In recent years approximately one in three women in the United States give birth by Cesarean delivery, a 60 percent increase since 1996. Cesarean birth can be a life-saver for both babies and moms, but the rapid increase in Cesarean birth rates, especially among first-time moms, has raised significant concern that Cesarean delivery is being overused without clear evidence that it's really needed in most low-risk situations.
What can be done to avoid unnecessary C-sections? The American College of Obstetricians and Gynecologists (ACOG), with help from the Society for Maternal-Fetal Medicine (SMFM), has just issued Safe Prevention of the Primary Cesarean Delivery, a new set of recommendations designed to decrease the nation's overall Cesarean rate.
Among the recommendations offered to doctors and others in the obstetrics community:
Allow moms more time in labor. Many women who spend a lengthy number of hours in the first stage of labor ultimately end up having C-sections. New guidelines urge OBs to have a little more patience when labor develops at a slower pace. As long as both the mom and baby are doing well, early (latent phase) labors that are "greater than 20 hours in a first-time mother and greater than 14 hours in multiparous women [moms who have given birth before] should not be an indication for cesarean." Once a mom reaches active labor, defined as cervical dilation of 6 cm, the threshold for "stalled labor" is now generally recommended as 4 hours of contractions with no progress, or at least 6 hours of oxytocin administration with no change.
"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," says Aaron B. Caughey, MD, a member of ACOG's Committee on Obstetric Practice who helped develop the new recommendations. "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."
Most moms are okay to push for hours. Likewise, in reviewing research on how much time moms spend in the second stage of labor (aka, the "pushing stage"), ACOG's panel didn't find very much evidence linking excessive time pushing to babies' risk for birth problems. The panel's new guideline is to allow for at least 3 hours of pushing for low-risk first-time moms, unless a complication arises. In moms who get an epidural, an extra hour of pushing should be expected.
Forceps should be back on the forefront. ACOG researchers found that "instrument delivery," or using forceps to assist birth, can reduce the need for Cesarean delivery. Why don't more OBs use instrument delivery now? ACOG authors noted concern that many obstetric residents do not feel competent using these techniques. In other words, med schools need to step it up when it comes to instrument training. How skilled is your OB with forceps and other instrument techniques? This is a great question to ask at your next appointment.
Induction of labor should be more selective. Because having labor induced increases risk for Cesarean birth, OBs should be more selective about recommending moms for inductions. According to new guidelines, induced labor should generally be saved for moms who are past their due dates (41 weeks), or unless there are "maternal or fetal indications" that an induction is needed. The guidelines also say that induction should only be considered "a failure" after 24 hours of oxytocin administration and ruptured membranes.
No more late pregnancy ultrasounds? According to ACOG researchers, ultrasounds done late in pregnancy is associated with an increase in cesareans, with no real evidence of benefit to babies' health. Late pregnancy ultrasound is usually to check on babies' birth size, but researchers point out that macrosomia (high birth weight) doesn't always mean a Cesarean is needed.
Doulas decrease Cesarean rates. Let's hear it for doulas! ACOG has finally recognized that continuous labor support, including support provided by doulas, is one of the most effective ways to decrease Cesarean rates. Researchers even note that this resource is currently underutilized. Does this mean OBs will start recommending doulas, and hospital staff will be more encouraging of having doulas present? Stay tuned.
And as for what all this means for you, it seems that if your pregnancy has progressing along just fine, this latest report can bolster your confidence (and your doctor's confidence) that your body-and your baby-will know exactly what to do when the big moment arrives.
-By Jacqueline Tourville