In Effort to Limit C-Sections, Two Methods Yield Different Results on Staten Island By SUSAN DOMINUS Published: April 19, 2010 This is a tale of two hospitals. One has the highest rate of Caesarean sections in the city, the other the fourth lowest. They represent some of the city’s obstetric extremes, yet they sit just five miles apart on Staten Island, serving similar populations. So what accounts for the difference? In large part, determination, whichDr. Mitchell A. Maiman, the chairman of the obstetrics and gynecology department at one of the two, Staten Island University Hospital, has in ample supply. As New York City’s C-section rate has soared in recent years — by 36 percent, between 2000 and 2007, according to the New York State Department of Health — Dr. Maiman has kept his hospital’s rate around 23 percent of all births. In 2008, according to numbers released by Choices in Childbirth, an advocacy group for pregnant women, working with state statistics, Staten Island University Hospital’s rate went down, while the rate at the other hospital, Richmond University Medical Center, went up again, to 48.3 percent. That made it, for the fifth consecutive year, the hospital with the highest C-section rate in the city. (The National Center for Health Statistics reported that the Caesarean rate reached 32 percent in 2007.) Caesarean births are generally considered more prone to complications than natural births, so most hospitals at least pay lip service to their devotion to reducing them. But very few have pulled it off. What seems to have made the difference for Dr. Maiman’s department is building that goal into policy, even when it is unpopular with doctors — even, sometimes, when it may be unpopular with patients. To start, Dr. Maiman and his colleagues do not allow unnecessary inductions for first-time pregnancies at any point before the 41st week, since they are a main cause of C-sections. They also do not allow C-sections for no reason other than the mother wants one. C-sections are thought to be relatively lawsuit-proof, and they also let everyone go home on time. But such conveniences do not inform Dr. Maiman’s thinking. “You have to draw the line somewhere,” he said in an interview. “If you went to your doctor and said, ‘I want my gall bladder taken out electively,’ your doctor wouldn’t do that, probably.” Mother-demanded C-sections are unusual enough that the policy is probably more useful to Dr. Maiman for the message it sends to doctors and patients, a clear sign that he values a noninterventionist policy as long as it is safe. It has become common for hospitals to prohibit what are known as VBACs (for Vaginal Birth After Caesarean, pronounced VEE-back) for reasons having to do with anesthesia availability and, more tacitly, a fear of lawsuits. Dr. Maiman actively encourages VBACs. Residents are trained not only to avoid unnecessary C-sections, but to let higher-ups know if they witness another doctor about to perform one. Obstetricians with high Caesarean rates, Dr. Maiman said, invite scrutiny; doctors either come to see things his way or end up leaving the hospital. “If a woman has a third or a fourth Caesarean, the maternal morbidity and mortality is astronomically higher,” Dr. Maiman said. “That’s when you see women dying in childbirth from obstetrical hemorrhage.” Whether or not you like his policy — maybe you believe a mother’s choice should extend to controlling the hour of her delivery and how much it will hurt — you have to give Dr. Maiman credit for not just creating protocols to protect women’s health, but enforcing them. There is not a lot of incentive for hospitals to let conviction trump convenience, especially when convenience comes with the added bonus of lower legal risk. Dr. Michael L. Moretti, the chairman of the obstetrics and gynecology department at Richmond University Medical Center, attributed the high rate of C-sections at his hospital to the reputation of its perinatal care center, which he said attracts women with high-risk pregnancies who are more likely to require surgically assisted births. Dr. Moretti said he and his colleagues were trying to reduce C-sections with peer review of one another’s procedures. Women requesting C-sections are now required to meet with Dr. Moretti to discuss the risks. “What we find is that about half who come in requesting a C-section will change their mind,” he said, “so that’s helped a lot.” Five miles away, Dr. Adi Davidov, one of Dr. Maiman’s colleagues, described similar conversations — but better results. “I find that most of the time, if you explain to a mother you’ll recover faster, it’s safer,” he said, “then most women will choose a vaginal delivery.” I cannot say which doctor is the better obstetrician, but it seems like Dr. Davidov is the better talker. When it comes to patient care, that counts, too.
Certified Professional Doula since 2007
Coerced C-Sections: The Latest Reach of Fetus-First Laws
November 4, 2015
In a ruling on a series of requests to either dismiss or narrow Dray’s case, the trial court ruled that even though a fetus is not recognized as a person until after a live birth under New York law, the state has an interest in protecting viable fetal life, which it advances by outlawing self-abortion and abortions after the 24th week of pregnancy. That state interest, the trial court reasoned, is enough “to override a mother’s objection to medical treatment at least where there is a viable full term fetus and the intervention itself presents no serious risk to the mother.”
In other words, because the State of New York has a certain interest in protecting a viable fetus, doctors in the state can, for now, override pregnant patient consent with impunity. The New York court’s interim order in the Dray case effectively makes doctors agents of the state capable of enforcing the “rights” of a fetus over the rights of their own patient.
The risk of death from a caesarean section is estimated at fewer than 1 in 2,500, according to information on the hospital's website. That is significantly more than the roughly 1-in-10,000 risk of death during a vaginal birth. http://www.boston.com/news/ Vaginal Birth a Safe Option After Multiple C-Sections "Landon found that the risk of uterine rupture was 0.9 percent in cases of women with a history of multiple prior cesarean deliveries undergoing a trial of labor, compared with 0.7 percent in the cases of patients who had experienced only one previous cesarean delivery. These data challenge the notion that women with more than one prior cesarean are at dramatically increased risk for uterine rupture with a VBAC attempt." - Ohio State University A Healthy Baby Isn't All That Matters "There are so many details of my cesarean that I have either left unwritten, or have written in fragments in various locations. A reply back to an online thread regarding the “safety” of a cesarean; or to a mom who is being told that her baby will be too big and she needs to have her baby surgically removed. But you see, my story doesn’t just end when we brought our son home from the hospital on Palm Sunday in 2004. My journey began when I found out I was pregnant in 2003, and it continues every day. Some days I wish it would all just be over with. Be done with the deeply seeded emotional pain, be done with the physical pain of ongoing adhesions and endometriosis from my cesarean – even 4 years later. "
What Every Woman Needs To Know About C-Sections See what Dr. Eisenstein has to say about C-sections, VBACs/HBAC and home births. Yes you read that correctly an OB writes about this important issue. Check out the C-Section rate at the hospital you will be delivering in? Were you aware that Cesarean section has become the most common operating room procedure in U.S. hospitals and involves much greater cost than vaginal birth? Cesarean sections are associated with increased risk for numerous health problems. For the mothers there is a higher risk of: blood clots and stroke, emergency hysterectomy, infection, more intense and longer-lasting pain. For the baby there is a higher risk of: breathing problems, surgical injury, reduced breastfeeding, and asthma in childhood and adulthood. There is a higher risk of fertility and placenta problems that endanger mothers and babies in future pregnancies such as ectopic pregnancy, placenta accreta, placental abruption. The American College of Obstetricians and Gynecologists (your doctor's medical board) recommends that most women with a previous cesarean be counseled and offered VBAC. A large proportion of women with a previous cesarean do not have this option, primarily because their caregiver or hospital is unwilling to offer it. At this time, over 9 in 10 women in the United States with a previous cesarean have repeat cesareans.
Elective repeat cesarean linked to increased need for NICU
care 5/27/09 NEW YORK (Reuters Health) - Full-term neonates delivered through elective repeat cesarean have higher rates of respiratory morbidity, hypoglycemia, and admission to a neonatal intensive care unit (NICU) than infants delivered by vaginal birth after a previous cesarean, investigators in Denver report in the June issue of Obstetrics & Gynecology. "Controversy remains on whether a trial of labor or an elective repeat cesarean delivery is preferable for a woman with a history of cesarean delivery," Dr. Beena D. Kamath at the University of Colorado School of Medicine and her colleagues note. Based on risk of uterine rupture and perinatal asphyxia, obstetricians often favor elective repeat cesarean. To compare the outcomes of elective cesarean versus vaginal birth aftercesarean delivery, the team studied 672 women with one prior cesarean and a singleton pregnancy without congenital anomalies, who delivered at term between 2005 and 2008. Subjects were categorized into four groups: elective repeat cesarean without labor (n = 239); elective cesarean after onset of labor (n = 104); successful vaginal birth after cesarean (n = 244); or failed vaginal birth after cesarean requiring emergent cesarean delivery (n = 85). Overall, neonates born by cesarean had higher NICU admission rates compared with those born by vaginal birth after cesarean (9.3% vs 4.9%, p = 0.025). Intended repeat cesarean was associated with a higher incidence of NICU admission for hypoglycemia and higher rates of oxygen supplementation and ventilatory support. The authors theorize that "the catecholamine surge that occurs during labor likely plays an important role in both clearance of fetal lung fluid and glycemic control after birth." More specifically, however, women who failed vaginal birth and required cesarean delivery were most likely to exhibit fetal distress requiring resuscitation, whereas a successful vaginal birth after previous cesarean had the fewest admissions to the NICU, shortest hospital stay, and the lowest incidence of ongoing respiratory support. These findings, say Dr. Kamath and her colleagues, argue for "greater selectivity in performing a cesarean delivery in the first place, and certainly a greater need for counseling before a primary elective cesarean delivery."