CAPPA Summary of “Safe Prevention of the Primary Cesarean Delivery” developed by the American Congress of Obstetricians and Gynecologist (ACOG) and the Society for Maternal Fetal Medicine (SMFM)
An integral part of the CAPPA mission is to support the right of families to make informed decisions about pregnancy, childbirth, the postpartum period, and breastfeeding, and give families the tools needed to move forward confidently into parenthood. We wish to share with our members and families around the world a summary of this recent statement by ACOG and SMFM.
Why is there such a high cesarean rate in the United States?
The most common reason for cesarean birth is a repeat cesarean. In this groundbreaking document, ACOG promotes the reduction of primary cesarean as the foundational key for reducing cesarean birth overall. Cesarean birth can reduce mortality and morbidity when it is needed, but carries increased risks to the mother and baby. With one in three first time mothers delivering by cesarean, its overuse has significant ramifications, particularly in future pregnancies.
Leading causes of primary cesarean:
- Labor dystocia (labor that does not progress within accepted norms)
- Abnormal or indeterminate fetal heart rate (non-reassuring heart rate)
- Fetal malpresentation (breech presentation or other malpositions)
- Multiple gestation (twins)
- Suspected macrosomia (suspected large baby)
New definitions of normal labor progress – Birth in hospital systems has been coordinated based on the Freidman curve since it was implemented in the 1950’s. Research proves that labor, in fact, does not follow the Freidman curve in the vast majority of cases. New standards are now available from the Consortium on Safe Labor.
- Today’s labor patterns show a marked difference from labors nearly fifty years ago. The labor pattern is often longer which may in part be due to higher body mass index (BMI), higher rates of labor induction, and the significant increase in the use of epidural anesthesia.
- Prolonged latent phase (early labor) is no longer an indication for cesarean. This is defined as longer than 20 hours in first time mothers (primiparas) or longer than 14 hours in mothers who have had previous children (multiparas)
- A high percentage of cesareans are currently performed during the latent (early) phase of labor. It is now understood that the latent phase of labor can extend up to 6 cm dilation before active labor begins. Active labor is now understood as starting at 6 cm dilation, and standards defining active labor as starting at 4 cm should no longer be applied.
- Active labor arrest (stalled labor or failure to progress), which is one criteria for performing a cesarean, has been redefined. Conditions now include no cervical change with at least 6cm dilation, ruptured membranes, and 4 hours of adequate labor or at least 6 hours of Pitocin augmentation. Cervical dilation of less than 6 cm is still considered latent phase, giving the mother more time to progress. This also seems to suggest that intact membranes can afford the woman more time.
New Guidelines for Second Stage
- The length of second stage (pushing) is not associated with adverse outcomes for newborns, even up to five hours. No specific maximum length of second stage is identified.
- Pushing is defined as starting at full dilation, but pushing times of at least 3 hours in primiparas and 2 hours in multiparas should be permitted. Longer pushing times may be appropriate, especially in cases of epidural use or fetal malposition. It is documented that pushing stages with an epidural are normally an hour longer than in unmedicated births.
- Instrumental delivery (use of forceps or vacuum extraction) should be available to reduce the need for cesareans. Consequently, physicians will need to be skilled in use of forceps.
New standards for induction
- Induction should not be done prior to 41 weeks without medical necessity.
- Cervical ripening with induction can decrease the risk of “failed induction” and cesarean.
- Combining cervical ripening agents (such as a Foley bulb and prostaglandin gel) can facilitate cervical ripening and reduce the risk of failed induction.
- Latent phase in an induction can be up to 24 hours or longer. Pitocin should be administered for at least 12-18 hours after rupture of membranes before the induction can be considered as having failed.
Abnormal or indeterminate fetal heart rate
- Recurrent variable decelerations of the baby’s heart rate seem to be a physiologically normal response to cord compression in labor rather than a sign of distress. Prolonged decelerations can, however, eventually lead to distress.
- Position changes, amnioinfusion, and other interventions are encouraged to deal with decelerations and can reduce the cesareans.
- Chorioamnionitis should not be a sole reason for cesarean, regardless of the duration of symptoms.
- External cephalic version should be offered whenever possible. Using epidural anesthesia during the version may improve success rates. Most mothers experiencing successful version will give birth vaginally.
- Women considering vaginal breech birth should be informed of increased risks. Vaginal breech birth is addressed as a possible option women may choose.
Vertex (Cephalic) Malpresentations
- Longer pushing time allowances may be appropriate for malpositioned babies.
- Forceps rotation is a reasonable intervention to facilitate vaginal birth for malpositioned babies.
- Instrumental delivery can also be appropriate. Recent studies show that forceps used by a skilled attendant can be safer for baby than vacuum or cesarean.
- The use of ultrasound to determine position prior to interventions for malposition is encouraged.
- Training and practice with simulators to maintain skills is highly recommended for all physicians.
- Twin outcomes are not improved with cesarean if the first twin is vertex (head down), regardless of the position of the second twin.
- Physicians are encouraged to maintain vaginal twin birth skills in order to offer this option and reduce the cesarean rate
Suspected Macrosomia (suspected large baby)
- Macrosomia (large baby) as determined by ultrasound is not a reason for delivery, and rarely an indication for cesarean delivery.
- Late pregnancy ultrasound increases the cesarean rate with no evidence of benefit to the baby.
- To avoid potential birth trauma, recommendation of cesarean delivery is limited to estimated fetal weights at least 5000g (11 lb) for women without diabetes or 4500g (9 lb 14.7 oz) for women with diabetes. These minimum weight estimations for cesarean delivery take into account concerns regarding shoulder dystocia.
- Estimates of fetal weight in late pregnancy are imprecise and instances of babies reaching 5000g are rare.
- Physicians should counsel women on nutrition, exercise, and appropriate weight gain throughout pregnancy.
- Mothers with a history of herpes simplex virus should be given suppressive therapy in the final weeks of pregnancy. Cesarean is not recommended for women with no outbreaks during labor.
- Internal hospital use of audit, feedback, second opinion, and culture changes have been shown to reduce cesarean rates by 13-27%.
- Tort reform to reduce medico-legal pressures to perform excessive cesareans will be necessary for implementation of these new practice standards.
Doulas endorsed by ACOG and SMFM
“Published data indicate that one of the most effective tools to improve labor and delivery outcomes is the continuous presence of support personnel, such as a doula. A Cochrane metaanalysis of 12 trials and more than 15,000 women demonstrated that the presence of continuous one-on-one support during labor and delivery was associated with improved patient satisfaction and a statistically significant reduction in the rate of cesarean delivery (111). Given that there are no associated measurable harms, this resource is probably underutilized.”
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