One Hospital’s Plan to Reduce C-sections: Communicate
There might be fewer unneeded cesarean sections if doctors learned to keep mothers informed at every stage of labor.
Erica Rice calls her 2017 V.B.A.C., or vaginal birth after cesarean, “a herculean team effort.” Not least of which because she delivered twins.
The team on call at the Beth Israel Deaconess Medical Center in Boston provided Ms. Rice with support and comfort measures, like turning her side to side, and gave her a well-placed mirror to encourage her. “They did whatever it took,” Ms. Rice, a 37-year-old lawyer in Jamaica Plain, Mass., told me. “I was blown away by the support.”
Ms. Rice’s vaginal births are more miraculous when you consider that a decade ago, three-quarters of women carrying twins received cesareans. C-section is the No. 1 surgery undergone by women in America, and the most common operation performed, period. It carries serious risks, including infection, hemorrhage and even death. The procedure has been performed too much for decades. Currently, 32 percent of live births are by cesarean delivery, more than double the World Health Organization’s recommended range of 10 to 15 percent. Had Ms. Rice delivered at another hospital, she probably would have had a C-section. However, she labored at Beth Israel Deaconess, which, unlike almost every other hospital in the country, has reduced its C-section rate by half in a little over a decade.
Misconceptions About C-sections
Cesarean technology is lifesaving for rare conditions, and for some high-risk women. For most births, the decision whether to perform a cesarean is up to doctors and hospitals. So they are rightly to blame for the crisis of over-operating. But that also explains why doctors and hospitals are now spearheading promising solutions. Dr. Neel Shah, an obstetrician and leader of one C-section reduction effort, said: “Women have goals in labor other than coming out unscathed. Survival, and not being cut open, should be the floor.”
Women are often blamed for what afflicts them, so it’s no shock that they’ve been condemned for the high C-section rate, too. They’ve been accused of choosing surgery for convenience, seeking “designer C-sections” to mimic celebrities or being “too Posh to push,” a phrase that arose when the former Spice Girl Victoria Beckham picked cesarean delivery. Still, it isn’t women’s choices that have driven the high rate.
Two factors account for a majority of unnecessary C-sections. The first is “arrest of labor,” or “failure to progress,” meaning that labor is stalled. The reason isn’t always clear. The second factor is “unreassuring fetal heart tones,” or opaque information from a fetal heart rate monitor about how well a baby is tolerating labor. Experts believe that probing these two areas could unlock the mystery of too many C-sections, and curtail them.
The “arrest of labor” diagnosis accounts for the most cesareans in women giving birth for the first time — 35 percent — so providers seeking change are targeting this group of women. Dr. Toni Golen, vice chair of quality, department of obstetrics and gynecology at Beth Israel, said, “If you can prevent a cesarean delivery in a woman who is having their first baby, they are far more likely to have a vaginal delivery in their second or subsequent baby.”
Those committed to lessening C-sections are applying new evidence like this to their work in delivery rooms. Using the newest, best evidence also means scrapping what is outdated and ineffective. Item one is the Friedman Curve, which has led to untold numbers of C-sections for “arrest of labor” for more than half a century.
Disproved 1950s Data
In 1955, the obstetrician Emanuel Friedman at Columbia University published a study of 500 white women who gave birth in the same hospital. Breaking with his predecessors, he plotted their labors on a graph to measure the average amount of time it took each woman’s cervix to dilate. He said active labor began when a women reached 4 centimeters dilated, and that after that, providers could expect an average dilation of 3 centimeters per hour until they reached 9 centimeters. Less dilation meant something was wrong. Dr. Friedman’s curve became the gold standard for gauging labor progress.It took more than 50 years to understand the study’s errors. Rebecca Dekker, a nurse and the founder of the educational resource Evidence Based Birth has said that any 1950s childbirth research is hard to apply to families today. Then, most women were sedated with drugs nicknamed “Twilight Sleep;” they had lower body weights and fewer inductions; and they gave birth much younger than women today. Half of Dr. Friedman’s subjects delivered with forceps, meaning that their babies were extracted with an implement.
Several 2010 studies on the labors of first-time mothers disproved Dr. Friedman’s curve with two discoveries. First, active labor didn’t begin at 4 centimeters, but at 6 centimeters. Second, the average dilation per hour was 1 centimeter, not 3 centimeters. “In Dr. Friedman’s time, if you were dilating at about 1 centimeter per hour, that was too slow,” Ms. Dekker said. “You would be considered to have failure to progress or abnormal labor. Today, research is finding very different averages for what is normal.”
According to Dr. Friedman’s study, active labor began sooner, and took less time, than it actually does today. This error has produced countless unnecessary C-sections. Doctors should have waited; instead they operated. Dr. Friedman’s curve lives on, despite having been disproved — it appeared in medical textbooks as recently as 2010. “We have generations of obstetric providers educated in that paradigm that have to change their practice,” Ms. Dekker said. “We don’t know how many people are still using the old-fashion information.” Hospitals with exorbitantly high cesarean rates may still be using the Friedman curve, while those committed to limiting unwarranted surgery have ditched it.
How One Hospital Cut C-sections in Half
C-sections dwindled at Beth Israel Deaconess Medical Center because the staff decided that they should. “When you move toward a decrease, it has to be valued, not just by the people leading the project, but by the obstetricians, nurses and midwives,” Dr. Golen said. Beth Israel is forensic in its use of the newest and best evidence. Providers don’t order C-sections as early as they did in the past. Rather than surgery, they first offer laboring women “supportive care,” hewing to the recommendation of the American College of Obstetricians and Gynecologists. “Supportive measures really just allow the patient more time,” Dr. Golen said. “Just by making the active stage start at 6 centimeters, it allows patients so much more time to reap the benefits of the supportive care that we can provide.”
She explained that measuring success, and creating a bit of competition by publicly praising doctors who lowered their rates, aided their quest. This recognition comes at department meetings, during rounds and on social media. “People are really proud when their name appears on the list of people who have met or exceeded the goal,” she said.
The School Supply Cure
What worked for Beth Israel hasn’t worked for all hospitals, at least not yet. Margie Bridges, a nurse at Overlake Medical Center in Bellevue, Wash., said her team has fought to lessen cesareans for years. “Our C-section rate is one of the best of the worst. And it’s not for lack of effort,” she said. Overlake’s cesarean rate has hovered around 30 percent since 2014, even after many of the measures that succeeded at Beth Israel were applied. Overlake discarded the Friedman curve years ago, it uses the new data and offers supportive care, and it sets goals and celebrates successes. But the rates didn’t budge.
Which brings up a successful practice used elsewhere that relies on an item commonly found in a home goods store. In January, the Team Birth Project, conceived in Boston’s Ariadne labs, began a study of this item in four community hospitals across the country, including Overlake. Dr. Shah directs the program, and he believes that it will limit cesareans with a simple tool — a large, white, dry erase board placed in a visible spot in every labor and delivery room. Overlake hangs its behind the bathroom doors.
What’s on the board? First, the name of every labor and delivery team member — birthing woman, obstetrician, nurse, doula and partner. Dr. Bettina Paek, a perinatologist at EvergreenHealth, another pilot hospital, in Kirkland, Wash., said, “This puts mom at the center of the care team.”
Next are the woman’s birthing preferences, which can change as labor does. This assures that a patient’s desires are communicated, because they are written where everyone can see them. Third is the status of the mom, baby and labor progress. Last is the time when the whole team will “huddle” or reconvene. All conversations about labor and the laboring woman are supposed to occur with her present. “It wasn’t our standard that we were having these conversations all together, and writing it down on a board so everyone could look at it,” Dr. Paek said. “When you put it in writing, you become more intentional about it.” Ms. Bridges noted that when providers are required to huddle with the laboring woman and her supporters, it eliminates the game of telephone that can transpire when conversations happen without her. “You lose the original message by the time it gets translated a couple of times,” she said.
Toward Better Birth
The combination of scientific evidence, transparent communication and support is what providers think could produce more vaginal births. The white board project is a yearlong clinical trial, so official findings are still months away. But early data are promising. “We’re seeing early indicators that it is likely to decrease C-sections,” Dr. Shah told me.
Patients are sold. Dr. Paek and Ms. Bridges say surveys they collect from women almost always show that the white board improved their experience, even when labor didn’t go as planned. In February, Kelsey Mooseker, a 33-year-old teacher in Lake Stevens, Wash., delivered twins at Evergreen Health family maternity center using the white board with her physician, Dr. Paek.
“It was an amazing planning tool,” Ms. Mooseker said. In 2008 she had a C-section, at a different hospital, without a white board, she said. “I really felt like everything was being done to me. Now, it was like: What do you want? To be asked that question, as a laboring mom, is powerful. It made me feel heard.” Ms. Mooseker delivered her babies via V.B.A.C.
For hospitals that have carried out evidence-based practice, using a white board may be the final detail needed to create a solution to the scourge of unnecessary C-sections. In addition, it could have other benefits. Dr. Shah said it was already putting the dignity back in childbirth for women, for whom birth is too often muddled, confusing and traumatic. It’s a small but important change for women laboring in hospitals in America to not only know what is happening at every moment, but also to have some control.
“It’s a different way of communicating, and the impact is profound,” Ms. Bridges said, speaking of the white board. “Because the patient understands her birth story. We know how close we hold our birth stories to our hearts. To have some understanding of your labor and how you got there is powerful.”
Allison Yarrow is a journalist and the author of “90s Bitch: Media, Culture, and the Failed Promise of Gender Equality” and a forthcoming book about pregnancy, birth and motherhood. This article was reported with the support of the International Women’s Media Foundation.
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An earlier version of this article misstated a result of a 1950 study by Dr. Emanuel Friedman. He said that after the start of active labor, care providers could expect cervical dilation at three centimeters per hour, not 1.2 centimeters.