32.3 in 2008!
35
30
25
North Carolina
20
Wake County
Orange
15
Mecklenburg
10
0
2001 2003 2005 2007 2008
30
20
15
10
0
Primary Cesarean Ranking in North Carolina
35.00%
30.00%
25.00%
20.00%
15.00%
10.00%
20 43 45 47 49 51 61 73 85 88
2 10
5.00%
0.00%
Maternal request
Medical-legal concerns
Increasing age of pregnant women
Increasing complications in pregnancy
Maternal obesity
Provider preference
Induction of labor protocols
Training of providers
Increased payment for CS v Vaginal Birth
VBAC standards
Rates of “no indicated risk” Cesareans
Surrogate for “maternal request”
• Of the five states with highest rates of CS, four are among AMA’s 2003
malpractice crisis states
• Of 19 malpractice crisis states, four in highest CS rate group, eight in
second highest group; five in middle group; two in second lowest group
Declerq et al: No evidence to support
increasing rates of maternal health problems
as significant cause of rising CS rates
Least
Success
TOL
CS with
Labor
CS without
Labor Most
Failed
VBAC
Index pregnancy
◦ Peripartum hysterectomy
Primary CS v vaginal delivery:
OR 6.48
Repeat CS v vaginal delivery:
OR 3.69
Peripartum hysterectomy and
cesarean delivery: a population-
based study. Stivanello. Act Ob
Gyn Scan 2010 March
◦ Endometritis
7-10% rates
◦ Wound Infections
5-15%
◦ Post Partum Hemorrhage due
to atony, requiring transfusion
OB
Indications
for CS
CS by
Maternal
Request
NTSV
Patient education regarding normal course of
labor
Await spontaneous labor
Avoid inductions with unfavorable cervix
Effective cervical ripening using same technique
Induce >41 weeks
Admit patients in active labor, not prodromal
Standardize effective pitocin protocol
Labor support
Be patient with prodromal labors