The Rising Cesarean Section in United States

Caesarian section, or cesarean section, is defined as delivery of the fetus through incisions in the abdominal wall and the uterine wall (hsyerotomy). This definition does not include removal of the fetus from the abdominal cavity in case of rupture of the uterus or abdominal pregnancy. Cesarean section is used whenever it is believed that further delay in the delivery would seriously compromise the fetus, the mother, or both, yet vaginal delivery is unlikely to be accomplished safely.

Cesarean section, perhaps the most dramatic of surgical operations, is technically simple, but the correct decision when to perform it embodies the art of obstetrics and often depends upon niceties of judgment acquired only through long years of clinical experience. With modern surgical safeguards the immediate mortality from cesarean section in the best obstetrics hospital has been reduced to less than 2 per thousand, approximately twice the mortality rate with vaginal delivery.

To the immediate risk must be added, however, the later, recurrent hazards of repeat cesarean section or possible uterine rupture associated with each succeeding pregnancy. The rate of delivery by cesarean section has increased at accelerated pace for the past 20 years in the United State and other developed countries. In the United States, the rate increased from 45 percent in 1965 to 23percent in 1985 and this was documented in all parts of the country and for women of all ages.

The reasons for this marked are not completely understood but some explanations include: there has been reduced parity almost half of pregnant women are nulliparas Therefore, an increased number of cesarean sections might be expected for those conditions that are more common in nulliparous women especially dystocia and pregnancy-induced hypertension. Second is that older-aged women are having children. In1980, approximately 2 percent of births in the United State were in women 30 years or older, but I 1985, this was 25 percent. The frequency of caesarian section increases with advancing age for American and Canadian women.

(Martel and associates, 1987; Taffel and co-workers,1987). Third, electronic fetal monitoring likely increases the chances of detecting fetal distress and probably results in an increased number caesarean sections. Fourth, breeches are delivered more frequently by cesarean section. For example, in 1985, 79 percent of ll breeches were delivered by cesarean section. (Taffel andassociaates,1987). Fifth, there are fewer forceps deliveries today. Between 1972 and 1980, forceps deliveries declined from 37 percent 18 percent, corresponding t an increased cesarean section rate from 7 to 17 percent (Pacek and collagues,1983).

Sixth, repeat cesarean sections have contributed significantly to the total increase in cesarean deliveries. Seventh, there is increasing concern for malpractice suits. In 1985, 73 percent of fellows of the American College of Obstetricians and Gynecologists reported that at least one malpractice claim had been filed against them! According to Haynes de Ragt and colleagues (1986), private nulliparous patients are much more likely to undergo caesarean delivery than clinic patients if dystocia, malpresentaion, or fetal distress is diagnosed.

In 1980, Bottoms and colleagues concluded that the major indications for ceasarean section that needed to be reassessed were dystocia and repeat operations. Between 1980 and 1985, more than three fourths of the 16. 5 to 22. 7 percent increase in the cesarean section rate was the consequence of repeat sections and dystocia. The contribution of each indication to the total section rate is a function of two variables: (1) the change in incidence of the indication. Dystocia was diagnosed in 7. 2 percent and 0.2 percent of women in 1980 and 1985, respectively, a 42 percent increase in the incidence of this complication.

It can be seen that cesarean delivery was performed in 67 percent of women diagnosed with dystocia in 1980 and 65 percent in 1985. There was a decreased of 3 percent in the number of repeat cesarean sections from 1980 to 1985; however the percentage of all women delivered by repeat cesarean section increased from 5. 1 percent to 8. 4 percent. This resulted in actual increase in the rate of repeat cesarean sections from 4. 9 percent in 1980 to 7. 9 in 1985, an increase of 48 percent.

Therefore, as predicted by Bottoms and associates (1980), the increase in cesarean sections in the United States is not likely to define unless repeat cesarean sections and those done for dystocia are reduced. As described subsequently, the safety and efficacy of vaginal delivery after cesarean section has been established. It is interesting that the percentage of cesarean sections foe all complications except breech have decreased. If this trend continues it is likely that an overall reduction in cesarean section rates will be achieved (Anderson and Lomas, 1984; Shiono and co-wotkers, 1987; Taffel and associates, 1987)

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