How to stop the relentless rise in cesarean deliveries.

I the United States we have experienced a relentless rise in the cesarean delivery rate from 5% in the 1960s to 32% today.1 It is unclear what an acceptable rate should be. Certainly the 5% level was too low, and the 32% rate of today is judged by many to be too high. However, recent data show that almost a third of primary cesarean deliveries are in nulliparous women,2 and with the decreasing rate of vaginal birth after cesarean delivery (VBAC) since 1996, the rate is likely to exceed 50% very soon in the United States. How can we curtail this runaway increase in cesarean deliveries? The question is simple, but the solution is complex. One solution is to make VBAC more accessible and more desirable. In this issue (see p. 342) Dr. James Scott tells us how this can be done.3 He outlines the dilemma we face today in trying to keep cesarean delivery rates low, covers the salient points of the 2010 National Institute of Child Health and Human Development consensus conference on VBAC, and discusses what is necessary to prepare for an improved climate for implementing VBAC. He presents valuable material on how to conduct the VBAC labor and delivery, and covers the rare but dreaded complication of uterine rupture. This Clinical Expert Series article will be a valuable resource for physicians and departments that wish to improve their ability to offer VBAC to patients. The struggle to improve acceptability of VBAC will not be easy, as some practical considerations make this choice difficult. The candidate patient may have had such a difficult labor before her primary cesarean delivery that she is unwilling to consider a trial of labor. Another patient may have had such an easy time with a scheduled cesarean delivery for a breech fetus that she prefers not to have a trial of labor. The physician has to devote considerably more time in the labor suite for a VBAC than for a scheduled repeat cesarean delivery. In addition, there is a small but serious risk of uterine rupture, and until there is tort reform the physician may be unwilling to take this risk. Furthermore, the hospital administrator makes a larger financial return on a cesarean delivery compared with a vaginal delivery. Of course, the basis of decision making should be what is best for the patient, but such considerations must be dealt with when organizing a comprehensive system for providing VBAC for patients. The second and even more critical solution is to prevent primary cesarean deliveries in the first place. At one time, obstetricians wishing to do cesarean deliveries were required to get a consultation from a colleague. Departments reviewed all primary cesarean deliveries. The scene has clearly changed. Today, cesarean deliveries may be done at a patient’s request, and vaginal delivery of breech fetuses is no longer taught in many training programs. Modern practices have made cesarean deliveries safer and recovery time shorter than decades ago. However, cesarean deliveries have significant risk for future pregnancies in placenta See related article on page 342.