Strategies to avoid unnecessary cesarean sections

Because there is a 35 to 50 percent incidence of false-positive prediction of fetal compromise on fetal heart-rate monitoring patterns, many unnecessary cesarean sections are performed. To reduce the number of unnecessary cesarean sections, the physician is urged to consider the following: (1) fetal heart-rate monitoring is associated with higher rates of cesarean sections than in those not monitored; (2) only high-risk patients should be monitored provided the low-risk patient is at term, with a normal-sized infant, and does not convert to a high-risk patient while in labor; (3) maintenance of variability is a better predictor of absence of acidosis than is fetal scalp pH; (4) fetal scalp stimulation by firm digital pressure or gentle nontraumatic clamping of scalp tissue or acoustic stimulation obviates the need for fetal scalp pH confirmation of acidosis in 50 percent of cases; (5) monetary considerations may unconsciously lead to increased cesarean sections, since insurance companies remunerate at a higher level for those as compared with vaginal deliveries; and (6) more patients with prior cesarean section should be given a trial of labor, since the initial reason for cesarean section often is not a recurring one and many could successfully be delivered vaginally. Ultimately there is a risk inherent in any decision regarding method of delivery. The patient must understand this risk and share in the decision-making process as a knowledgeable person, aware of the limitation of her physician.