Safe Prevention of the Primary Cesarean Delivery - New Statement by ACOG & SMFM

​Cesarean delivery is over-used. The lowest cesarean rate in the United States is 23%, the highest is 40%! In Oregon the cesarean rate is 29.4% (from ACOG article). The new statement by ACOG and SMFM will hopefully change those numbers.

The American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine issued a joint Obstetrics Care Consensus statement: Safe Prevention of the Primary Cesarean Delivery. This is a big game changer for the medical field of labor and delivery. It discusses the rate of cesarean in the United States, the causes and the outcomes of the over use of cesarean and suggests steps to take to change the cesarean environment. The study states “the alarming and sustained increase in the cesarean rate in the United States has not improved either maternal or neonatal outcomes. In fact, data suggest that there is increased maternal mortality and morbidity associated with cesarean delivery.”

The authors provide a new set of guidelines that offer ways to lower the cesarean rate and make labor and birth more safe for the mother and baby. The guidelines also offer a more hands off approach to the management of labor which would allow moms to labor longer, doctors would be forced to be more patient towards the natural (and sometimes slow) progression of normal labor. They suggest a respect for and understanding of women’s ability to give birth.  This impacts hospitals as well, as they will have to plan for longer stays for women in labor and delivery. A safe and healthy mother and child are the end result; cesareans are not the only (and shouldn’t be the first choice) for that result.

The hope and the goal is for women to have confidence in their ability to give birth and for all those involved (doctors, nurses, staff, friends, family, etc) to also respect a women’s body and ability to progress through labor on her own, in her own time and through her own means.

Some of the new guidelines are:

• Continuous labor support, including support provided by doulas, is one of the most effective ways to decrease the cesarean rate. The authors note that this resource is probably underutilized. (YAY DOULAS!!!!)
• Induction of labor can increase the risk of cesarean. Before 41 0/7 weeks induction should not be done unless there are maternal or fetal indications. Cervical ripening with induction can decrease the risk of cesarean. An induction should only be considered “a failure” after 24 hours of oxytocin administration and ruptured membranes. 
• Recurrent variable decelerations appear to be physiologic response to repetitive compressions of the umbilical cord and are not pathologic. There is an in depth discussion of fetal heart rate patterns and interventions other than cesarean to deal with this clinically. Amnioinfusion for variable fetal heart rate decelerations may safely reduce the rate of cesarean delivery.
• Ultrasound done late in pregnancy is associated with an increase in cesareans with no evidence of neonatal benefit. Macrosomia is not an indication for cesarean. 
• Perinatal outcomes for twin gestations in which the first twin is in cephalic presentation are not improved by cesarean delivery (even if the second twin is a noncephalic presentation).
• Before a vaginal breech birth is considered, women need to be informed that there is an increased risk of perinatal or neonatal mortality and morbidity and provide informed consent for the procedure. 
• The Consortium on Safe Labor data rather than the Friedman standards should inform labor management. Slow but progressive labor in the first stage of labor should not be an indication for cesarean. With a few exceptions, prolonged latent phase (greater than 20 hours in a first time mother and greater than 14 hours in multiparous women) should not be an indication for cesarean. As long as mother and baby are doing well, cervical dilation of 6 cm should be the threshold for the active phase of labor. Active phase arrest is defined as women at or beyond 6 cm dilatation with ruptured membranes who fail to progress despite 4 hours of adequate uterine activity, or at least 6 hours of oxytocin administration with inadequate uterine activity and no cervical change.

​The American Academy of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine are to be applauded for their careful research and willingness to make recommendations for labor management based on best evidence. They have provide direction for health care providers and women. This is a most welcome change.

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Read the full ACOG article here
Read the full overview of the ACOG article from Science & Sensibility here