. Across the country, why does hospital A have a low C-section rate compared to hospital B, when high risk factors and other variables are removed? Watch this three minute video. It will get you thinking and asking questions about what we can do to lower C-section rates.
You can read about Dr Shah and the Childbirth Overtreatment Project in-depth at the Ariadne Labs website: https://www.ariadnelabs.org/childbirth-projects/.
C-Section Rates by Hospital
Obstetrician C-Section Rates
Obstetrician C-section rates are not published publicly. You can ask a provider what his/her primary C-section rate is, but they may not know or tell you. An interesting and informative article from ACOG, Safe Prevention of the Primary Cesarean Delivery, can be read here.
Does it matter what an obstetrician’s C-section rate is? I don’t think so. This will come as a surprise to the pregnant women out there looking for a doctor to give them the normal vaginal delivery they want. But consider the odds of that doctor actually being there the day you deliver. Say you see a doctor in a practice of five physicians. On Monday through Friday, one of those doctors will be on call for deliveries each day. You have a one in five chance your own doctor will deliver your baby. On the weekend, many practice groups cross cover. That reduces greatly the chances your own doctor will be on call. Do you know every one of those providers, how they manage labor, and what their individual C-section rates are?
Labor & Delivery Nurses
The person with you all day or all night, managing your labor minute to minute, assessing fetal well being, and functioning as a patient advocate is your nurse. It’s not your personal physician – their role is prenatal care, actual delivery, and post-partum care. Labor, and the management of labor (according to hospital policy and physician orders) falls solely on the nurse.
Is labor progressing? Does the patient need oxytocin (Pitocin) to help regulate contractions, or to induce labor? Do you have any idea when this drug should be used, how it is used, how often the drip should be increased and by how much, or reasons why it is decreased or shut off? Do you really need Pitocin at all? I know because I’m a labor and delivery nurse. So do my fellow OB nurses. But do they use their knowledge to act appropriately on your behalf?
Hospital culture, discussed in Dr. Shah’s video, plays a role. If you have many patients laboring and few beds to put them in, you need to increase the throughput. How? Start Pitocin. Push the Pit. Get that labor moving. The question every L & D nurse hates: What's the Pit on? Click To Tweet It doesn’t matter. What matters is frequency, duration and strength. How often are the contractions, how long do they last, and how strong are they to palpation. Are the contractions adequate to dilate the cervix?
Does the nurse give too much Pitocin, causing uterine hyperstimulation and the resulting fetal distress? Does the nurse dawdle with turning up the Pitocin, hoping to avoid a change of shift delivery and the resulting paperwork and keeping her late to leave? What is the staffing level like? Is the nurse doing something else – caring for more than one patient at a time, preventing timely increases in Pitocin? Are the nurses switching assignments in order to manage a busy labor unit? How many different nurses did the same patient have during her labor? (Read this article: Continuity of nursing care and its link to cesarean birth rate.) And those are just a few examples of nursing influence, a mere scratch on the surface of hospital and nursing culture.
The nurse has a huge amount of control about what happens during labor – whether labor progresses to a vaginal delivery, whether labor fails and results in a c-section, or whether your personal labor plan is followed and communicated to the whole team. But the nurse isn’t the only player. The patient (frustrated, tired of waiting, unable to tolerate pain, begging for c-section) and the baby (fetal distress) tie our hands. We can’t control everything, but we sure can control a lot. Do nurses play a role in c-section rates? Hell yes! Click To Tweet