Cesarean Delivery in Family Medicine (Position Paper)

Overview and Purpose

Obstetric care is an integral part of many family physicians’ scope of practice and an important component of family medicine residency training.1,2 A substantial percentage of perinatal care in the United States is provided by family physicians, especially in rural and underserved communities, in which family physicians provide a disproportionate amount of perinatal care.3 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.4 A cooperative relationship among family physicians, obstetrics subspecialists, and nurse midwives is essential in order to provide pregnant women with consistent, comprehensive care. The most important objective must be the highest standard of obstetric care, regardless of specialty.

In 2004, a report of the Future of Family Medicine project outlined the broad spectrum of services that family physicians must provide to renew the specialty and meet the needs of patients and society.5 The report stated that family medicine education should continue to include training in maternity care. Provision of comprehensive, accessible care is a characteristic of the patient-centered medical home (PCMH) model promoted by the AAFP and other organizations.6 Operative delivery and other advanced perinatal services are ideally suited for this model of care, which includes extended and advanced services.

Cesarean delivery is one of the most common surgical procedures in the United States.7 According to the National Center for Health Statistics (NCHS), approximately 1.3 million cesarean deliveries are performed in the United States annually.8 In 2013, 32.7% of U.S. births were cesarean deliveries.9 Previous cesarean delivery, labor dystocia, abnormal or indeterminate fetal heart rate tracing, fetal malpresentation, multiple gestation, and suspected fetal macrosomia are some of the most common indications for cesarean delivery.10 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 that does not require transporting the patient.

Provision of cesarean delivery by well-trained family physicians augments maternity care services available to women or, in some cases, provides a service that would not otherwise be available. Quality patient care requires that all physicians—regardless of specialty—practice within their ability, as determined by training, experience, and current competence.11 Given that many family physicians currently perform cesarean delivery, and many are being trained to provide this service, it is important to have shared common standards of perinatal care, as well as a common understanding of the place of cesarean delivery within a family physician’s scope of practice and within the health care delivery system.

This document should serve as a resource for family physicians who are training to perform cesarean delivery and planning to include this service in their practices. It also will help hospital and health plan credentialing committee members and administrators, obstetrics subspecialists, nurse midwives, and clinical staff understand the role of family physicians in providing cesarean delivery.

Section II - Scope of Practice for Family Physicians

Family medicine is a specialty based on comprehensive care that encompasses a wide range of medical services. Family physicians practice among diverse populations and in geographically varied settings, including rural communities. They choose a personal scope of practice based on factors that include their training experiences, their practice interests, and the needs of their patient populations. Broadly speaking, the following indicate the extent to which cesarean delivery is within the current scope of family medicine:

  • A joint AAFP/ACOG statement on cooperative practice and hospital privileges affirms that surgical delivery is within the scope of family medicine.12
  • The AAFP’s recommended curriculum guidelines for family medicine residents describe training in both core obstetric skills and advanced obstetric skills, which include performance of cesarean delivery.13
  • In the United States, there are approximately 32 family medicine fellowships in obstetrics, many of which seek to train family physicians to perform cesarean delivery independently.14,15 Many graduates of these programs practice in rural and/or underserved areas and have cesarean delivery privileges.

There are limited data on outcomes of cesarean deliveries performed by family physicians, and much of the literature is dated. However, studies have shown that the maternal and infant outcomes of cesarean deliveries performed by family physicians in active practice or in training can meet or exceed national standards.16,17,18 A small 2013 study showed that patients who had a cesarean delivery performed by a family physician did not face increased overall risk.19 In addition, there is some evidence that women who receive perinatal care from family physicians have lower cesarean delivery rates than patients cared for by obstetrics subspecialists.20,21 This is important for social and financial reasons, and because surgical delivery carries a significantly increased risk of maternal morbidity and mortality compared with vaginal delivery.

Section III - Training Methods

Cesarean delivery is a major abdominal surgical procedure that typically is learned during residency, extended residency, or fellowship training. The AAFP’s recommended curriculum guidelines indicate that family medicine residents who seek cesarean delivery training because of their planned practice sites should be able to acquire this advanced skill during the course of a three-year residency.22 Data indicate that many family physicians have achieved proficiency in operative delivery during residency, preparing them to perform cesarean delivery in various practice settings.23,24,25,26 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.27

In approximately 32 U.S. family medicine fellowships in obstetrics,28 cesarean delivery is identified as a key skill and training is provided. Another training model involves a four-year family medicine residency curriculum that includes an enhanced obstetrics track. A 2005 review of the first six years of one residency program’s enhanced obstetrics track found that residents who completed it had cesarean and high-risk delivery numbers comparable to those of residents completing an obstetrics/gynecology residency.29 Although the curriculum for fellowships and advanced training programs is not standardized by the Accreditation Council for Graduate Medical Education (ACGME) Residency Review Committee, a 2008 survey of 165 graduates of family medicine fellowships in obstetrics throughout the United States found that 66% of graduates had obtained cesarean delivery privileges.30 Another possible route to the acquisition of cesarean delivery skills is preceptorship by a family physician, an obstetrics subspecialist, or a general surgeon who already has these privileges. Because cesarean delivery is a major surgical procedure, it would be unusual to acquire cesarean delivery skills in brief (e.g., weekend or weeklong) courses.

As with many other procedures, the number of cesarean deliveries a physician must perform during training to gain competence has not been extensively studied. The literature documents high variability in the training numbers necessary for mastery of procedural skills.31,32 A 2006 study of the cesarean delivery training curriculum in one three-year family medicine residency program found an average of 60 cesarean deliveries performed per resident.33 In a survey of family medicine maternity care fellowships, the estimated mean num­ber of cesarean deliveries per­formed annually by fellows was 108.6 (SD=48.2), with a range of 60 to 190 performed.34 A study of cesarean deliveries performed by three family physicians in a rural hospital found that the physicians had performed 37 to 50 primary cesarean deliveries and assisted on 75 to 110 cesarean deliveries before they were credentialed at the hospital.35 One of these physicians was trained in a residency program with a strong rural focus, one was trained in a fourth-year rural obstetrics fellowship program, and the third was trained while employed in the National Health Service Corps. The variability of training numbers for cesarean delivery emphasizes the need for careful supervision and review of trainees, and the need for progressive proctoring in training and assessment of competence that is not heavily based on training numbers.

Acquisition of the psychomotor skills needed for cesarean delivery should be coupled with the development of cognitive skills required to know when to perform the procedure and how to manage medical and surgical complications, such as those listed in Table A1. Family physicians should be able to recognize and manage complications of cesarean delivery, or obtain necessary consultation. Another important topic that should be part of cesarean delivery training is identification and understanding of preoperative risk factors that should prompt consultation, referral, or transfer of patients before surgery (Table A2). In addition, because cesarean delivery is an abdominal surgery, experience with other abdominal procedures is helpful for skill development.

Section IV - Testing, Demonstrated Proficiency, and Documentation

The AAFP recommends an approach that gives family physicians who perform procedures three methods to demonstrate competence:

    1)    Perform the procedure in high enough volume that any quality trends
           are detectable
    2)    Have references attesting to competence
    3)    Have a proctor attest to competence

Regarding the first method, the volume threshold should be evidence based. If the literature does not support a specific volume threshold, one should be established by the consensus of a multidisciplinary group of physicians that includes family physicians.

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 whether physicians completing training are proficient in cesarean delivery.36,37,38

The volume of cesarean deliveries needed to maintain proficiency has not been extensively studied. In a 15-year retrospective study that showed that maternal and infant outcomes of cesarean deliveries performed by family physicians met or exceeded national standards, the number of cesarean deliveries performed by study participants ranged from five to 22 procedures per physician per year.39 A 2008 survey of graduates of U.S. family medicine fellowships in obstetrics found an overall average of 28.9 cesarean deliveries per year; only 22.5% of respondents averaged more than 30 procedures per year.40

Family 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 for patients on whom they have operated, or assembling a case database that includes details such as those suggested in Table A3.

In 2009, the American Board of Physician Specialties began offering certification in family medicine obstetrics to recognize “the advanced level of training and experience that some [family physicians] gain through recognized fellowship programs or their historical equivalent.”41 For eligible applicants, the process of certification for family medicine obstetrics involves satisfactory completion of a written examination and an oral examination, and confirmation of surgical competence 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 competence in this area.

Section V - Credentialing and Privileges

For hospitals and medical staff, the policies of respected national organizations are the best source of guidance on the credentialing of appropriately trained, competent family physicians who seek hospital privileges. In their joint statement on cooperative practice and hospital privileges, the AAFP and ACOG state the following42:

    “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, in order to [ensure] 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 who receives training 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. All physicians should be subject
     to a proctorship period to allow demonstration of ability and current
     competence. These principles should apply to all health care systems.”

According to these guidelines, it would be improper to base the granting of privileges on the specialty of a physician’s residency training.

The American Medical Association’s (AMA’s) policy on staff privileges states the following: “Decisions regarding hospital privileges should be based upon the training, experience, and demonstrated competence of candidates, taking into consideration the availability of facilities and the overall medical needs of the community, the hospital, and especially patients.”43

The Joint Commission’s hospital accreditation standards state the following: "The credentialing and privileging process involves a series of activities designed to collect, verify, and evaluate data relevant to a practitioner's professional performance. These activities serve as the foundation for objective, evidence-based decisions regarding appointment to membership on the medical staff, and recommendations to grant or deny initial and renewed privileges. In the course of the credentialing and privileging process, an overview of each applicant's licensure, education, training, current competence, and physical ability to discharge patient care responsibilities is established."44

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 a department 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 procedure. If a hospital has coexisting departments of family medicine and obstetrics, the departments may or may not have a cooperative credentialing arrangement.

Family physicians moving to a new practice site would benefit from extensively researching the policies and procedures of their chosen site regarding privileges for cesarean delivery and other procedures, and obtaining these privileges before actually moving to the new practice site, if possible. This approach is particularly advisable if a family physician is the first to request cesarean delivery privileges in an environment in which obstetrics subspecialists alone hold such privileges.

The number of procedures performed in training is often used as a criterion for credentialing; however, numbers alone do not demonstrate quality of outcomes. Family physicians seeking cesarean delivery privileges should have extensive documentation of their experience, including the following45:

  • Number of procedures performed during training and in practice
  • Outcomes data (see suggested items in Table A3)
  • Letters from instructors, preceptors, and proctors that document training, experience, demonstrated abilities, and current competence

Lack of community need may be cited as a reason to withhold cesarean delivery privileges from family physicians who practice in environments shared with obstetrics subspecialists. However, this approach is not consistent with Joint Commission, AMA, or joint AAFP/ACOG credentialing guidelines. Services provided by family physicians, obstetrics subspecialists, and nurse midwives are different and offer patients options for care. Obstetric services are provided by family physicians in the context of whole-person family care, often in a PCMH, and usually with subsequent neonatal care. Furthermore, “turf battle” situations could lead to legal action on the basis of discrimination and restraint of trade (i.e., antitrust).

At some institutions, ability to manage complications of cesarean delivery may be a requirement for obtaining privileges. For example, the ability to perform a cesarean hysterectomy for persistent hemorrhage may be required, in spite of the fact that cesarean hysterectomy is a rare procedure that a family physician would not typically need to perform.46 All physicians, regardless of specialty, would be expected to seek consultation for a rare condition, and numerous effective temporizing techniques are available to manage severe blood loss during cesarean delivery while consultation is being arranged.47,48,49  In addition, a significant percentage of patients who are at high risk of severe hemorrhage and subsequent cesarean hysterectomy—most notably those who have a history of previous cesarean delivery or placenta previa—can be identified before surgery.50 Although no risk-assessment system can predict the outcomes of all cesarean deliveries, preoperative risk factors (Table A2) for complications of cesarean delivery that are outside of the family physician’s scope of practice can be identified to prompt consultation, referral, or transfer of patients before surgery, as necessary.

A family physician who performs cesarean delivery should have an established system for consulting with partners, other family physicians, general surgeons, and obstetrics subspecialists, as appropriate. In addition, resources (e.g., laminated protocol cards, an electronic database) should be available in the delivery suite for immediate reference if assistance is needed. Assistance via video conferencing might be especially useful for family physicians who practice in rural communities.

Section VI - Miscellaneous Issues

Quality Programs
Family physicians who perform cesarean delivery should establish ongoing case-review programs to monitor their delivery and surgical outcomes. Table A3 provides a suggested model for collection of data on maternal and infant outcomes that can be compared with standard outcomes.

Public Health and Community Implications
High-quality surgical care is important for good perinatal outcomes. Because family physicians are the most widely available physicians, particularly in rural and underserved areas,51,52 expanding and improving cesarean delivery skills could improve access to modern perinatal care for many patient populations.53,54 There is extensive literature that documents better birth outcomes when local maternity care services are available.55,56,57,58 The survival of small rural hospitals often depends on their ability to continue providing perinatal care. Therefore, rural hospitals need physicians who can perform normal deliveries and operative deliveries. Collaborative efforts by physicians of several specialties in Canada can serve as models of training and support that equip family physicians to provide cesarean delivery in rural communities that lack access to obstetric services.59,60

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

  1. Documenting the ongoing outcomes of cesarean delivery by family physicians
  2. Investigating differences between family physicians and obstetrics subspecialists in the management of labor and cesarean delivery rates
  3. Evaluating training methods (including cognitive and procedural aspects of training); identifying the points at which proficiency in cesarean delivery and other procedures is reached; and determining what learner qualities predict earlier mastery
  • 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.

    4.    Identifying conditions under which a trial of labor after cesarean
           (TOLAC) is acceptable and evaluating the effect of policies regarding
           vaginal birth after cesarean (VBAC) on access to care for women in
           rural communities

Relationship With Other Organizations
The AAFP and ACOG should maintain a dialogue on the issue of cesarean delivery by family physicians. The AAFP/ACOG Joint Statement on Cooperative Practice and Hospital Privileges and the AAFP’s recommended maternity care curriculum guidelines for family medicine residents should be periodically reaffirmed and revised.62,63 Cooperation between family physicians and obstetrics subspecialists for the common goal of improving access to quality maternity care and availability of such care (as modeled by the collaborative efforts seen elsewhere64) should be encouraged. (B1997) (2010 COD)

Section VII - References

1.    American Academy of Family Physicians. Recommended curriculum guidelines for family medicine residents. Maternity care. Leawood, Kan: AAFP; 2015. AAFP Reprint No. 261. http://www.aafp.org/dam/AAFP/documents/medical_education_residency/program_directors/Reprint261_Maternity.pdf. Accessed October 5, 2015.
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.    American College of Obstetricians and Gynecologists. Health disparities in rural women. Committee Opinion No. 586. Obstet Gynecol. 2014;123:384–388.
4.    American Academy of Family Physicians, American College of Obstetricians and Gynecologists. AAFP-ACOG joint statement on cooperative practice and hospital privileges. http://www.aafp.org/about/policies/all/aafp-acog.html. Accessed October 5, 2015.
5.    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.
6.    American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, American Osteopathic Association. Joint principles of the patient-centered medical home. http://www.aafp.org/dam/AAFP/documents/practice_management/pcmh/initiatives/PCMHJoint.pdf . Accessed October 5, 2015.
7.    Centers for Disease Control and Prevention. National Hospital Discharge Survey, 2010. Number of all-listed procedures for discharges from short-stay hospitals, by procedure category and age: United States, 2010. http://www.cdc.gov/nchs/data/nhds/4procedures/2010pro4_numberprocedureage.pdf(www.cdc.gov). Accessed October 5, 2015.
8.    Osterman MJ, Martin JA. Trends in low-risk cesarean delivery in the United States, 1990-2013. Natl Vital Stat Rep. 2014;63(6):1-16.
9.    Martin JA, Hamilton BE, Osterman MJ, Curtin SC, Matthews TJ. Births: final data for 2013. Natl Vital Stat Rep. 2015;64(1):1-65.
10.  American College of Obstetricians and Gynecologists; Society for Maternal-Fetal Medicine. Obstetric care consensus no. 1: safe prevention of the primary cesarean delivery. Obstet Gynecol. 2014;123(3):693–711.
11.  American Academy of Family Physicians, American College of Obstetricians and Gynecologists. AAFP-ACOG joint statement on cooperative practice and hospital privileges. http://www.aafp.org/about/policies/all/aafp-acog.html. Accessed October 5, 2015.
12.  American Academy of Family Physicians, American College of Obstetricians and Gynecologists. AAFP-ACOG joint statement on cooperative practice and hospital privileges. http://www.aafp.org/about/policies/all/aafp-acog.html. Accessed October 5, 2015.
13.  American Academy of Family Physicians. Recommended curriculum guidelines for family medicine residents. Maternity care. Leawood, Kan: AAFP; 2015. AAFP Reprint No. 261. http://www.aafp.org/dam/AAFP/documents/medical_education_residency/program_directors/Reprint261_Maternity.pdf. Accessed October 5, 2015.
14.  American Academy of Family Physicians. Family medicine fellowship directory. https://nf.aafp.org/Directories/Fellowship/Search. Accessed October 5, 2015.
15.  Peterson LE, Blackburn B, Phillips RL Jr, Puffer JC. Structure and characteristics of family medicine maternity care fellowships. Fam Med. 2014;46(5):354-359.
16.  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.
17.  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.
18.  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.
19.  Homan F, Olson AL, Johnson DJ. A comparison of cesarean delivery outcomes for rural family physicians and obstetricians. J Am Board Fam Med. 2013;26(4):366-372.
20.  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.
21.  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.
22.  American Academy of Family Physicians. Recommended curriculum guidelines for family medicine residents. Maternity care. Leawood, Kan: AAFP; 2015. AAFP Reprint No. 261. http://www.aafp.org/dam/AAFP/documents/medical_education_residency/program_directors/Reprint261_Maternity.pdf. Accessed October 5, 2015.
23.  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.
24.  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.
25.  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.
26.  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.
27.  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.
28.  American Academy of Family Physicians. Family medicine fellowship directory. https://nf.aafp.org/Directories/Fellowship/Search. Accessed October 5, 2015.
29.  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.
30.  Chang Pecci C, Leeman L, Wilkinson J. Family medicine obstetrics fellowship graduates: training and post-fellowship experience. Fam Med. 2008;40(5):326-332.
31.  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.
32.  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.
33.  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.
34.  Peterson LE, Blackburn B, Phillips RL Jr, Puffer JC. Structure and characteristics of family medicine maternity care fellowships. Fam Med. 2014;46(5):354-359.
35.  Homan FF, Olson AL, Johnson DJ. A comparison of cesarean delivery outcomes for rural family physicians and obstetricians. J Am Board Fam Med. 2013;26(4):366-372.
36.  Loafman M, Nanda S. Who will deliver our babies? Crisis in the physician workforce. Am J Clin Med. 2009;6(2):11-16.
37.  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.
38.  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.
39.  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.
40.  Chang Pecci C, Leeman L, Wilkinson J. Family medicine obstetrics fellowship graduates: training and post-fellowship experience. Fam Med. 2008;40(5):326-332.
41.  American Board of Physician Specialties. Board certification in family medicine obstetrics. http://www.abpsus.org/family-medicine-obstetrics(www.abpsus.org).  Accessed October 5, 2015.
42.  American Academy of Family Physicians, American College of Obstetricians and Gynecologists. AAFP-ACOG joint statement on cooperative practice and hospital privileges. http://www.aafp.org/about/policies/all/aafp-acog.html. Accessed October 5, 2015.
43.  American Medical Association. E-4.07 Staff privileges [Policy statement]. http://www.ama-assn.org/ama/pub/about-ama/our-people/house-delegates/policyfinder.page(www.ama-assn.org). Accessed October 5, 2015.
44.  Joint Commission on Accreditation of Healthcare Organizations. 2015 Hospital Accreditation Standards. Oakbrook Terrace, IL: Joint Commission on Accreditation of Health Care Organizations; 2015.
45.  American Academy of Family Physicians. Resolving problems with obtaining or modifying hospital privileges. http://www.aafp.org/practice-management/administration/privileging/resolve-problems.html. Accessed October 5, 2015.
46.  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.
47.  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.
48.  Fawcus S, Moodley J. Postpartum haemorrhage associated with caesarean section and caesarean hysterectomy. Best Pract Res Clin Obstet Gynaecol. 2013;27(2):233-249.
49.  Main EK, Goffman D, Scavone BM, et al. National Partnership for Maternal Safety: consensus bundle on obstetric hemorrhage. Obstet Gynecol. 2015;126(1):155-162.
50.  Machado LS. Emergency peripartum hysterectomy: Incidence, indications, risk factors and outcome. N Am J Med Sci. 2011;3(8):358-361.
51.  Nesbitt TS, Baldwin LM. Access to obstetric care. Prim Care. 1993;20(3):509-522.
52.  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.
53.  Loafman M, Nanda S. Who will deliver our babies? Crisis in the physician workforce. Am J Clin Med. 2009;6(2):11-16.
54.  Deutchman M, Roberts RG. VBAC: protecting patients, defending doctors [Editorial]. Am Fam Physician. 2003;67(5):931-932, 935-936.
55.  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.
56.  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.
57.  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.
58.  Kornelsen J, Grzybowski S. Safety and community: the maternity care needs of rural parturient women. J Obstet Gynaecol Can. 2005;27(6):554-561.
59.  Kornelsen J, Grzybowski S, Iglesias S. Is rural maternity care sustainable without general practitioner surgeons? Can J Rural Med. 2006;11(3):218-220.
60.  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 Physician. 1999;45:2416-2422, 2426-2432.
61.  American Academy of Family Physicians. Clinical practice guideline: planning for labor and vaginal birth after cesarean. January 2015. http://www.aafp.org/pvbac. Accessed October 5, 2015.
62.  American Academy of Family Physicians, American College of Obstetricians and Gynecologists. AAFP-ACOG joint statement on cooperative practice and hospital privileges. http://www.aafp.org/about/policies/all/aafp-acog.html. Accessed October 5, 2015.
63.  American Academy of Family Physicians. Recommended curriculum guidelines for family medicine residents. Maternity care. Leawood, Kan: AAFP; 2015. AAFP Reprint No. 261. http://www.aafp.org/dam/AAFP/documents/medical_education_residency/program_directors/Reprint261_Maternity.pdf. Accessed October 5, 2015.
64.  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. 1. http://sogc.org/wp-content/uploads/2012/09/BirthingStrategyVersioncJan2008.pdf(sogc.org). Accessed October 5, 2015.

 

Appendix

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

Endomyometritis

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