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Groups urge steps to cut back on primary cesareans

Friday February 21, 2014
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Allowing most women with low-risk pregnancies to spend more time in the first stage of labor may avoid unnecessary cesareans, according to The American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine.

Issued jointly in an Obstetric Care Consensus guideline, the new recommendations are targeted at preventing women from having cesareans with their first birth and at decreasing the national cesarean rate.

“Evidence now shows that labor actually progresses slower than we thought in the past, so many women might just need a little more time to labor and deliver vaginally instead of moving to a cesarean delivery,” Aaron B. Caughey, MD, a member of the College’s Committee on Obstetric Practice who helped develop the new recommendations, said in a news release.

“Most women who have had a cesarean with their first baby end up having repeat cesarean deliveries for subsequent babies, and this is what we’re trying to avoid. By preventing the first cesarean delivery, we should be able to reduce the nation’s overall cesarean delivery rate.”

In 2011, one in three women in the U.S. gave birth by cesarean delivery, a 60% increase since 1996. Approximately 60% of all cesarean deliveries occur among women with their first birth (primary cesareans). Although cesarean birth can be life-saving for babies and mothers, the rapid increase in cesarean birth rates raises significant concern that cesarean delivery is overused without clear evidence of improved maternal or newborn outcomes.

The guideline, “Safe Prevention of the Primary Cesarean Delivery discusses ways to decrease cesarean deliveries, including:

• Allowing prolonged latent-phase labor.

• Considering cervical dilation of 6 cm, instead of 4 cm, as the start of active-phase labor.

• Allowing more time for labor to progress in the active phase.

• Allowing women to push for at least two hours if they have delivered before, three hours if the delivery is their first, and even longer in some situations — for example, with an epidural.

• Using techniques to assist with vaginal delivery, the preferred method when possible. Such techniques may include the use of forceps, for example.

• Encouraging patients to avoid excessive weight gain during pregnancy.

“Physicians do need to balance risks and benefits, and for some clinical conditions, cesarean is definitely the best mode of delivery,” Vincenzo Berghella, MD, president of SMFM, who helped develop the new recommendations, said in the news release. “But for most pregnancies that are low-risk, cesarean delivery may pose greater risk than vaginal delivery, especially risks related to future pregnancies.”

The College and SMFM encourage clinicians, organizations and governing bodies to conduct research that provides a better knowledge base to guide decisions about cesarean delivery and to encourage policy changes that safely lower the rate of primary cesarean delivery.

“Safe Prevention of the Primary Cesarean Delivery” is the first in a new Obstetric Care Consensus series from the College and SMFM. The objective of the series is to provide high-quality, consistent and concise clinical recommendations for practicing obstetricians and maternal-fetal medicine subspecialists.

The guideline is published in the March issue of Obstetrics & Gynecology: http://bit.ly/1nQpf0G


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