Safe Prevention of the Primary Cesarean Delivery: ACOG and SMFM Change the Game

I hope that readers of Science & Sensibility (and anyone working in the field of maternal infant health) are sitting down. Be prepared to be blown away. ACOG and SMFM have just released a joint Obstetric Care Consensus statement that has the potential to turn maternity care in the USA on its end. I feel like this blog post title could be "ACOG and SMFM adopt Lamaze International's Six Healthy Birth Practices." (Okay, that may be a little overenthusiastic!) I could not be more pleased at the contents of this statement and cannot wait to see some of these new practice guidelines implemented. Judith Lothian, PhD, RN, LCCE, FACCE summarizes the statement and shares highlights of this stunning announcement. - Sharon Muza, Science & Sensibility Community Manager

Today, the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine issued a joint Obstetric Care Consensus statement: Safe Prevention of the Primary Cesarean Delivery. It is being published concurrently in Obstetrics and Gynecology, (the Green Journal). The ACOG press release is here, with much more detail of the study, not behind a firewall. There is no doubt about it-this just released statement is a game changer.

The alarming and sustained increase in the cesarean rate in the United States has not improved either maternal or neonatal outcomes. In fact, data suggest that there is increased maternal mortality and morbidity associated with cesarean delivery. This statement describes the myriad of complications associated with cesarean and the increased risks associated with cesarean for mother and baby. The authors suggest that potentially modifiable factors, such as patient preferences and practice variation among hospitals, systems, and health care providers are likely to contribute to the escalating cesarean rates. There is a need to prevent overuse of cesarean, particularly the primary cesarean.

The most common reasons for cesarean include labor dystocia, abnormal or indeterminate fetal heart rate tracing, fetal malpresentation, multiple gestation, and suspected fetal macrosomia. The authors revisited the definition of labor dystocia in light of the fact that labor progresses at a rate that is slower than what we had thought previously. They also reviewed research related to interpretation of fetal heart rate patterns, and access to nonmedical interventions during labor that may reduce cesarean rates. External cephalic version for breech presentation and a trial of labor for women with twin gestations when the first twin is in a cephalic presentation can lower the cesarean rate. The authors analyzed the research using a rubric that rated the quality of the available evidence. The result is a set of guidelines that have the potential to substantially decrease the cesarean rate.

These guidelines change the rules of the labor management game.

These are some of the new recommended guidelines:

• The Consortium on Safe Labor data rather than the Friedman standards should inform labor management. Slow but progressive labor in the first stage of labor should not be an indication for cesarean. With a few exceptions, prolonged latent phase (greater than 20 hours in a first time mother and greater than 14 hours in multiparous women) should not be an indication for cesarean. As long as mother and baby are doing well, cervical dilation of 6 cm should be the threshold for the active phase of labor. Active phase arrest is defined as women at or beyond 6 cm dilatation with ruptured membranes who fail to progress despite 4 hours of adequate uterine activity, or at least 6 hours of oxytocin administration with inadequate uterine activity and no cervical change.

• Adverse neonatal outcomes have not been associated with the duration of the second stage of labor. The absolute risks of adverse fetal and neonatal outcomes of increasing second stage duration appear to be, at worst, low and incremental. Therefore, at least 2 hours of pushing in a multiparous woman and at least 3 hours of pushing in a first time mother should be allowed. An additional hour of pushing is expected with the use of an epidural, as there is progress. Interestingly, there is no discussion of position change during second stage, including the upright position, to facilitate rotation and descent of the baby. Also, the authors note that second stage starts at full dilatation rather than when the mother has spontaneous bearing down efforts. Research suggests it is beneficial to consider the start of second stage when spontaneous bearing down by the mother begins. (Enkin et al, 2000; Goer & Romano, 2013). Using this definition might also decrease the incidence of cesarean.

• Instrument delivery can reduce the need for cesarean. The authors note concern that many obstetric residents do not feel competent to do a forceps delivery.

• Recurrent variable decelerations appear to be physiologic response to repetitive compressions of the umbilical cord and are not pathologic. There is an in depth discussion of fetal heart rate patterns and interventions other than cesarean to deal with this clinically. Amnioinfusion for variable fetal heart rate decelerations may safely reduce the rate of cesarean delivery.

• Neither chorioamnionitis nor its duration should be an indication for cesarean.

• Induction of labor can increase the risk of cesarean. Before 41 0/7 weeks induction should not be done unless there are maternal or fetal indications. Cervical ripening with induction can decrease the risk of cesarean. An induction should only be considered "a failure" after 24 hours of oxytocin administration and ruptured membranes.

• Ultrasound done late in pregnancy is associated with an increase in cesareans with no evidence of neonatal benefit. Macrosomia is not an indication for cesarean.

• Continuous labor support, including support provided by doulas, is one of the most effective ways to decrease the cesarean rate. The authors note that this resource is probably underutilized.

• Before a vaginal breech birth is considered, women need to be informed that there is an increased risk of perinatal or neonatal mortality and morbidity and provide informed consent for the procedure.

• Perinatal outcomes for twin gestations in which the first twin is in cephalic presentation are not improved by cesarean delivery (even if the second twin is a noncephalic presentation).

These guidelines offer great promise in lowering the cesarean rate and making labor and birth safer for mothers and babies. They also suggest an emerging respect for and understanding of women's ability to give birth and a more hands off approach to the management of labor. Women will be allowed to have longer labors. Obstetricians will need to be patient as nature guides the process of birth. Hospitals will have to plan for longer stays in labor and delivery. And women will need to have more confidence in their ability to give birth. Childbirth educators can play a key role here. The prize will be safer birth and healthier mothers and babies.

The authors rightly note that changing local cultures and obstetricians' attitudes about labor management will be challenging. They also note that tort reform will be necessary if practice is to change. It's interesting to consider whether standards of practice based on best evidence (as these guidelines are) rather than on fear of malpractice might make tort reform more likely.

The American Academy of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine are to be applauded for their careful research and willingness to make recommendations for labor management based on best evidence. These guidelines provide direction for health care providers and women and will make a difference in not just the cesarean rate but women's experiences. The game has changed. It is a most welcome change.

What are your first impressions after learning of the elements of this new ACOG/SMFM statement? What impact do you think these changes will have on the care that women receive during labor and birth? Are you considering what barriers to change might exist in the hospitals you serve? How will you share this new information with the families that you work with? As a side note, I found it interesting that this Consensus statement did not suggest using midwives for normal, low risk women. Research has consistently shown that midwives working with low risk populations can reduce the cesarean rate. - SM

Further press information -

Lamaze International Statement - New Consensus Statement Important Step to Reduce Unnecessary Cesareans

Group Calls for Safe Reduction In Cesareans

ACOG Press Release

References

Enkin, M., Keirse, M., Neilson, J., Crowther, C., et al (2000). A Guide to Effective Care in Pregnancy and Childbirth. New York: Oxford Press.

Goer, H. & Romano, A. (2013). Optimal Care in Childbirth: The Case for a Physiologic Approach. Seattle: Classic Day Publishing (Chapter 13).

Safe prevention of the primary cesarean delivery. Obstetric Care Consensus No. 1. American College of Obstetricians and Gynecologists. Obstet. Gynecol. 2014; 123: 693-711.

About Judith Lothian

Judith Lothian, PhD, RN, LCCE, FACCE is a nurse and childbirth educator. She is an Associate Professor at the College of Nursing, Seton Hall University and the current Chairperson of the Lamaze Certification Council Governing Body. Judith is also the Associate Editor of the Journal of Perinatal Education and writes a regular column for the journal. Judith is the co-author of The Official Lamaze Guide: Giving Birth with Confidence. Her research focus is planned home birth and her most recent publication is Being Safe: Making the Decision to Have a Planned Home Birth in the US published in the Journal of Clinical Ethics (Fall 2013).

Published: February 18, 2014

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