Whither Cesarean? | to pdf >>
A Book Review
By David Preskill, MD

For us obstetricians, cesarean section is an icon, a touchstone. We judge ourselves based on our prowess with the procedure, and we are judged by others on the basis of our application of cesarean section in our clinical decision-making. We sweat over our decisionsto wait, or to cut?and we tell each other stories of our harrowing cases. We are told by our customers that cesarean section rates reflect the quality of our obstetric services, although whether higher or lower rates of using cesarean section represents higher or lower quality is a matter of opinion. What constitutes an "appropriate" rate is the topic of endless debate on all obstetric frontsclinical, financial, medicolegal, ethical. Remarkably, just a hundred years ago, cesarean section was anathemaan almost certain death sentence for the unfortunate woman whose circumstances required the procedure. In those days, delivery at term by bull goring was more likely than c-section was to result in successful recovery! As we near the next millennium, cesarean section has become the most common major surgical procedure in the United States. There seems to be general agreement that too many c-sections are done but no consensus as to the cause of this situation or its cure. Two particular issues have captured a large share of discussion in the last few years: appropriate use of cesarean section and the role of vaginal birth after cesarean (VBAC) in reducing the number of procedures done.

Into this maelstrom SCPMG partner Bruce Flamm, MD, has sailed his skiff. Based at the Riverside, California medical center, Dr. Flamm has been studying and reporting on these issues since the early 1980s. He has published two booksone (for the general public) about VBAC and one (for the professional community) which addresses the appropriate place of cesarean section in obstetric practice.

Birth After Cesarean: The Medical Facts is written for women who have had cesarean section and are now pregnant or considering another pregnancy. In a series of clearly written chapters, Dr. Flamm explains the cesarean section procedure and its history. He explains the origin of the idea that VBAC was undesirable. In a way that makes the data clear and compelling, he presents the results of numerous studies supporting VBAC. Dr. Flamm also places the relative risks of vaginal and cesarean birth in perspective and addresses our patients' frequently asked questions about VBAC.

Make no mistake: Dr. Flamm does advocate VBAC, and this book is especially suited for women who have VBAC in mind. Nonetheless, the discussion is never strident, and Dr. Flamm makes clear that the final decision is one that only a woman and her family can make in partnership with her caregiver. Women ready to pursue VBAC will be reassured about their
decision by reading this book. Those who are unsure what to do will be better informed and more comfortable after reading this book, regardless of their ultimate decision. All of us who provide care to women who read this book will find them better prepared to discuss their concerns and make a decision.

Dr. Flamm is joined by E.J. Quilligan, MD, in editing Cesarean Section: Guidelines for Appropriate Utilization, one of the Clinical Perspectives in Obstetrics and Gynecology monograph series from Springer-Verlag. Twenty-three contributors, including many distinguished professors in our field, lend their expertise to illuminating this issue, five of whose 18 chapters are authored by Dr. Flamm. The text explores trends in the US and abroad as well as diagnosis and management of clinical situations such as failure to progress, breech presentation, macrosomia, and multiple gestation; and gives an overview of the active management of labor. Medicolegal and ethical issues in choosing cesarean section get special attention as do discussions of methods for safely reducing the frequency of c-section as well as the impact of programs (including midwifery) which seek to achieve this end. In the final chapter, Dr. Flamm summarizes guidelines for reducing the frequency of c-section, including the roles of nurses, midwives, childbirth educators, educators of medical residents, medical directors, administrators, quality managers, health care payers, and lawyers in reducing this frequency. Clearly, Dr. Flamm sees this as a systems problem, and his intent is to ensure that everyone involved understands their role in the solution. In 260 pages, he gives us food for thought and a guide for action.

Over the years, most of the discussions I have joined about the appropriateness of cesarean section have produced much passion but little progress. Dr. Flamm has produced two works that may help to reverse that trend. Whether they agree with Dr. Flamm or think he's missed the boat entirely, those who care about the frequency of cesarean section should become familiar with these books.

Birth After Cesarean: The Medical Facts. Bruce Flamm, MD, Simon and Schuster, 1990. $11.

Cesarean Section: Guidelines for Appropriate Utilization. Bruce Flamm, MD & Edward J. Quilligan, MD, eds., Springer-Verlag, 1995. $75.

David Preskill, MD, is Chief of Obstetrics and Gynecology for The Southern California Permanente Medical Group, San Diego.

Other books received, written by Permanente authors
House Officer's Guide to Arthrocentesis and Soft Tissue Injection, Bruce C. Anderson, MD. JJ & R Publishing; Portland OR 1997. ISBN 0-9635534-3-7. $12.95. Dr. Anderson is Director of Medical Orthopedics at the KP Sunnyside Medical Center in Oregon.