Top Doctors: Understanding C-sections

If someone in your family is expecting a baby, don't be surprised if the mother-to-be is whisked into surgery for a Caesarean section delivery.

It's a common scenario across the United States, especially on Long Island. In 2007, Caesarean rates in Nassau and Suffolk counties - at 41.5 percent and 42.7 percent, respectively - eclipsed the state average of 33.7 percent, according to Public Citizen, a consumer advocacy group based in Washington, D.C. The national average was 31.8 percent.

With a Caesarean birth, or C-section, as it's often called, the baby is delivered through a surgical incision in the wall of the mother's abdomen and uterus instead of vaginally. The most common type of cut is horizontal, across the lower abdomen.

REASONS

Experts say many factors play into the rising rate of Caesarean births in this country, including maternal and fetal conditions, physician and patient preferences, and fear of malpractice.

Often, Caesareans are performed when dilation of the woman's cervix and the baby's descent slows or stops, a condition called "arrest of active labor," explained Dr. Alan Monheit, a clinical associate professor of obstetrics, gynecology and reproductive medicine at Stony Brook University School of Medicine.

The general rule of thumb has been to do a Caesarean if, after two hours, a woman in active labor fails to progress, he said. But recent evidence suggests extending that two-hour window might help more women avoid surgery.

With a little patience, many of these women are able to deliver vaginally, said Dr. Chaur-Dong Hsu, chairman of obstetrics and gynecology at Nassau University Medical Center in East Meadow. "So why hurry to section the patient?" he asked.

Sometimes a woman's obstetrician anticipates difficulties with a vaginal birth, such as a pregnancy involving multiple babies, a very large infant or a baby in a breech position. In such cases, surgery usually is scheduled in advance. A mother's medical condition - having HIV, for example - may also trigger a Caesarean delivery.

Many times, though, Caesareans are unplanned, the result of fetal distress caused by a lack of oxygen, placenta previa (a complication that can cause heavy bleeding) or another medical emergency. A Caesarean may be the best course of action for both mother and baby; for example, when the woman experiences severe preeclampsia, a dangerous spike in blood pressure.

RISKS

For a woman, Caesarean birth poses an increased risk for bleeding, blood clots and infection. The recovery time may be longer and more painful, as well.

With repeat Caesareans, there is an increased risk of placenta accreta, a serious condition in which the placenta attaches itself too deeply and firmly into the uterine wall, Monheit said. That can cause severe hemorrhaging and may require a hysterectomy.

Babies who are delivered by Caesarean are more apt to have fluid in their lungs and rapid breathing. There's also a chance that the surgeon's knife would nick the baby, though the risk for that happening is slight.

CURRENT THINKING

In July, the American Congress of Obstetricians and Gynecologists issued guidelines encouraging doctors to give pregnant women who had a Caesarean previously the option of attempting a vaginal birth. The advice follows a statement in March from an expert panel convened by the U.S. National Institutes of Health that urged professional societies to revisit their guidelines on vaginal births after Caesareans (VBAC).

"VBAC definitely needs to be advocated," Hsu said. But he added that the choice of a hospital for the birth is also critical. If a hospital doesn't have an experienced nurse and 24-hour anesthesiologist on hand to handle an emergency C-section should trouble arise during the VBAC, "then that would be a disaster," he said.

THE LONG ISLAND SCENE

To ensure optimal care for pregnant women at risk for hemorrhage, Stony Brook University Medical Center calls a "Code Noelle" to put physicians, nurses and blood bank personnel on high alert should additional resources be needed.

At Nassau University Medical Center, Hsu meets weekly with residents and attending physicians to review C-section cases and ensure that women were offered a VBAC.

Who's who

This is the eighth installment of a 26-week series in which Newsday presents Castle Connolly's list of top L.I. doctors. Today: Maternal and fetal medicine, Ob/Gyn, and neonatal/perinatal medicine

MATERNAL & FETAL MEDICINE

Dr. Adiel Fleischer

LIJ Med. Ctr., Dept. Ob/Gyn, 270-05 76th Ave., New Hyde Park, 718-470-7636

Dr. Chaur-Dong Hsu

2201 Hempstead Tpke., Dept. Ob/Gyn, Nassau Univ. Med. Ctr., East Meadow, 516-572-4670

Dr. Victor Klein

825 Northern Blvd., Great Neck, 516-472-5700

Dr. Natalie Meirowitz

LIJ Med. Ctr., Dept. Ob/Gyn, 270-05 76th Ave., New Hyde Park, 516-470-7636

Dr. Alan Monheit

6 Technology Dr., East Setauket, 631-444-4686

Dr. Burton Rochelson

N. Shore Univ. Hosp., Dept. Maternal/Fetal Med., 300 Community Dr., Manhasset, 516-562-4458

Dr. Anthony Vintzileos

Winthrop Univ. Hosp., Dept. Ob/Gyn, 259 First St., Mineola, 516-663-8657

OBSTETRICS & GYNECOLOGY

Dr. David Baker

6 Technology Dr., East Setauket, 631-444-4686

Dr. Ann Barbaccia

2000 N. Village Ave., Rockville Centre, 516-678-4222

Dr. Leonard Benedict

433 Uniondale Ave., Uniondale, 516-483-8798

Dr. Deborah Davenport

100-16 S. Jersey Ave., East Setauket, 631-689-6400

Dr. Michael Gentilesco

48 Route 25A, Smithtown, 631-862-3800

Dr. Joan Haselkorn

556 Merrick Rd., Rockville Centre, 516-255-2044

Dr. Paula Hirt

83 W. Main St., East Islip, 631-277-5800

Dr. Jessica Jacob

3003 New Hyde Park Rd., New Hyde Park, 516-488-8145

Dr. Mitchell Kramer

180 E. Pulaski Rd., Huntington Station, 631-425-2218

Dr. Eileen Krim

3111 New Hyde Park Rd., North Hills, 516-365-6100

Dr. Douglas Lee

118 North Country Rd., Port Jefferson, 631-475-4404

Dr. Laurence Mack

1130 N. Broadway, N. Massapequa, 516-799-3462

Dr. Charles Mann

48 Route 25A, Smithtown, 631-862-3800

Dr. Martin Matalon

375 E. Main St., Bay Shore, 631-665-8226

Dr. Michael Nimaroff

825 Northern Blvd., Great Neck, 516-472-5700

Dr. Allen Ott

595 Hampton Rd., Southampton, 631-283-0918

Dr. David Rothbaum

233 E. Shore Rd., Great Neck, 516-487-3498

Dr. Gerardo San Roman

118 North Country Rd., Port Jefferson, 631-473-7171

Dr. Allen Toles

1554 Northern Blvd., Manhasset, 516-390-9242

Dr. Kusum Vasudeva

2 Pro Health Plaza, Lake Success, 516-608-6800

Dr. Manuel Veloso

303 E. Park Ave., Long Beach, 516-431-2828

NEONATAL-PERINATAL MEDICINE

Dr. Harriet Boxer

Nassau Univ. Med. Ctr., Div. Neonatology, 2201 Hempstead Tpke., East Meadow, 516-572-3319

Dr. Dennis Davidson

Steven and Alexandra Cohen Children's Medical Center, Neonatal Div., 269-01 76th Ave., New Hyde Park, 718-470-3440

Dr. Aruna Parekh

Stony Brook Univ. Med. Ctr., Dept. of Pediatrics, Stony Brook, 631-444-5437

Dr. Richard Schanler

North Shore Univ. Hosp., Neonatal-Perinatal Medicine, 300 Community Dr., Manhasset, 516-562-4665

Dr. Andrew Steele

Steven and Alexandra Cohen Children's Medical Center, 269-01 76th Ave., New Hyde Park, 718-470-3440

How they were picked

Castle Connolly Medical Ltd. is a health care research and information company founded in 1991 by a former medical college board chairman and president to help guide consumers to America's top doctors and hospitals. Castle Connolly's established survey and research process, under the direction of a doctor, involves tens of thousands of doctors and the medical leadership of leading hospitals.

Castle Connolly's team of researchers follows a rigorous screening process to select doctors on national and regional levels. Using mail and telephone surveys, and electronic ballots, they ask physicians and the leadership of top hospitals to identify exceptional doctors. Careful screening of doctors' educational and professional experience is essential to the committee. Newsday is not part of the selection process.

Doctors do not and cannot pay to be selected and profiled as Castle Connolly Top Doctors.

To see the whole list . . .

Who else is on the list of Top Doctors? More than 6,000 listings are in the New York Metro Area edition of "Top Doctors," published by Castle Connolly Medical Ltd. The soft-cover list price is $34.95. For more information, go to castleconnolly.com, or call 800-399-DOCS.