Reducing needless C-sections

When a pregnant mother or her baby is in danger, surgical intervention in the form of a Cesarean section (C-section) can be a lifesaver. but far too many C- sections are performed in this country. that’s why Monmouth medical Center is leading the way in cutting the number of these operations.

When a pregnant mother or her baby is in danger, surgical intervention in the form of a Cesarean section (C-section) can be a lifesaver. but far too many C- sections are performed in this country. that’s why Monmouth medical Center is leading the way in cutting the number of these operations.

In 2007, the C-section rate in the U.s. reached 32 percent, its highest level ever, the Centers for Disease Control and prevention reported this march. and new Jersey led all states with a rate of 38 percent.

Cesarean section has become the most common operation in american hospitals. but most health experts find it hard to believe that one in three women need surgical help to give birth. and surgery increases the risk for serious complications for both mother and baby.

These new figures have many hospitals scrambling to see what they can do to bring those numbers down. but Monmouth saw this trend coming years ago, says Robert Graebe, M.D., chair of obstetrics and gynecology. For eight years it has been examining its policies, procedures and systems to improve all of the department’s outcomes, including lowering C-section rates. and this effort has worked.

In the first half of 2010, Monmouth’s C-section rate was just 24.22 percent, well below both state and national averages, Dr. Graebe says. And the hospital has also improved by other benchmarks for birthing success, including rates of severe laceration to the mother and vaginal birth after Caesarean (VBAC) rates. (See “Safer Deliveries, by the Numbers,” opposite.) Many hospitals refuse to allow women who have had a C-section to deliver subsequent children naturally. But doctors say that in many cases VBACs are safer than surgery, and in late July the American College of Obstetricians and Gynecologists issued new guidelines to make more VBACs possible. That fit with what Monmouth was already doing.

“Everyone in our department, from nurses and mid-wives to physicians and administration, has bought into a policy of constantly striving to improve patient safety,” says Dr. Graebe. “We continually look at the medical literature for best practices and apply them to where we are and where we want to go, all in the interest of quality of care.”

Several changes made in the past few years have contributed to this success, he says. (See “How Monmouth Has Led the Way in Cutting Unnecessary C-sections.”)

Though risk can’t be eliminated entirely, Dr. Graebe says, the medical center is always searching for new ways to minimize it. And its success with C-sections and VBACs proves its dedication to improvement. “We expect that re-cent press reports about this issue will cause the public to demand a reduction in these surgeries, but we’ve already arrived there,” he says. “We can say, ‘Been there, done that.’”
 

Robert Graebe, M.D., MONMOUTH MEDICAL CENTER’S chair of obstetrics and gynecology, says his hospital’s success in reducing its cesarean-section rate—now significantly lower than state and national averages—has been due in part to five changes it has implemented in recent years:

How Monmouth has led the way in cutting unnecessary C-sections

 

How Monmouth has led the way in cutting unnecessary C-sections

• Expert Help. The medical center arranged to have a specialist in obstetric anesthesiology available 24/7. “We assured that this position was dedicated to obstetrics, not shared with other departments,” says the doctor.
• Beefed-Up Staffing. “We wanted to be confident staffing was adequate for our volume of patients, which in the past five years has increased by nearly 50 percent, from about 3,000 deliveries a year to about 4,300,” he says. “Now, in addition to the residents, there are always at least two attending physicians on duty at all times—the laborist, an ob/gyn on a hospital-based shift who backs up the staff of attending physicians; and the ‘doctor of the day,’ the attending physician who supervises the resident staff. so we are staffed to handle any emergency at a moment’s notice.”
• An Empowered Staff. “We made sure that the staff felt they could challenge a doctor’s orders if they thought it was in the best interests of the patient,” says Dr. Graebe. “A team effort that gives all members a voice in patient care helps us avoid problems.”
• Tighter Rules. “We eliminated elective c-sections or inductions of labor for patients at less than 39 weeks’ gestation (full term),” adds the doctor. “Only specified health issues, such as severe hypertension, insufficient amniotic fluid or problems with the baby’s growth, could trigger induction or c-section.
• Regular Follow-up. Finally, a performance improvement committee was established to meet monthly and review all outcomes. “The committee evaluates patient charts and interviews the physicians whenever we have a negative outcome, such as infections, severe lacerations or readmissions to the hospital,” he says. “In a few years, this process has helped cut negative outcomes in half.”

 

Safer deliveries, by the numbers

In frequency of induced labor, Monmouth Medical center is about where the averages are—a strong showing given the serious cases it treats. By other measures it’s far ahead.

C-Section Rate

MMC (1st half 2010)                 24.22%

N.J. (2008)                                39.4%

U.S. (2004)                                32.3%

Rate of Induced Labor

MMC (1st half 2010)                 21.97%

N.J. (2008)                                20%

U.S. (2004)                                21.2%

3rd- And 4th-Degree Laceration Rate

MMC (1st half 2010)                  2.11% (3rd) amd 0.34% (4th)     

U.S. (2002)                                5.4% (combined)

VBAC Rate

  MMC (1st half 2010)                17.39%

N.J. (2006)                                  8.8%

U.S. (2004)                                  9.2%

VBAC Success Rate*

MMC (1st half 2010)                   77.41%

U.S.   (est.)                                 60%-70%

 

And the improvement continues…

1st-half-of-the-year comparisons,         

Monmouth Medical Center                   2010                 2009             CHANGE  

OB admissions                             2,152               2,146           +0.28%         

Deliveries                                      2,068                2,044          +1.17%

C-Sections                                    510                   542              -5.9%

Inductions of Labor                       992                   1,019           -2,65%

For information on having your baby at the Eisenberg Family Center at Monmouth Medical Center— including more on vaginal birth after Cesarean—call 888-SBHS-123 (888-724-7123).