Judge Obstetricians by Intention; Not Intervention
The current high rate of caesarean births is perceived as an important women’s health issue1. However, may be this is the time to change public and media perception. To support my argument I would like to quote here an example of an extraordinary clinician from Dublin (Dr Kieran O’Driscoll) who faced undue criticism for low caesarean section rate. He was the author of the book “Active management in Labour”. Active management of labour resulted in lower caesarean section rate however he was criticised for this approach although low caesarean section rate or instrumental delivery was not the main goal of active management of labour. Dr O’Driscoll emphasised that the word “active” referred to more involvement of the obstetrician during labour, as opposed to more active surgical intervention2. This is an example where unfortunately a great obstetrician of his time was criticised as “interventionist” and his practice and intention to treat his patients was mis-interpreted in the media and public.
Historically, when the caesarean section rate was 5% in Republic of Ireland, it was 15% in the UK. The publication from the National Perinatal Reporting System shows that the Caesarean Section rate, which was 10.6% in 1990, rose to 25.9% in 20083, and there were multiple factors but one of the factors was negative criticism in the media against clinicians at the Maternity Hospital, Dublin. Active management of labour may be no more of an issue but today we debate how to achieve low still birth rate, early versus late induction of labour in decreased fetal movement and small for gestation age, continuous electronic fetal monitoring versus intermittent auscultation. Obstetricians face the same challenge of keeping a balance between maintaining a target of low caesarean section rates without compromising perinatal outcome.
Obstetricians must focus on evidence based intervention with the best methodology available at the present time to meet today’s new challenges and demands. If this approach comes along with the baggage of increased intervention (caesarean section) then it should not be criticised and should be accepted in the light of the fact that an obstetrician is intervening in the best interest of mum and the un-born baby. Stillbirth or cerebral palsy may not be completely preventable because we have no diagnostic or predictive tool with high sensitivity or specificity available in the scenarios mentioned above. Hence it is unfair to blame clinicians for the poor outcomes even when they have intervened in their best intention. The paradigm shift needed, which is to ‘’Judge Obstetrician by intention not intervention”.
Dr Junaid Rafi MBBS,MRCPI,DFSRH
Ipswich Hospital NHS Trust, IP4 5PD, UK
1: Karin B N, Thomas P S, Dwight J R. Electronic fetal monitoring, cerebral palsy, and caesarean section: assumptions versus evidence BMJ 2016; 355:i6405
2: Thomas F. Baskett. A Tribute to Kieran O’Driscoll .J Obstet Gynaecol Can 2007;29(8):672–673
3: O’Dwyer V, Turner MJ: Is the caesarean section rate in Ireland too high? Ir Med J.2011 May; 104(5):133-4