Meeting the challenge of the rising cesarean birth rate.

The rising cesarean birth rate is a matter of national concern, and the goal of clinical obstetricians is to contain this trend while maintaining good maternal and perinatal outcome. Despite published reports suggesting that excellent perinatal outcome can be achieved with modest cesarean birth rates, the general increase of abdominal delivery in the United States appears to continue unabated. An educational approach to modify the community cesarean rate was directed at physicians, nurses, and interested lay groups via presentations in the Denver metropolitan community over a 5-year period. The content of these presentations included management of patients with previous cesarean births, diagnosis and management of fetal distress, the approach to patients with apparent failed progress in labor, indications and strategies for the indicated induction of labor, alternatives in the management of breech presentations and twin deliveries, and identification of patients at risk for genital herpes. The total cesarean birth rate increased to a level of 19.3% in this community in 1986, largely accounted for by the increase in the primary rate to 13.7%. Repeat cesarean birth rates remained relatively stable at 5.6% over the 2-year survey. Hospitals in which resident house officers either managed the entire service or participated in patient care achieved some of the lowest rates of both primary and repeat cesarean birth. Although intellectual arguments for decreasing cesarean births are acknowledged by physicians and nurses alike, translating them into practice on a daily basis is tempered by the constraints of time and the burden of medicolegal concerns. Educational efforts alone, therefore, are likely to produce change only slowly.