A personal audit of private obstetric practice

This is a retrospective review of 7398 deliveries under the direct care of the author over 25 years, from data input on personal handheld computers at the time of delivery. A more detailed look at 409 deliveries over 2.5 years where all the case notes were studied was also undertaken. The rate of cesarean section is outlined. For the last 10 years of the study, the rate of cesarean section was maintained at 19%. This was in quite an elderly population. Two main factors seemed responsible for the relatively low rate of cesarean: vaginal births after cesarean (VBACs) and rotational Kiwi deliveries.


| INTRODUC TI ON
I have been a practicing obstetrician for over 35 years. Trained in Dublin, London and Liverpool, I worked in Paris for over 4 years and Limerick for 26 years. I greatly value vaginal birth and make every effort to achieve this safely. At various times my preferred method of instrumental delivery has been Neville-Barnes forceps or vacuum delivery. Manual rotation has been used, Kielland's forceps, even "les Spatules de Thierry". 1 However, since 2008 the Kiwi vacuum has become the go-to tool of choice.
Around the world the incidence of cesareans is increasing. In 2020 the rate of cesareans at the University Maternity Hospital of Limerick was 38.2% for 4062 women delivered. So far for 2021 the rate appears to have breached 40%. There is a mixture of public and private practice. In private practice the total care of the patient is in the hands of one doctor. This gives excellent homogeneity. It is therefore very interesting to keep a personal audit of one's practice. Despite the rate in the hospital rising, my own rate of cesareans in private practice has remained static at 18%-19% for the last decade. The perinatal mortality rate (PMR) for the whole group is 47/7398 (6.35/1000) births, or 4.05/1000 corrected for lethal congenital abnormalities. Since 2011, the PMR was 11/1616 (6.7/1000), or 2.4/1000 corrected.
I have kept an electronic record of every private delivery and every public out-of-hours delivery as well as every operation done for 26 years. Until June 2010 a Psion handheld device was used for recording, and since that date, each entry was made on the Apple iPhone Calendar. All entries from the Psion machines have been transferred to a Microsoft Excel spreadsheet. In all there have been over 7400 private deliveries. A running total of the number of normal vaginal deliveries, cesarean sections, vacuum extractions, forceps deliveries, as well as twin deliveries, breeches, and late miscarriages is kept up to date. Knowing these statistics I have always been keen to discuss labor ward outcomes, but finding the correct forum has until now been difficult. The graph in Figure 1 shows the number of hospital deliveries and the number of personal private deliveries.
As well as type of delivery, the birth order, the sex, and the birth weight are always recorded. A contemporaneous note is taken in cases of vaginal birth after cesarean (VBAC), stillbirth, neonatal death, and congenital abnormality. In cases of cesarean section, the indication is entered. Several failsafes are in place so the record is very complete. The entry is checked at the 6-week postnatal visit and the medical secretaries use the information for billing purposes. when it reached over 32% ( Figure 2). This was ahead of the national curve and criticism was frequently leveled at Limerick for its high rate. By organizing a weekly labor ward meeting where vaginal delivery was encouraged, it was possible to lower the cesarean rate and return to the national average, for at least 6 or 7 years.
In 2020 the hospital cesarean rate was 38.2%, against a national average of 35.4%.
My personal cesarean rate started high, but generally remained 3% or 4% lower than the hospital rate.  3.503). The mean birth weight was 3.36 kg (SD 0.512). This low birth weight is probably a reflection of my practice of inducing labor in most cases before term.

| VAG INAL B IRTH S AF TER CE SARE AN
In total, 344 VBACs were achieved. In 2009, 2011, 2015, and 2018, almost 10% of all deliveries were VBACs. Counting only those 4 years, the cesarean rate was 17.8%. It should be noted that VBACs need very close surveillance in labor. In private practice there can be a temptation to perform repeat cesareans which is better remunerated and certainly much easier to manage. Soon year for 5-6 years, which led to a falling cesarean section rate ( Figure 3). There was a second wave from 2013 which lasted for 3 years when I was the lead investigator for the Optibirth 2 VBAC study in Limerick. This was a pan-European study and private patients were excluded to conform with the other countries. While the Optibirth study did not lead to an increased VBAC rate or a decreased cesarean rate in the study population, it did have such an effect on my private patients.
There was only one uterine rupture in a patient who had a previous myomectomy and this occurred prior to labor. Personal management affords a certain degree of safety. It is imperative that VBAC labor progresses smoothly, and in the event of any glitches there must be immediate recourse to cesarean section.
There is probably 20 min in which to deliver the baby in the event of rupture and it is my fervent hope that in the event of such a complication, delivery would be even quicker. There were 10 cases of uterine dehiscence. Six of these occurred prior to labor and the F I G U R E 2 Annual hospital cesarean section (CS) rate (%, in orange) versus the author's CS rate (%, yellow).   and did a detailed chart review ( Table 2). Among other benefits, this allowed knowledge of which labors had been induced and which merely accelerated.

| ROTATI ONAL DELIVERIE S WITH THE K IWI VACU UM
Groups 1 and 2, primigravidae in spontaneous and induced labor, had a cumulative cesarean rate of 19%. Of the 88 patients in group 2, two (2.27%) were in group 2b requiring a cesarean before labor.
If the patient achieved a successful vaginal delivery, she then enters group 3 or 4 in her next pregnancy; she becomes a multiparous patient in spontaneous or induced labor. The cumulative cesarean rate for these two groups (despite an 80% induction rate) was less than 1%-that is, achieving a vaginal birth on the first pregnancy greatly enhances the prospect of further vaginal births.
One of the two cesareans done in group 4 was done prior to labor (Group 4b) for a minor fetal anomaly.

F I G U R E 4
The author's cesarean section (CS) rate (%, in blue) versus his instrumental rate (%, red). In this same cohort of 409 patients, only 16 went to 40 weeks and 3 days, or beyond. The remainder were either delivered spontaneously or were induced by this date. This would seem to add weight to the theory that good outcomes are associated with early induction of labor. 6 hypertension, intrauterine growth restriction, even macrosomia, take precedence. Induction of healthy women with healthy babies, before problems occur, is not conducive to good night's sleep for the obstetrician.

| CON CLUS I ON -A PER SONAL VIE W
In my view, this type of management is an example of supportive care. Despite a growing tendency towards early induction, I am passionate about patient choice, and not averse to allowing the patient to go 10 or even 14 days post-term provided liquor volume is maintained, and no other risk factors appear. However, I am aware that a criticism of paternalism will be leveled by some who feel that "natural labor" is desirable.
For many obstetricians in private practice, a maternal age of 35 or more per se is often thought to be an indication for cesarean.
Despite running a practice where more than half of the patients are this age, there still appears to be benefit in vaginal delivery, with a low incidence of complications, even if the planned family size is small.
While the 2014-2016 cesarean section rate is low, at 74/409 (18.1%), the Kiwi vacuum rate is quite high, at 89/409 (21.8%) patients. The background hospital instrumental rate is currently 18.5% versus a national rate of 14%. I will show in a future paper that this form of instrumental delivery is associated with a low complication rate.

CO N FLI C T O F I NTE R E S T S TATE M E NT
I have no conflicts of interest.

DATA AVA I L A B I L I T Y S TAT E M E N T
Data sharing is not applicable to this article as no new data were created or analyzed in this study.