Guidelines Discourage Elective C-Sections, Early Deliveries

Yael Waknine

March 22, 2013

Vaginal deliveries should be the norm and early cesarean deliveries should be avoided, according to American College of Obstetricians and Gynecologists (ACOG) guidelines published March 21 in Obstetrics & Gynecology.

The recommendations are intended to curb the skyrocketing rate of US cesarean deliveries by limiting "maternal-request" surgeries and early deliveries for presumed "big babies."

According to the report, US cesarean delivery rates are at the highest level ever, with more than 1.3 million surgical deliveries (32.9% of all births) performed in 2009. An estimated 2.5% of all births are maternal-request cesarean deliveries, and the rate of non–medically indicated early-term deliveries continues to increase despite ACOG's stance against fetal lung maturity as an indication for delivery.

"In the absence of maternal or fetal indications for cesarean delivery, a plan for vaginal delivery is safe and appropriate," ACOG states, noting that fear of childbirth pain is not a valid reason for surgery.

Although planned cesarean deliveries carry a lower chance of hemorrhage, they are also linked to risks for bladder and bowel injury, longer hospital stays, higher infection rates, and increased neonatal respiratory morbidity. Moreover, rates of postpartum pelvic pain, sexual dysfunction, pelvic organ prolapse, and depression — which some women hope to avoid via surgical delivery — remain unchanged.

ACOG emphasizes that surgical delivery be especially avoided in women planning to have several children because subsequent cesarean deliveries are tied to increasing risks for complications, such as placenta previa or accreta, uterine rupture, and emergency hysterectomy.

Even when cesarean deliveries are medically indicated, clinicians should make every effort to perform them after the 39-week gestation mark, unless conditions such as preeclampsia/eclampsia, fetal growth restriction, placental abruption, multiple gestation, or poorly controlled diabetes are present. According to ACOG, suspicion of macrosomia is not an indication for early induction or surgical delivery, nor is fetal lung maturity, because other organs may require further development.

In fact, those last few weeks can be critical: Babies born at 37 and 38 weeks are at 2.3- and 1.4-fold increased risk for neonatal death relative to 39 and 40 weeks. Infant mortality rates are likewise elevated by factors of 1.9 and 1.2, respectively, as surviving neonates find their young lives complicated by respiratory distress, respiratory failure, pneumonia, and other conditions requiring intensive care.

According to ACOG, reducing the number of non–medically indicated early-term births and improving newborn outcomes is possible — hard-stop policies (hospital prohibition), soft-stop policies (clinicians agree to refrain), and education programs have all been shown to decrease rates by more than 50%. The reduction is greatest with the hard-stop approach (8.2% to 1.7%; P = .007) and slightly less when soft-stop is used (8.4% to 3.3%; P = .025).

As always, ACOG notes that decisions regarding timing of delivery must be individualized, even when maternal, fetal, or placental complications warrant late-preterm or early-term delivery.