Cesarean Delivery in Family Medicine (Position Paper)

Family physicians deliver 20 percent of babies born in the United States.¹ In some geographic areas family physicians deliver 100 percent of babies. Birth is central in the creation of families and has a profound impact on the health of individuals, families and communities. Birth is an inseparable part of family medicine. Where family physicians are the sole or major providers of perinatal care, for example, in rural areas, they may need to possess the surgical skills to perform cesarean delivery if they are to participate in perinatal care at all. The arbitrary removal of the cesarean delivery birth option from family medicine would not be good for patients. Further, there is no valid reason why family physicians trained and skilled in cesarean delivery cannot perform the procedure in environments that are not rural or underserved.

Cesarean delivery is one of the most common surgical operations. Approximately one million cesareans are performed in the United States annually based on an annual birth rate of four million and cesarean arise suddenly and unpredictably during the course of labor. No risk-assessment system is capable of predicting all instances where cesarean delivery will be needed. An essential component of modern perinatal care, therefore, is the prompt availability of surgical intervention without physically transferring the patient from one location to another.

When the topic of cesarean delivery is discussed, the issues of the rate of cesarean delivery and the cost of surgical delivery versus vaginal delivery invariably arise. These issues have important implications relating to the role of family physicians in perinatal care in general and surgical delivery in particular. There is evidence that women who receive their perinatal care from family physicians have a significantly lower cesarean rate than patients cared for by obstetrician/gynecologists. This is important not only for social and financial reasons but also because surgical delivery carries a significantly increased risk of maternal morbidity and mortality over vaginal delivery. The Centers for Disease Control and Prevention have recommended that by the year 2010 the U.S. cesarean delivery rate for women giving birth for the first time decrease to 15 percent from the 1998 baseline rate of 18 percent. The CDC further recommends the cesarean delivery rate for women who have had a previous cesarean delivery decrease to 63 percent from the 1998 baseline rate of 72 percent. A national reduction in the cesarean rate from 25 percent to 15 percent would save one billion dollars, assuming a savings of the excess cost of surgical delivery over vaginal delivery of $3,000 dollars per case.^2-3

It is the position of the American Academy of Family Physicians that clinical privileges should be based on each individual physician’s documented training and/or experience, demonstrated abilities and current competence; not on specialty designation alone. This general policy would of course apply to privileges for cesarean delivery.

The Joint Commission on Accreditation of Healthcare Organizations and the American Medical Association hold similar positions, which ratify the position of the AAFP that the right to perform a given procedure is not the exclusive province of any one specialty. The American College of Obstetricians and Gynecologists also holds a similar position. In its Standards for Obstetric-Gynecologic Services, Seventh Edition, ACOG states: "Privileges should be granted on the basis of education, experience and demonstrated competence, not solely on the basis of board certification, fellowship in the American College of Obstetricians and Gynecologists, membership in other organization’s or the physician’s rank or tenure."

That the performance of cesarean delivery is within the scope of family medicine is evidenced by the following:

Published data and data presented at a national research forum document that cesarean care provided by family physicians can meet or exceed national standards for maternal and infant outcomes. ^{(7, 12, 13)}

Table 1 presents the major indications for cesarean delivery and shows them both as a percentage of cesarean delivery and as a percentage of all births.

There is a great deal of medical literature on the topic of indications for cesarean delivery as well as suggestions about which indications provide the most promise for alterations in labor management to result in reduced cesarean rates. Table 2 displays current common rates and target rates of cesarean as a percentage of all births. As Table 2 indicates, "previous cesarean delivery" and "dystocia" are the indications that are most likely to be amenable to reduction. Breech presentation, non-reassuring fetal heart rate, and other indications, including bleeding complications, are less likely to be impacted by cesarean delivery rate-reduction programs. These indications are also those that are least predictable in any one case. Any family physician who provides perinatal care will most certainly encounter these clinical situations even in the course of care for low-risk patients.

The medical literature documents that patients under the care of family physicians can have lower cesarean rates than matched patients under the care of obstetrician/gynecologists.¹⁴ In those studies, the two major causes of the lower cesarean rates are lower rates of repeat cesarean and less frequent diagnosis of dystocia. Most of these studies do not address the issue of whether or not the family physicians involved in the study had the skill and privileges to perform cesarean delivery and whether this would affect their cesarean rate. Other studies have shown that when family physicians practice side-by-side with obstetricians their labor management practices come to resemble those of the obstetricians.^{15, 16} It might be assumed, therefore, that when family physicians gain the skill and privileges to do cesarean delivery they would perform more cesareans. The only two studies in the medical literature that shed some light on this topic suggest otherwise.^7,17 A third longitudinal study also supports the observation that family physicians with cesarean skills and privileges still manage to maintain their lower cesarean section rate.¹³

Cesarean delivery is classified as a major abdominal surgical procedure. As such, it is usually learned during residency. The joint AAFP-ACOG document⁵ indicates that family medicine residents who need to learn the cesarean delivery procedure because of their planned practice sites should be able to acquire this skill during the course of the normal three-year residency. In addition to three-year residency programs, several fellowship and advanced training programs across the country provide cesarean training as one of their target skills. Another possible route to the acquisition of cesarean skills is preceptorship of a family physician by another family physician or a supportive obstetrician or general surgeon. Depending on practice location, cesarean delivery may be performed by family physicians, obstetrician/gynecologists, or general surgeons. Cesarean delivery is also a procedure performed by general practitioners. It would be unusual to acquire this skill in brief courses such as weekend or week-long courses, particularly since it is a major surgical procedure for which there are no models or simulators available.

The number of cesareans that it is customary for a physician to perform during training to gain competence has not been extensively studied. Obstetrics and gynecology residents perform a mean number of about 200 cesareans during their four years of residency but are commonly deemed competent to perform them independently after far fewer procedures. The only published study documenting the training volumes of family physicians who perform cesareans found the average number completed in training to be 46 with a range between about 25 and 100.7 These physicians produced outcomes comparable to or exceeding national standards.

The issue of the acquisition of the psychomotor skill involved in performing cesarean delivery should be coupled with the acquisition of the cognitive skills involved in knowing when to perform the procedure. Any program that seeks to provide the surgical training should also provide the cognitive training.

Because cesarean delivery is an abdominal operation, experience in other abdominal operations should be very helpful in cesarean skill development. In addition to an abdominal operation, however, a cesarean is also a birth; therefore, experience in performing assisted vaginal deliveries may have some transfer to cesarean delivery skills.

The discussion of training methods above focuses on the "how" and "when" of performing cesarean delivery. Other important topics that should be part of training include these: first, an understanding of what clinical settings indicate that a particular cesarean is likely to have a high risk of complications and therefore should lead to patient transfer or consultation when possible; and second, the recognition and means of resolving complications. Table 3 lists clinical conditions likely to produce a complicated cesarean, and Table 4 lists complications that physicians performing cesarean delivery should be able to recognize and either manage or obtain the consultation necessary to resolve.

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. 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, or assembling a case database including items such as those listed in Table 5.

The issue of the volume of continuing surgical experience needed to maintain proficiency in cesarean delivery has not been extensively studied. The only published data that link outcomes of cesareans performed by family physicians to documentation of ongoing experience found that excellent outcomes were maintained at ongoing surgical volumes ranging from 5 to 22 per year.⁷ Most of the family physicians studied also had other ongoing surgical experience in the form of procedures that they performed or procedures in which they assisted consultant physicians. These physicians also had active maternity care practices and performed normal and assisted vaginal deliveries.

Current policies and procedures for credentialing family physicians in cesarean delivery vary markedly from site to site. In hospitals that have departments of family medicine where other family physicians perform cesareans, the department of family medicine may credential its own members. In hospitals where it is not usual for family physicians to perform cesareans, there may be no mechanism for family medicine credentialing in this or a number of other invasive procedures. In those institutions, completion of a residency in obstetrics and gynecology may be stated as a prerequisite for obtaining cesarean privileges. This is in contrast to JCAHO, AMA and ACOG credentialing guidelines, which state that credentialing should be based on such criteria as training, experience, demonstrated ability, current licensure and health status rather than medical specialty.^{9, 10, 11}

"Community need" is often cited as a reason to withhold cesarean 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 test of JCAHO, AMA or ACOG credentialing guidelines. Unfortunately, in such situations the credentialing process may end up in a "turf battle" potentially leading to legal action on the basis of discrimination and restraint of trade (antitrust).

Although the number of procedures performed in training is often used as a prerequisite for credentialing, numbers alone do not demonstrate quality of outcomes. Family physicians seeking cesarean privileges would do well to document the following:

Family physicians moving to new practice sites would do well to extensively research the policies and procedures of their chosen site regarding privileges for cesarean delivery and other procedures, and obtain these privileges before actually moving to the new practice site. This approach would be particularly helpful if the family physician is to be a "pioneer" in requesting these privileges in an environment shared with obstetrician/gynecologists.

At some institutions, a significant credentialing issue is, "Can a family physician perform a cesarean hysterectomy?" At such institutions the ability to perform a cesarean hysterectomy may become a necessary condition for obtaining cesarean privileges. Although even obstetrician/gynecologists very rarely perform cesarean hysterectomies, their additional experience in gynecologic surgery in general and hysterectomy on non-pregnant patients in particular should theoretically help them when they are faced with clinical situations that would necessitate the performance of the cesarean hysterectomy. Arguments against requiring cesarean hysterectomy skills on the part of family physicians include the following:

Although no risk-assessment system can predict all instances where cesarean delivery will be needed, a significant percentage of the patients who are at high risk for severe hemorrhage and subsequent cesarean hysterectomy are identifiable before surgery.^{19, 20, 21} Most of the pertinent risk factors are listed in Table 3. These 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.

A. Quality Assurance

Family physicians performing cesarean delivery should set up ongoing case review programs to monitor their surgical outcomes. The data items in Table 5 could serve as a model for data collection compared to standard outcomes.^{26, 27, 28}

B. Public Health 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,^1,29 expanding and improving their surgical skills in cesarean delivery could improve access to modern perinatal care for patient populations in need.³⁰

C. Community Implications

Perinatal care constitutes a major portion of the clinical care provided by many hospitals, particularly rural hospitals. To continue providing perinatal care, such hospitals need physicians who can perform not only normal deliveries but also assisted vaginal deliveries and cesarean delivery when necessary. The survival of small hospitals may therefore partly hinge on the presence of family physicians who can provide modern maternity care, including cesarean delivery.

D. Research Agenda

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

E. Formal Relationships With Other Organizations

The AAFP and the ACOG should maintain a dialogue on the issue of cesarean delivery by family physicians. The joint AAFP-ACOG document should be reaffirmed and revised when necessary.⁵ Cooperation between family physicians and obstetrician/gynecologists in this area should be encouraged.³⁵

(2003)