Women's Health

November 8, 2018

Initiative to reduce C-sections showing positive results

As the worldwide medical community takes notice of the nearly doubled rate of cesarean section surgeries since 2000, Vanderbilt University Medical Center has seen a steady decrease in its rate of primary C-sections over the last 11 months.

As the worldwide medical community takes notice of the nearly doubled rate of cesarean section surgeries since 2000, Vanderbilt University Medical Center has seen a steady decrease in its rate of primary C-sections over the last 11 months.

In January, the Vanderbilt Center for Women’s Health enrolled in the Reducing Primary Cesareans Project, a collaborative run by the American College of Nurse Midwives aimed at reducing unnecessary cesareans in low-risk pregnancies through education and support for maternity care professionals. The program provides monthly webinars that allow participating hospitals to learn new techniques, share successes and concerns, and gain insight on both their own progress and the progress of other health care systems.

Laurie DeSantis, MSN, CNM, left, Susan Lewis, MSN, CNM, and colleagues are working to reduce the number of primary cesarean section births at Vanderbilt. (photo by Susan Urmy)

The team at VUMC reviews patient charts weekly to track data and meets once per month to talk through the results for continued improvement.

“Working to lower the number of primary C-sections in our department requires a complete culture change for our unit,” said Susan Lewis, MSN, CNM, assistant professor of Clinical Obstetrics and Gynecology. “It involves a collaborative effort between care team members from every angle, including attending physicians, physician residents, nurses and midwives.”

Since enrolling in the program, the rate of primary C-sections performed by Vanderbilt for full-term, singleton pregnancies has dropped by more than 10 percent, down to less than 25 percent over the last few months from roughly 35 percent in January.

Avoiding C-section deliveries that are not medically necessary reduces a range of risks for both the mother and baby, including the risk of infection, blood loss, chronic pain from adhesions after surgery, neonatal respiratory distress, admission to the neonatal intensive care unit (NICU) and even mortality. While rare, the likelihood of these complications increases with each subsequent pregnancy.

“While they are sometimes lifesaving operations, cesarean births can carry significant risks to mothers and babies,” said William (Josh) Kellett, MD, associate professor of Obstetrics and Gynecology.

“The ‘once a C-section, always a C-section’ mentality now becomes a reality that moms and families must confront. Higher order cesarean deliveries lead to higher risks of significant morbidity, including abnormal placentation and even peripartum hysterectomy. Such morbidity is associated with higher medical costs and, unfortunately, increasing rates of maternal mortality, all of which could be potentially avoided with more detailed attention to reducing primary cesarean deliveries.”

“The best way for us to reduce the risk of morbidity and mortality related to abnormal location of the placenta is to reduce the number of cesarean deliveries in women having their first babies,” added Ronald Alvarez, MD, chair of Vanderbilt’s Department of Obstetrics and Gynecology. “We are doing all we can to get that rate as low as possible.”

According to Lewis, about 50 percent of unnecessary C-sections are due to potentially modifiable reasons, including not giving the mother enough time to progress in labor and variations among providers when interpreting fetal heart rate tracing.

Beyond these areas, Vanderbilt is also more accurately admitting women who are in active labor. When women in the latent phase of labor are admitted to the hospital, the likelihood of potentially avoidable medical intervention increases.

Other strategies for reducing primary cesareans include promoting mobility to help alleviate pain for women who are not using epidurals, using positioning techniques for women with epidurals and hosting weekly team meetings to review fetal heart tracings.

Setting more flexible timelines for determining when a patient may need a C-section and considering the patient’s weight are also factors, as women with higher body mass indexes typically take longer to deliver vaginally.

“We’ve all had friends and family members who have had C-sections who feel well and are healthy. Because of this, it can be difficult for us to take the potential consequences seriously,” said Lewis.

“Our primary goal is for women to be able to deliver safely. We also know that when a woman delivers vaginally, she will feel better afterwards. We want each mother to feel strong and enjoy her time with her baby. Recovery from surgery takes longer.”