Nation’s Ob-Gyns Take Aim at Preventing Cesareans

New Guideline Recommends Allowing Women to Labor Longer to Help Avoid Cesarean

Washington, DC—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 (The College) and the Society for Maternal-Fetal Medicine (SMFM). In a jointly-issued 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,” said Aaron B. Caughey, MD, a member of The College’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.”

In 2011, one in three women in the US gave birth by cesarean delivery, a 60% increase since 1996. Today, approximately 60% of all cesarean births are primary cesareans. Although cesarean birth can be life-saving for the baby and/or the mother, the rapid increase in cesarean birth rates raises significant concern that cesarean delivery is overused without clear evidence of improved maternal or newborn outcomes.

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

• Allowing prolonged latent (early) 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 it’s their first delivery, and even longer in some situations, for example, with an epidural.
• Using techniques to assist with vaginal delivery, which is the preferred method when possible. This 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,” said Vincenzo Berghella, MD, SMFM President, who helped develop the new recommendations. “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 physicians, 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 series will provide high-quality, consistent, and concise clinical recommendations for practicing obstetricians and maternal-fetal medicine subspecialists.

Obstetric Care Consensus #1 “Safe Prevention of the Primary Cesarean Delivery” is published in the March issue of Obstetrics & Gynecology.

Additional Resources:

• Primary Cesarean Delivery Rates, by State: Results From the Revised Birth Certificate, 2006–2012.
• Committee Opinion #559 “Cesarean Delivery on Maternal Request” (April 2013)
• Committee Opinion #579 “Definition of Term Pregnancy” (November 2013)
• Practice Bulletin #115 “Vaginal Birth After Previous Cesarean Delivery” (Reaffirmed 2013)
• Patient FAQ: Cesarean Birth (C-section)

Other recommendations issued in the March Obstetrics & Gynecology:

Committee Opinion #588 "Human Papillomavirus Vaccination" (Revised)

ABSTRACT: The Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention recommends that human papillomavirus (HPV) vaccination routinely be targeted to females and males aged 11 years or 12 years as part of the adolescent immunization platform to help reduce the incidence of anogenital cancers and genital warts associated with HPV infection. The quadrivalent HPV vaccine is approved for use in males and females, whereas the bivalent HPV vaccine is approved for use only in females. For those not vaccinated at the target age, catch-up vaccination is recommended up to age 26 years. The American College of Obstetricians and Gynecologists endorses these recommendations. Although obstetrician–gynecologists are not likely to care for many patients in the initial HPV vaccination target group, they have the opportunity to educate mothers about the importance of vaccinating their children at the recommended age and are critical to vaccinating adolescent girls and young women during the catch-up period. Obstetrician–gynecologists should advise patients and parents that HPV vaccines are most effective in preventing genital cancers when administered before the onset of sexual activity. However, sexually active individuals can receive some benefit from the vaccination because exposure to all HPV types prevented by the vaccines is unlikely in persons aged 13 years through 26 years. Although HPV vaccination in pregnancy is not recommended, neither is routine pregnancy testing before vaccination. Lactating women can receive either HPV vaccine. The need for ongoing cervical cytology screening should be emphasized in all women aged 21 years and older, even those who received HPV vaccination before the onset of sexual activity.

Committee Opinion #589 "Female Age-Related Fertility Decline" (Revised)

ABSTRACT: The fecundity of women decreases gradually but significantly beginning approximately at age 32 years and decreases more rapidly after age 37 years. Education and enhanced awareness of the effect of age on fertility are essential in counseling the patient who desires pregnancy. Given the anticipated age-related decline in fertility, the increased incidence of disorders that impair fertility, and the higher risk of pregnancy loss, women older than 35 years should receive an expedited evaluation and undergo treatment after 6 months of failed attempts to conceive or earlier, if clinically indicated. In women older than 40 years, more immediate evaluation and treatment are warranted.

Committee Opinion #590 "Preparing for Clinical Emergencies in Obstetrics and Gynecology" (Revised)

ABSTRACT: Patient care emergencies may occur at any time in any setting, particularly the inpatient setting. It is important that obstetrician–gynecologists prepare themselves by assessing potential emergencies, establishing early warning systems, designating specialized first responders, conducting emergency drills, and debriefing staff after actual events to identify strengths and opportunities for improvement. Having such systems in place may reduce or prevent the severity of medical emergencies.

Committee Opinion #591 "Challenges for Overweight and Obese Women" (Revised)

ABSTRACT: Overweight and obesity are epidemic in the United States. Obesity is a risk factor for numerous conditions, including diabetes, hypertension, high cholesterol, stroke, heart disease, certain types of cancer, and arthritis. The prevalence of obesity is high, exceeding 30% in adult women and men. Many women, irrespective of demographic characteristics or income, are vulnerable to becoming overweight or obese because of limited resources for physical activity and healthy food choices, work commitments, and family demands. Clinicians and public health officials should address not only individual behavior but also the built environment in their efforts to reduce overweight and obesity in their patient populations.

Practice Bulletin #143 "Medical Management of First-Trimester Abortion" (Revised)

ABSTRACT: Over the past three decades, medical methods of abortion have been developed throughout the world and are now a standard method of providing abortion care in the United States. Medical abortion, which involves the use of medications rather than a surgical procedure to induce an abortion, is an option for women who wish to terminate a first-trimester pregnancy. Although the method is most commonly used up to 63 days of gestation (calculated from the first day of the last menstrual period), the treatment also is effective after 63 days of gestation. The Centers for Disease Control and Prevention estimates that 64% of abortions are performed before 63 days of gestation (1). Medical abortions currently comprise 16.5% of all abortions in the United States and 25.2% of all abortions at or before 9 weeks of gestation (1). Mifepristone, combined with misoprostol, is the most commonly used medical abortion regimen in the United States and Western Europe; however, in parts of the world, mifepristone remains unavailable. This document presents evidence of the effectiveness, benefits, and risks of first-trimester medical abortion and provides a framework for counseling women who are considering medical abortion.

The American College of Obstetricians and Gynecologists (The College), a 501(c)(3) organization, is the nation’s leading group of physicians providing health care for women. As a private, voluntary, nonprofit membership organization of approximately 57,000 members, The College strongly advocates for quality health care for women, maintains the highest standards of clinical practice and continuing education of its members, promotes patient education, and increases awareness among its members and the public of the changing issues facing women’s health care. The American Congress of Obstetricians and Gynecologists (ACOG), a 501(c)(6) organization, is its companion organization. www.acog.org

The Society for Maternal-Fetal Medicine (est. 1977) is the premiere membership organization for obstetricians/gynecologists who have additional formal education and training in maternal-fetal medicine. The society is devoted to reducing high-risk pregnancy complications by sharing expertise through continuing education to its 2,000 members on the latest pregnancy assessment and treatment methods. It also serves as an advocate for improving public policy, and expanding research funding and opportunities for maternal-fetal medicine. The group hosts an annual meeting in which groundbreaking new ideas and research in the area of maternal-fetal medicine are shared and discussed. Visit www.smfm.org.