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Adverse Perinatal Events and Subsequent Cesarean Rate

From the MacGregor Medical Association, Department of Obstetrics and Gynecology, Houston, Texas.

Address reprint requests to: Mark A. Turrentine, MD MacGregor Medical Association 6410 Fannin Street, Suite 200 Houston, TX 77030 E-mail: drt318{at}aol.com

	Abstract

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Objective: To determine whether severe intrapartum complications resulting in poor neonatal outcome increased obstetricians’ cesarean delivery rates.

Methods: From July 1996 through June 1998 we prospectively studied 3008 deliveries by 12 obstetricians. We chose adverse neonatal outcomes that would be viewed by obstetricians as anxiety-provoking experiences that are rare in obstetric practice. Index events included head entrapment of breech infants, Apgar score less than 3 at 10 minutes, shoulder dystocia resulting in persistent brachial plexus injury, and intrapartum fetal death. After an index event was identified, the obstetrician’s cesarean delivery rate for the 50 deliveries before the index event was compared with the 50 deliveries after the index event. Obstetricians who had no intrapartum complication during the observational period were matched as controls.

Results: Six index events were identified, three cases of shoulder dystocia and three intrapartum fetal deaths. In three of these six cases, the Apgar score at 10 minutes was less than 3. Obstetricians who attended a delivery with severe intrapartum complications had an average increase in their cesarean delivery rate of 37% in the 50 deliveries after the index event (21.0% to 28.7%, P < .05). This rate was greater (P < .05) than that of matched control obstetricians observed during the same observation period (19.0% to 18.7%).

Conclusion: Intrapartum complications such as persistent neonatal brachial plexus injury or fetal death increased the cesarean delivery rate of the obstetrician experiencing these events. Obstetricians should be aware of the effect of these adverse events on their practice of obstetrics.

Many attempts have been made to reduce the cesarean delivery rate in the United States by increasing vaginal birth after cesarean, using specific indications for induction after cervical preparation, attending to poor labor progress, modifying use of conduction anesthesia, clarifying the diagnosis of fetal distress, and providing in-house attending obstetric coverage.¹ However, the individual obstetrician has been found to be a major determinant in the method of delivery.² Increased cesarean rates might, in part, be due to a fear of malpractice litigation because of failure to do a cesarean delivery.³ However, physicians’ recent medical-legal experiences have not been shown to influence the cesarean delivery rate.² Others have argued that a perceived medical-legal risk affects the obstetrician’s decision regarding operative delivery.⁴ It is unknown if obstetricians’ choice of delivery method is influenced by the perceived medical-legal risk resulting from a poor neonatal outcome or the perception that neonatal morbidity could have been avoided by a cesarean delivery. We sought to determine the effect that an adverse intrapartum event has on an obstetrician’s cesarean rate.

	Materials and Methods

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MacGregor Medical Association is a multispecialty group with 24 obstetricians who deliver 3000 infants annually at four hospitals in Houston, Texas. Twelve of the obstetricians practice exclusively at a 900-bed hospital that serves as the tertiary referral center for the group. Obstetricians take in-house call, and in-house anesthesia coverage is available on a 24-hour basis. No resident physicians participate in patient care. In July 1996, a computerized perinatal database was established, and prospective intrapartum information was collected on the delivery physician, indication and delivery method, obstetric complications, and neonatal outcomes.

We prospectively studied the effects of unanticipated severe obstetric complications on obstetricians’ cesarean rates. Obstetricians were unaware that adverse events were being monitored. Adverse neonatal outcomes were defined as follows: head entrapment of a breech infant, Apgar score less than 3 at 10 minutes, shoulder dystocia resulting in persistent brachial plexus injury in the newborn at 48 hours of life, and intrapartum fetal death. When an index case was identified, we compared the obstetrician’s cesarean delivery rate for the 50 deliveries before the index case with the 50 deliveries afterward. A control obstetrician at the same hospital was randomly matched to the physician who experienced a severe obstetric complication. The control obstetrician during the observation period had no severe obstetric complications. The control obstetrician’s cesarean rate for the 50 deliveries before the time of the index case and 50 deliveries after the time of the index case was determined. The cesarean delivery rates before and after the index case of obstetricians who experienced a severe obstetrical complication were compared with each other and with those of control obstetricians. Cesarean births for the physicians who experienced an index event were then analyzed according to the following five indications: elective repeat cesarean birth, breech presentation, dystocia, fetal distress, and other. The proportions of each indication before and after the index event were compared. Comparisons were made using Wilcoxon signed rank test. Statistical significance was considered if P < .05.

	Results

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From July 1996 through June 1998, data on 3008 deliveries were collected. The mean cesarean rate was 22.7%. For the study period, the departmental cesarean rate was 21.4%. Breech presentation was noted in 3.7% of deliveries, of which 95.5% were delivered by cesarean. No head entrapment of a breech infant was reported. Six index cases were identified. All six obstetricians involved were board-certified obstetrician-gynecologists. Sixty-seven percent of the physicians were women with an average age of 38.7 years. Five of six (83%) control physicians were board-certified with the remaining being board-eligible, and 50% were women with an average age of 37.2 years. Gestational age of all six infants was greater than 36 weeks. Three infants had a 10-minute Apgar score less than 3, and these cases resulted in intrapartum fetal death.

Obstetricians reported shoulder dystocia in 1.5% of deliveries. Six cases of brachial plexus injury were noted after delivery. Three of those cases resolved within 24 hours after birth. The remaining three cases had a brachial plexus injury persistent at 48 hours of birth. The three cases of shoulder dystocia are given in Table 1 (physicians 1, 2, and 3). Average 1-minute and 5-minute Apgar scores were 4 and 8, respectively. In all three cases, the following maneuvers were done to assist with delivery: McRoberts maneuver, suprapubic pressure, Wood’s maneuver, and proctoepisiotomy. The two infants delivered vaginally had persistent brachial plexus injuries at 20 and 23 months of life. In the third delivery a Zavanelli maneuver was done, and the infant was delivered by cesarean. The infant remained neurologically impaired at 8 months of life.

Table 1 illustrates each obstetrician’s cesarean rate before and after the severe complications. The cesarean rate for this group of six obstetricians significantly increased by 37% from 21.0% to 28.7% (P < .05). Six matched control obstetricians whose cesarean rates were also determined before and after each index event showed no differences in cesarean rates during the same time periods (19.0% to 18.7%). For obstetricians who experienced a complication, the cesarean rate for the 50 deliveries after an index event significantly increased (P < .05) compared with that of control obstetricians.

Table 2 lists the percentage of all deliveries in each of the five diagnostic classes before and after the index event for the six physicians and the percentage change during that period. This table shows the proportion of the total increase in the cesarean birth rate that is attributable to each of the five diagnostic classes. For obstetricians who experienced a brachial plexus injury, the largest increase in cesarean rate corresponded with the diagnosis of dystocia, whereas physicians who experienced an intrapartum fetal death had the largest increase in cesarean rate corresponding with diagnoses of fetal distress. No differences were statistically significant.

	Discussion

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Does the individual physician’s perception that neonatal morbidity could be avoided by cesarean delivery influence the decision to do a cesarean? In the present study, physicians who experienced an obstetric complication that resulted in long-term neonatal injury or fetal death had a significant increase in their cesarean delivery rate. This increase occurred despite no malpractice litigation during the 50 deliveries that followed an index event (average 6-month period). One can argue that fear of malpractice litigation from the index event resulted in the obstetrician doing more cesareans in subsequent deliveries. However, in the current study all six obstetricians who experienced an index event had prior involvement in at least one obstetric medical malpractice case in their career (personal communication with each study physician). It is not known from the present study whether this previous involvement with malpractice litigation resulted in an automatic reaction leading to more cesarean deliveries. An alternative explanation is that the individual physicians questioned their level of self-confidence, which resulted in more cesarean deliveries to avoid potential neonatal morbidity. The portion of diagnosis for cesarean deliveries was influenced by the type of injury, with brachial plexus injury resulting in more diagnoses of dystocia and intrapartum fetal death resulting in more diagnoses of fetal distress. Yet the implications from this study are limited because of small sample size.

The types of adverse neonatal outcomes were chosen subjectively. What an obstetrician discerns as poor obstetric outcome is influenced by training and experience. Our impression is that most obstetricians would view head entrapment of breech infants, Apgar score less than 3 at 10 minutes, severe shoulder dystocia, and intrapartum fetal deaths as anxiety-provoking experiences that are fortunately rare in obstetric practice. In the current study, no head entrapment of breech infants occurred. However, most breech births involve cesarean delivery, which is the practice at our institution. An Apgar score less than 3 at 10 minutes has been a powerful predictor of neurologic impairment in neonates.⁶ It has been reported that 34% of infants weighing over 2500 g at birth with an Apgar score of less than 3 at 10 minutes died.⁶ In the present study, the only infants with an Apgar score less than 3 at 10 minutes were those that died perinatally. Shoulder dystocia resulting in persistent brachial plexus injury was chosen as an index event because many of these injuries resolve spontaneously in a short time. We believe that if the injury resolves by the time the infant is discharged from the hospital, anxiety the obstetrician felt about the delivery would be minimal. The incidence of brachial plexus injury in the current study (1.66 per 1000 live births) is similar to that reported in the literature.⁷ Intrapartum fetal deaths are a devastating experience for parents and obstetricians. Since the introduction of electronic fetal monitoring, the incidence of intrapartum fetal death has been reported to be 0.1%.⁸ A similar rate was found in the current study.

After experiencing a poor neonatal outcome, the obstetrician might justify a lower threshold to perform a cesarean delivery as a mechanism to reduce fear of this event. However, higher cesarean delivery rates have not been shown to reduce neonatal morbidity.^2,8 From the current study, poor neonatal outcomes increase an obstetrician’s cesarean delivery rate in the short term. The effect this has over the duration of an obstetrician’s practice is unknown. Obstetricians should be aware of this and recognize it as a cause of increased cesarean delivery. Physicians may need help from professionals or peers to cope with this stress. Support networks have been recommended to help physicians involved with malpractice litigation.⁹ Perhaps discussion of sentinel events in a forum that provides peer support can identify situations where no other outcome was possible, which could help the obstetrician distinguish areas where changes in practice could enhance outcome.

	Footnotes

 
PII S0029-7844(99)00315-4

Received September 28, 1998. Received in revised form January 6, 1999. Accepted January 28, 1999.

	References

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1. Porreco RP, Thorp JA. The cesarean birth epidemic: Trends, causes, and solutions. Am J Obstet Gynecol 1996;175:369–74.[Medline]

2. Goyert GL, Bottoms SF, Treadwell MC, Nehra PC. The physician factor in cesarean birth rates. N Engl J Med 1989;320:706–9.[Abstract]

3. Amirikia H, Zarewych B, Evans TN. Cesarean section: A 15-year review of changing incidence, indications, and risks. Am J Obstet Gynecol 1981;140:81–6.[Medline]

4. Rostow VP, Osterweis M, Bulger RJ. Medical professional liability and the delivery of obstetrical care. N Engl J Med 1989;321:1057–60.[Medline]

5. Guillemin J. Babies by cesarean: Who chooses, who controls? Increasing incidence and medical ‘necessity.’ Hastings Cent Rep 1981;11:15–8.

6. Nelson KB, Ellenberg JH. Apgar scores as predictors of chronic neurologic disability. Pediatrics 1981;68:36–44.[Abstract/Free Full Text]

7. Boo NY, Lye MS, Kanchanamala M, Ching CL. Brachial plexus injuries in Malaysian neonates: Incidence and associated risk factors. J Trop Pediatr 1991;37:327–30.[Abstract/Free Full Text]

8. Minkoff HL, Schwarz RH. The rising cesarean section rate: Can it safely be reversed? Am J Obstet Gynecol 1980;56:135–43.

9. American College of Obstetricians and Gynecologists. Coping with the stress of malpractice litigation. ACOG committee opinion no. 150. Washington DC: American College of Obstetricians and Gynecologists, 1994.

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