Longer Labor Okay to Avoid Cesarean, New Guidelines Say

Laurie Barclay, MD

February 19, 2014

Most women with low-risk pregnancy should be allowed to spend more time in the first stage of labor to avoid unnecessary cesareans, according to new joint guidelines from the American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine (SMFM), published in the March issue of Obstetrics & Gynecology.

"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," lead author Aaron B. Caughey, MD, a member of the college's Committee on Obstetric Practice, said in an ACOG 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."

One third of US women giving birth in 2011 had cesarean delivery, which represents a 60% increase since 1996. At this time, more than half (approximately 60%) of all cesarean deliveries are primary cesareans performed in women delivering their first infant.

The most frequent indication for primary cesarean delivery is labor dystocia, followed by abnormal or indeterminate fetal heart rate tracing, fetal malpresentation, multiple gestation, and suspected fetal macrosomia. These indications could shift according to improved and standardized fetal heart rate interpretation and management or other advances in obstetrical and fetal care.

The guidelines authors acknowledge that cesarean birth may be a life-saving intervention for the infant and/or the mother. However, the rapid rise in rates of cesarean section suggests possible overuse of this delivery method, especially in the absence of clear evidence of improved maternal or newborn outcomes.

"Physicians do need to balance risks and benefits, and for some clinical conditions, cesarean is definitely the best mode of delivery," said SMFM President Vincenzo Berghella, MD, 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."

Specific Recommendations to Safely Reduce Primary Cesareans

  • Allow prolonged latent (early)-phase labor.

  • Consider the start of active-phase labor to be defined as cervical dilation of 6 cm (instead of 4 cm).

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

  • Allow multiparous women to push for 2 or more hours and primiparous women to push for 3 or more hours. In some situations, for example, when epidural anesthesia is used, pushing may be allowed to continue even longer.

  • Use techniques, such as use of forceps, to facilitate vaginal delivery, which is the preferred method when possible.

  • Encourage patients to avoid excessive weight gain during pregnancy.

  • Increase access to nonmedical interventions during labor, such as continuous labor and delivery support, which has been shown to lower cesarean birth rates.

  • Perform external cephalic version for breech presentation.

  • Allow a trial of labor for women with twin gestations when the first twin is in cephalic presentation.

ACOG and SMFM recommend research to expand the evidence base that could inform decisions regarding cesarean delivery and promote policy changes that could safely reduce the rate of primary cesarean delivery.

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

Obstet Gynecol. 2014.

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