Cesarean Delivery in Family Medicine (Position Paper)

Overview and Purpose

Obstetric care for patients is an integral part of many family physicians’ scope of practice and remains an important component of family medicine residency training.1,2 An American Academy of Family Physicians (AAFP)/American College of Obstetricians and Gynecologists (ACOG) Joint Statement asserts that access to high-quality maternity care is an important public health concern in the United States.3 A cooperative and collaborative relationship among obstetricians, family physicians, and nurse midwives is essential for provision of high-quality care for pregnant women. The most important objective must be the highest standard of care regardless of specialty.

Family physicians provide substantial perinatal care in this country, especially to rural and underserved populations, delivering 100% of the babies in some geographic areas. Obstetric services provided by family physicians have declined in the past decade, with only 23% providing deliveries and fewer than 10% providing prenatal visits.4,5 The Future of Family Medicine Project first outlined the broad spectrum of services that family physicians will be expected to provide to renew the specialty and meet the needs of patients and society.6 Comprehensive accessible care is further described in the more recent Patient-Centered Medical Home (PCMH) model promoted by the AAFP and other organizations.7 Operative deliveries and other advanced perinatal services are ideally suited for this model of comprehensive care, which involves extended or more advanced services.

Several factors contribute to current and future demand for routine and advanced maternity care services by family physicians. To provide the appropriate access to care that all women deserve,2 the following must be considered: Rural areas rely on comprehensive perinatal care provided by family physicians, including cesarean delivery.8,9 A high percentage of family physicians in rural areas provide obstetric care (e.g., 46% in the West North Central United States).5

  • The cost of medical malpractice insurance has continued to increase and remains a major factor in obstetrician/gynecologist’s career dissatisfaction.10
  • Obstetricians increasingly are choosing subspecialty careers, dropping obstetrics from their practices, retiring early, or practicing in areas that are already well served.11-13
  • Cesarean delivery rates in this country are at an all time high of more than 31.1% of all deliveries, having risen 50% over the past decade.14,15

Cesarean delivery is one of the most common surgical procedures. According to the CDC approximately 1.3 million cesarean deliveries are performed in the United States annually. Despite the use of risk assessment systems and protocols, the need for cesarean delivery can arise suddenly and unpredictably during the course of labor. An essential component of modern perinatal care is the prompt availability of surgical intervention without the need to transport the patient.

Provision of cesarean delivery by well trained family physicians augments services available to women, in some places providing additional options for care, and in other places providing a service that would not otherwise be available. Regardless of specialty, there should be shared common standards of perinatal care. Quality patient care requires that all physicians practice within their ability as determined by training, experience, and current competence.3 Given that many family physicians currently perform cesarean deliveries and many continue to be trained for this service, it is important that there be a common understanding of the place for cesarean delivery as part of a family physician’s scope of practice and as part of the health care delivery system.

This document should serve as a resource for family physicians who are training for and planning to include cesarean delivery in their practice. It also will assist hospital and health plan credentialing committee members and administrators, obstetricians, midwives, nurses, and other clinical staff to understand the role of family physicians in providing cesarean delivery in their practice of medicine.

Section II - Scope of Practice for Family Physicians

Family medicine is a specialty based on comprehensive care encompassing a breadth of medical services. Family physicians practice among diverse populations and in geographically varied, often remote, settings. Family physicians choose their personal scope of practice based on their experiences in training, practice interests, and the needs of their practice populations. Broadly speaking, the following indicate the extent to which cesarean delivery is within the current scope of family medicine practice:

  • A joint AAFP/ACOG statement recommended core educational guidelines, and a joint statement on hospital privileges affirms that surgical delivery is within the scope of family practice.1,3
  • About 4.3% of active AAFP members, or 4,000 family physicians, perform cesarean delivery. In predominantly rural areas, such as the West North Central region of the United States, an average of 15.3% of family physicians perform cesarean deliveries.16
  • Among family medicine residencies, 55% provide cesarean delivery training.17
  • Nationally, about 25 family medicine fellowships in obstetrics exist, many of which specifically seek to train family physicians to perform cesarean delivery independently.18
  • More than 2,000 U.S. family physicians have hospital privileges to perform cesarean delivery.19

Published data document that cesarean delivery care provided by family physicians in active practice or in training can meet or exceed national standards for maternal and infant outcomes.19-21 In addition, there is some evidence that women who receive their perinatal care from family physicians have lower cesarean delivery rates than patients cared for by obstetrician/gynecologists.21,22 This is important for social and financial reasons and because surgical delivery carries a significantly increased risk of maternal morbidity and mortality over vaginal delivery. There is much written on the indications for cesarean delivery, but the indications most commonly given are listed in the Appendix, Table 1.15,9,53

Section III - Training Methods

Cesarean delivery is a major abdominal surgical procedure, and usually is learned during residency, extended residency, or fellowship training. A joint AAFP/ACOG statement indicates that family medicine residents who seek cesarean delivery training because of their planned practice sites should be able to acquire this skill during the course of three-year residencies.1 Significant documentation supports this approach, with many family physicians achieving proficiency in operative delivery during residency and actively providing cesarean deliveries in various practice settings.19,21,23,24 In 2009, a Society of Teachers of Family Medicine (STFM) task force published a consensus document affirming that cesarean delivery proficiency can be achieved in traditional family medicine residencies.25

In addition to three-year residency programs, approximately 25 fellowships18 and advanced training programs across the country provide cesarean delivery training as one of their target skills. Another successful model involves a four-year family medicine residency curriculum that includes an enhanced obstetrics track. Residents completing this program have cesarean- and high-risk delivery numbers comparable with those of residents completing an obstetrics and gynecology residency.23 Although the curriculum for fellowships and advanced programs is not standardized by the Residency Review Committee for the Accreditation Council for Graduate Medical Education, published surveys find the training across programs to be similar, with 66% of graduates maintaining active cesarean delivery privileges.18 Another possible route to the acquisition of cesarean delivery skills is preceptorship by another family physician, an obstetrician, or a general surgeon who already has these privileges. It would be unusual to acquire cesarean delivery skills in brief courses such as weekend or week-long courses, particularly because it is a major surgical procedure without available simulators or models.

The number of cesarean deliveries a physician must perform during training to gain competence, as with many other procedures, has not been extensively studied. The AAFP Template for Core Privileges states that a minimum of 30 procedures as primary operator is to be expected.26 The literature documents high variability in the training numbers necessary for mastery of procedural skills.27,28 One published study documented the training volumes of family physicians who perform cesarean deliveries to average 46 cesarean deliveries, with a range of about 25 and 100, with outcomes comparable with or exceeding national standards.19 More recent publications report an average number of cesarean deliveries in training to be 60 in one three-year program21 and 99 among 165 graduates of family medicine obstetrics fellowship programs, with a range of less than 50 to more than 150.18 The variability of these numbers further emphasizes the need for careful supervision and review of trainees and progressive proctoring in training leading to assessment of competency that is not heavily numbers based.

Acquisition of the psychomotor skills needed for cesarean delivery should be coupled with the development of cognitive skills involved in knowing when to perform the procedure and in managing any medical and surgical complications (Appendix, Table 2). Because cesarea delivery is an abdominal surgery, experience with other abdominal procedures is helpful for skill deverlopment. Much discussion of training methods focuses on the "how to" and "when" of performing cesarean devliery. Other important topics that should be part of training include an understanding of the clinical settings in which a cesarean delivery has a higher risk of complications (Appendix, Table 3), and therefore should lead to patient transfer or consultation, and the recognition and means of resolving complications. Table 2 in the Appendix lists possible complications of cesarean delivery that physicians should be able to recognize and manage, or obtain the consultation necessary to resolve.

Section IV - Testing, Demonstrated Proficiency, and Documentation

Testing and demonstration of proficiency in major surgical procedures such as cesarean delivery is usually done by direct observation during training or during a period of proctorship under another physician who is significantly more experienced. The literature describes several processes for supervising physicians to determine proficiency in cesarean delivery for those completing training.2,21,23

Physicians seeking to document their experience may do so in a variety of ways. These include keeping a file of operative reports and discharge summaries of patients they have operated on and assembling a case database that includes details such as those suggested in the Appendix, Table 4.

In 2010 the American Board of Physician Specialties, although less well recognized than the American Board of Medical Specialties, is offering certification in family medicine obstetrics.29 The Family Medicine Obstetrics Board recognizes the advanced level of training and experience that some family physicians gain through recognized fellowship programs or their historical equivalent. The process of certification for family medicine obstetrics involves satisfactory completion of a written examination, an oral examination, and confirmation of surgical competency by peer observers. This certification should not be a requirement for privileges in routine obstetric care and should not be mandatory for certification in advanced maternity care skills such as high-risk obstetrics and cesarean delivery. It is merely one of several mechanisms for verification of training and competency in this area.

The volume of surgical deliveries needed to maintain proficiency in cesarean delivery has not been extensively studied. The only published data that link outcomes of cesarean deliveries performed by family physicians to documentation of ongoing experience found that excellent outcomes were maintained at five to 22 procedures per year.19 A survey of family medicine fellowship graduates found an overall average of 28.9 procedures per year, with 77.5% doing fewer than 30.18 The AAFP recommends an approach that gives family physicians who do procedures three methods to demonstrate competency: do the procedure in high enough volume that any quality trends might be detectable; have references attesting to competency; and have a proctor attest to competency. Regarding the first option, the number chosen should be evidence-based, and where no supporting literature exists for a specific number, the criteria should be established by the consensus of a multidisciplinary group of physicians.

Section V - Credentialing and Privileges

Current hospital and health care organization policies and procedures for credentialing family physicians in cesarean delivery vary markedly from site to site. In hospitals that have departments of family medicine, the department may credential its own members. In hospitals that have no experience with family physicians performing cesarean delivery, there may be no mechanism for credentialing in this or a number of other invasive procedures. Where departments of family medicine and obstetrics coexist, there may or may not be cooperative credentialing arrangements.

Policies of respected national organizations are the best source of guidance for hospitals and medical staff in approaching the credentialing of appropriately trained and competent family physicians who seek hospital privileges. According to the AAFP/ACOG joint statement on Cooperative Practice and Hospital Privileges,3 the assignment of hospital privileges is a local responsibility, and privileges should be granted on the basis of training, experience, and demonstrated current competence. All physicians should be held to the same standards for granting of privileges, regardless of specialty, to assure the provision of high-quality patient care. Prearranged, collaborative relationships should be established to ensure ongoing consultations, as well as consultations needed for emergencies. The standard of training should allow any physician trained in a cognitive or surgical skill to meet the criteria for privileges in that area of practice. Provisional privileges in primary care, obstetric care, and cesarean delivery should be granted regardless of specialty as long as training criteria and experience are documented. A proctorship period should be required for all physicians to allow for demonstration of ability and current competence. These principles should apply to all health care systems.

The Joint Commission, American Medical Association, and ACOG guidelines state that credentialing should be based on such criteria as training, experience, demonstrated ability, current licensure, and health status rather than medical specialty.31-33 According to these guidelines, it would be improper to base the granting of privileges on specialty of residency training.

ACOG’s guidelines for women’s health care state that standards for granting privileges should be established by the institution’s governing board and applied uniformly within a specialty and across specialties. Documented successful completion of training should allow any practitioner regardless of specialty, to meet the criteria for privileges in a specific area of practice. Credentialing and granting of privileges should be based on training, experience, and demonstrated competence. The guidelines add that physicians who are trained appropriately, have sufficient experience, and have demonstrated current competence should be granted privileges accordingly.33

Community need is often cited as a reason to withhold cesarean delivery privileges from family physicians practicing in environments shared with obstetricians. In such environments, obstetricians may not perceive a community need for family physicians to provide this service. Such an approach does not meet the Joint Commission, AMA, or ACOG credentialing guidelines. Furthermore, it does not appreciate that these services are provided by family physicians in the context of whole person family care, often in a patient-centered medical home, and usually with subsequent neonatal care. Given that, family physician, midwife, and obstetrician services are different, offering patients options for care. Such “turf battle” situations could lead to legal action on the basis of discrimination and restraint of trade (antitrust).

The AAFP Procedural Privileges Legal Opinion,34 developed through review of the policies of accrediting agencies and professional organizations and by a review of court cases and state and federal statutes, presents this executive summary:

  • Hospitals and peer review participants risk liability if they base decisions to grant or deny privileges on factors other than the demonstrated experience, training, and competence of the family physician in question.

The number of procedures performed in training is often used as a prerequisite for credentialing; however, numbers alone do not demonstrate quality of outcomes. Individuals gain competence with different numbers of procedural experience. Family physicians seeking cesarean delivery privileges would be supported by extensive documentation of their experience including the following30:

  1. Numbers of procedures during training and practice.
  2. Outcomes in data as described in the Appendix, Table 4.
  3. Letters from instructors, preceptors and proctors documenting training, experience, demonstrated abilities, and current competence.30

Family physicians moving to new practice sites would benefit from extensively researching the policies and procedures of their chosen site regarding privileges for cesarean delivery and other procedures and by obtaining these privileges before actually moving to the new site. This approach would be particularly helpful if the family physician is to be the first in family medicine to request these privileges at an institution.

Managing complications of cesarean delivery, such as the ability to perform a hysterectomy for persistent hemorrhage, may be presented as necessary at some institutions for obtaining privileges. Although no risk-assessment system can predict the outcomes all instances of cesarean delivery, a significant percentage of the patients who are at high risk for severe hemorrhage and subsequent cesarean hysterectomy, most notably those with a previous cesarean delivery or placenta previa, are identifiable before surgery.35-37 Most of the pertinent risk factors are listed in the Appendix, Table 3. The preoperative risk factors could be used to facilitate consultation, referral, or transfer of patients before surgery by those family physicians who do not manage these conditions. Cesarean hysterectomy skills on the part of family physicians would typically not be necessary for several reasons:

  • Cesarean hysterectomy is a rare procedure, necessary in fewer than 0.1% of all births and fewer than 0.5% of cesarean deliveries36,38
  • Numerous effective temporizing techniques are available to manage severe blood loss during cesarean delivery while consultation is being arranged.
  • Most cases of severe bleeding can be managed with supracervical hysterectomy, which is safer than total hysterectomy and acceptable in emergency situations.40,41
  • All physicians, regardless of specialty, can expect to require consultation for rare conditions.

A family physician performing cesarean delivery should have an established system for consulting with partners, other family physicians, general surgeons, or obstetrician/gynecologists. Protocols and resources also should be available in the delivery suite for immediate reference if assistance is needed. Such references could include laminated protocol cards, an electronic database, or video conferencing assistance, especially in rural areas.

Section VI - Miscellaneous Issues

Quality Programs
Family physicians performing cesarean delivery should set up ongoing case review programs to monitor their delivery and surgical outcomes. The data items in the Appendix, Table 4 could serve as a model for data collection compared with standard outcomes.42,43

Public Health and Community Implications
High-quality surgical care is important to good perinatal outcomes. Because family physicians are the most widely distributed physicians, particularly in rural and underserved areas,44,45 expanding and improving their cesarean delivery skills could improve access to modern perinatal care for many patient populations.2,46 There is extensive literature that documents better birth outcomes with local maternity care services.45,47-49 The survival of small rural hospitals often depends on their ability to continue providing perinatal care. Therefore, local hospitals require physicians who can perform not only normal deliveries but also operative deliveries. Struggling with the declining ability of rural hospitals and communities to provide delivery services, physicians of several specialties are collaborating to promote the training and support of family physicians to provide cesarean delivery in Canada.50,51

Research Agenda
The research agenda relating to cesarean delivery by family physicians should focus on four major areas.

  • Documenting the ongoing outcomes of cesarean delivery performed by family physicians.
  • Investigating differences between family physicians and obstetricians in their management of labor and cesarean delivery rates.
  • Evaluating training methods, including cognitive and procedural aspects, identifying the points at which proficiency in cesarean delivery and other procedures is reached, and determining what qualities of the learner predict earlier mastery in some. This area of research should include investigating whether tools such as videos, multimedia programs, and simulators can be developed to prepare physicians to manage rare complications.
  • Identifying conditions under which a trial of labor after cesarean (TOLAC) is acceptable and evaluating the effect of vaginal birth after cesarean (VBAC) policies on access to care for rural women. TOLAC, once encouraged as a major way to decrease the overall cesarean delivery rate through successful VBAC, has fallen into disfavor because of concerns about potentially life-threatening rupture of the uterine scar during labor. (Risk of symptomatic scar rupture of 24 to 52 per 100,00046) In a 1999 practice bulletin, ACOG recommended that VBAC be conducted only in settings with physicians immediately available to perform emergency cesarean delivery.52 This has led to a decrease in access to TOLAC services, particularly in small and rural hospitals, and a resultant dramatic increase in repeat cesarean delivery rates.14

Relationships with Other Organizations
The AAFP and ACOG should maintain a dialogue on the issue of cesarean delivery by family physicians. The joint AAFP/ACOG documents, “Cooperative Practice and Hospital Privileges” and “Recommended Core Educational Guidelines for Family Practice Residents,” should be reaffirmed and revised on a periodic basis. Cooperation between family physicians and obstetrician/gynecologists for the common goals of improving access and availability to quality maternity care should be encouraged,33 as modeled by the collaborative efforts seen elsewhere.54

Section VII - References

  1. Recommended curriculum guidelines for family medicine residents. Maternity and gynecologic care. American Academy of Family Physicians, Leawood, Kan.; 1998. http://www.aafp.org/dam/aafp/documents/medical_education_residency/program_directors/Reprint261_Maternity.pdf(18 page PDF)(26 page PDF). Accessed December 12, 2009.
  2. Loafman M, Nanda S. Who will deliver our babies? Crisis in the physician workforce. Am J Clin Med. 2009;6(2):11-16.
  3. AAFP-ACOG joint statement on cooperative practice and hospital privileges. 2004. http://www.aafp.org/about/policies/all/aafp-acog.html. Accessed December 12, 2009.
  4. Cohen D, Coco A. Declining trends in the provision of prenatal care visits by family physicians. Ann Fam Med. 2009;7(2):128-133.
  5. American Academy of Family Physicians. Table 34. Performance of OB-routine delivery in hospital practices of family physicians by census division, July 2008. Accessed March 3, 2010.
  6. Martin JC, Avant RF, Bowman MA, et al.; Future of Family Medicine Project Leadership Committee. The Future of Family Medicine: a collaborative project of the family medicine community. Ann Fam Med. 2004;2(suppl 1):S3-S32.
  7. American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, American Osteopathic Association. Joint principles of the patient-centered medical home. March 2007. http://www.aap.org/en-us/professional-resources/practice-support/quality-improvement/Documents/Joint-Principles-Patient-Centered-Medical-Home.pdf(www.aap.org)(www.aap.org). Accessed December 2009.
  8. Deutchman M. Who ever heard of family physicians performing cesarean sections? J Fam Pract. 1996;43(5):449-453.
  9. Dresang L, Koch P. The need for rural physicians who can perform cesareans. Am J Clin Med. 2009;6(2):39-41.
  10. Becker JL, Milad MP, Klock SC. Burnout, depression, and career satisfaction: cross-sectional study of obstetrics and gynecology residents. Am J Obstet Gynecol. 2006;195(5):1444-1449.
  11. Anderson BL, Hale RW, Salsburg E, Schulkin J. Outlook for the future of the obstetrician-gynecologist workforce. Am J Obstet Gynecol. 2008;199(1):88.el-8.
  12. Chan BT, Willett J. Factors influencing participation in obstetrics by obstetrician-gynecologists. Obstet Gynecol. 2004;103(3):493-498.
  13. Dresden GM, Baldwin LM, Andrilla CH, Skillman SM, Benedetti TJ. Influence of obstetric practice on workload and practice patterns of family physicians and obstetrician-gynecologists. Ann Fam Med. 2008;6(suppl 1):S5-S11.
  14. Hamilton BE, Martin JA, Ventura SJ; Division of Vital Statistics. Births: Preliminary data for 2007. http://www.cdc.gov/nchs/data/nvsr/nvsr57/nvsr57_12.pdf(www.cdc.gov)(www.cdc.gov). Accessed December 12, 2009.
  15. DeFrances CJ, Hall MJ; Division of Health Care Statistics. 2005 National hospital discharge survey. http://www.cdc.gov/nchs/data/ad/ad385.pdf(www.cdc.gov)(www.cdc.gov). Accessed November 14, 2008.
  16. American Academy of Family Physicians. Facts about family medicine. http://www.aafp.org/about/the-aafp/family-medicine-facts.html. Accessed November 14, 2008.
  17. Sakornbut EL, Dickinson L. Obstetric care in family practice residencies: a national survey. J Am Board Fam Pract. 1993;6(4):379-384.
  18. Chang Pecci C, Leeman L, Wilkinson J. Family medicine obstetrics fellowship graduates: training and post-fellowship experience. Fam Med. 2008;40(5):326-332.
  19. Deutchman M, Connor P, Gobbo R, FitzSimmons R. Outcomes of cesarean sections performed by family physicians and the training they received: a 15-year retrospective study. J Am Board Fam Pract. 1995;8(2):81-90.
  20. Richards TA, Richards JL. A comparison of cesarean section morbidity in urban and rural hospitals. A three-year retrospective review of 1,177 charts. Am J Obstet Gynecol. 1982;144(3):270-275.
  21. Heider A, Neely B, Bell L. Cesarean delivery results in a family medicine residency using a specific training model. Fam Med. 2006;38(2):103-109.
  22. Hueston WJ, Applegate JA, Mansfield CJ, King DE, McClaflin RR. Practice variations between family physicians and obstetricians in the management of low-risk pregnancies. J Fam Pract. 1995;40(4):345-351.
  23. Eidson-Ton WS, Nuovo J, Solis B, Ewing K, Diaz H, Smith LH. An enhanced obstetrics track for a family practice residency program: results from the first 6 years. J Am Board Fam Pract. 2005;18(3):223-228.
  24. Barclay AM, Knapp DP, Kallail KJ. The provision of labor and delivery services by graduates of four Kansas family practice residencies. Kans Med. 1996;97(1):19-23.
  25. Kelly BF, Sicilia JM, Forman S, Ellert W, Nothnagle M. Advanced procedural training in family medicine: a group consensus statement. Fam Med. 2009;41(6):398-404.
  26. American Academy of Family Physicians. Clinical privilege request for family medicine with maternity care. www.aafp.org/online/etc/medialib/aafp_org/documents/prac_mgt/priv_proc/privilegesob.Par.00. Accessed December 12, 2009.
  27. Dijksterhuis MG, Voorhuis M, Teunissen PW, et al. Assessment of competence and progressive independence in postgraduate clinical training. Med Educ. 2009;43(12):1156-1165.
  28. Van Hove C, Perry KA, Spight DH, et al. Predictors of technical skill acquisition among resident trainees in a laparoscopic skills education program. World J Surg. 2008;32(9):1917-1921.
  29. American Board of Physician Specialties. Family medicine obstetrics. http://www.abpsus.org/family-medicine-obstetrics(www.abpsus.org)(www.abpsus.org). Accessed January 3, 2010.
  30. American Academy of Family Physicians. Hospital Bylaws on Low Volume/No Volume Privileging-policy. http://www.aafp.org/about/policies/all/hospital-bylaws.html. Accessed March 3, 2010
  31. Comprehensive Accreditation Manual for Hospitals: The Official Handbook. Oakbrook Terrace, Ill.: Joint Commission on Accreditation of Healthcare Organizations; 2009.
  32. Physician’s Guide to Medical Staff Bylaws Chicago, IL: American Medical Association; 2010. http://www.ama-assn.org/ama/pub/about-ama/our-people/member-groups-sections/organized-medical-staff-section/helpful-resources/omss-bylaws.page(www.ama-assn.org)(www.ama-assn.org). Accessed March 3, 2010
  33. Guidelines for Women’s Health Care: A Resource Manual. 3rd ed. Washington, DC: American College of Obstetricians and Gynecologists; 2007: 30-34.
  34. American Academy of Family Physicians. Procedural privileges legal opinion. May 2005. http://www.aafp.org/online/en/home/practicemgt/privileges/assistancepriv/legalopinion.html. Accessed March 3, 2010.
  35. Stanco LM, Schrimmer DB, Paul RH, Mishell DR Jr. Emergency peripartum hysterectomy and associated risk factors. Am J Obstet Gynecol. 1993;168(3 pt 1):879-883.
  36. Shellhaas CS, Gilbert S, Landon MB, et al.; Eunice Kennedy Shriver National Institutes of Health and Human Development Maternal-Fetal Medicine Units Network. The frequency and complication rates of hysterectomy accompanying cesarean delivery. Obstet Gynecol. 2009;114(2 pt 1):224-229.
  37. Zelop CM, Harlow BL, Frigoletto FD Jr, Safon LE, Saltzman DH. Emergency peripartum hysterectomy. Am J Obstet Gynecol. 1993;168(5):1443-1448.
  38. Bodelon C, Bernabe-Ortiz A, Schiff MA, Reed SD. Factors associated with peripartum hysterectomy. Obstet Gynecol. 2009;114(1):115-123.
  39. Doumouchtsis SK, Papageorghiou AT, Arulkumaran S. Systematic review of conservative management of postpartum hemorrhage: what to do when medical treatment fails. Obstet Gynecol Surv. 2007;62(8):540-547.
  40. Punnonen R, Teisala K, Heinonen PK, Tuimala R, Pystynen P. Subtotal hysterectomy in emergency obstetrics. Ann Chir Gynaecol. 1984;73(5):293-295.
  41. Plauche WC. Peripartal hysterectomy. In: Plauche WC, Morrison JC, O’Sullivan MJ, eds. Surgical Obstetrics. ed. Philadelphia, Pa.: Saunders; 1992.
  42. Petitti DB. Maternal mortality and morbidity in cesarean section. Clin Obstet Gynecol. 1985;28(4):763-769.
  43. Yasin SY, Walton DL, O’Sullivan M. Problems encountered during cesarean delivery. In: Plauche WC, Morrison JC, O’Sullivan MJ, eds. Surgical Obstetrics.. Philadelphia, Pa.: Saunders; 1992
  44. Nesbitt TS, Baldwin LM. Access to obstetric care. Prim Care. 1993;20(3):509-522.
  45. Nesbitt TS, Connell FA, Hart LG, Rosenblatt RA. Access to obstetric care in rural areas: effect on birth outcomes. Am J Public Health. 1990;80(7):814-818.
  46. Deutchman M, Roberts RG. VBAC: Protecting patients, defending doctors [Editorial]. Am Fam Physician. 2003;67(5):931-932, 935-936.
  47. Nesbitt TS, Larson EH, Rosenblatt RA, Hart LG. Access to maternity care in rural Washington: its effect on neonatal outcomes and resource use. Am J Public Health. 1997;87(1):85-90.
  48. Larimore WL, Davis A. Relation of infant mortality to the availability of maternity care in rural Florida. J Am Board Fam Pract. 1995;8(5):392-399.
  49. Kornelsen J, Grzybowski S. Safety and community: the maternity care needs of rural parturient women. J Obstet Gynaecol Can. 2005;27(6):554-561.
  50. Kornelsen J, Grzybowski S, Inglesias S. Is rural maternity care sustainable without general practitioner surgeons? Can J Rural Med. 2006;11(3):218-220.
  51. Joint position paper on training for rural family practitioners in advanced maternity skills and cesarean section. College of Family Physicians of Canada, Society of Rural Physicians of Canada, Society of Obstetricians and Gynaecologists of Canada. Can Fam Physian. 1999;45:2416-2422, 2426-2432.
  52. ACOG practice bulletin. Vaginal birth after previous cesarean delivery. Number 5, July 1999 (replaces practice bulletin number 2, October 1998). Clinical management guidelines for obstetrician-gynecologists. American College of Obstetricians and Gynecologists. Int J Gynaecol Obstet. 1999;66(2):197-204.
  53. Deutchman M, Connor P, Gobbo R, FitzSimmons R. Outcomes of cesarean sections performed by family physicians and the training they received: a 15-year retrospective study. Obstet Gynecol Surv. 1995;50(9):650-652.
  54. The Society of Obstetricians and Gynecologists of Canada. A national birthing initiative for Canada. An inclusive, integrated and comprehensive pan-Canadian framework for sustainable family-centered maternity and newborn care. January 2008. http://ww(www.sogc.org)(www.sogc.org)rg/projects/pdf/BirthingStrategyVersioncJan2008.pdfw.sogc.o(www.sogc.org)(www.sogc.org). Accessed March 3, 2010.

(B1997) (2016 COD)


Table A1: Complications of Cesarean Delivery

Injury to maternal bladder

Injury to maternal bowel

Extension of uterine incision into uterine arteries

Extension of uterine incision into the cervix or vagina

Uterine atony

Dense adhesions from previous surgery

Hemorrhage from placental implantation site

Uterine rupture

Wound hematoma


Wound infection

Table A2: Preoperative Risk Factors for Complications of Cesarean Delivery

Preterm pregnancy

Multiple gestations

Grand multiparity

Placenta previa

Placenta accreta

Morbid obesity

Fetal anomalies

Transverse fetal lie

Maternal coagulopathy

Large uterine fibroids

Repeat cesarean delivery in a patient with extensive adhesions

Medical problems that would make maternal anesthesia hazardous

Table A3: Suggested Data List for Documentation of Cesarean Delivery Experience

Patient identification or code

Date of procedure

Name of hospital

Patient’s age

Patient’s number of previous pregnancies

Medical problems during pregnancy

Clinical reason(s) for cesarean delivery

Physician’s role in surgery; (i.e. primary surgeon, first assistant or second assistant)

Supervising surgeon

Occurrence of postoperative infection

Surgical complications and treatment

Infant Apgar score and weight

Admission to neonatal intensive care unit