LETTERS.

Changing the Rules

As a rural practitioner, I would like to throw in my 2 cents worth on the discussion of cesarean sections ("Elective C-Sections Stir Up Controversy," October 2000, p. 1).

Having finished residency in 1977, I participated in the transition from a 6% cesarean section rate in 1974 to a 17%-20% cesarean section rate by 1980. Even then I recognized that a cesarean was less traumatic than a midplane delivery. My cesarean section rate has been approximately 14%-17% since that time, in part because I do vaginal births after cesarean (VBACs) as often as possible.

Now that the American College of Obstetricians and Gynecologists has drawn a line in the sand regarding safe criteria for cesarean delivery, those of us in rural areas simply won't be able to offer VBAC any longer because we don't have house staff available 24/7 to meet those goals.

It is true that elective cesarean section has very low risks, but we have all had cases in which massive scarring was encountered or spontaneous large windows in the lower uterine segment developed. We will see an increase in maternal mortality and morbidity if we swing too far on this pendulum, but there will be fewer gut-wrenching, middle-of-the-night decisions about whether to persist in the vaginal birth or do a cesarean before everyone gets too exhausted.

Then there's the peer review process. As we have seen the absolute guidelines for gynecologic procedures and the management of obstetrics melt away in long over-due response to patient demand, combined with an oversupply of physicians, it is important to remember that the peer review process is always relative and that we should be careful in reprimanding people who seem to be outside the bubble.

I for one will see an increase in both repeat and patient-request cesarean sections, and that is just fine, but I don't want to hear another word, ever, about cesarean rates.