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The rate of cesarean delivery in the United States is on the rise, occurring in one third of women giving birth in 2011, which represents a 60% increase since 1996. Approximately 60% of all cesarean deliveries are primary cesarean, performed in women delivering their first infant. Although cesarean delivery may be a life-saving intervention for the infant and/or the mother, the rapid increase in cesarean delivery rates suggests possible overuse, which may result in adverse consequences.
Safe Prevention of the Primary Cesarean Delivery is the first guideline in the new Obstetric Care Consensus series from the Society for Maternal-Fetal Medicine (SMFM).
Most women with low-risk pregnancy should be permitted to spend more time in the first stage of labor to avoid unnecessary cesarean deliveries, according to new joint guidelines from the American College of Obstetricians and Gynecologists (ACOG) and 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," said lead author Aaron B. Caughey, MD, a member of the College's Committee on Obstetric Practice, 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. Currently at this time, more than half (approximately 60%) of all cesarean deliveries are primary cesarean, 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 based on improved and standardized fetal heart rate interpretation and management or other advances in obstetric 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 increase in rates of cesarean delivery 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 Cesarean Deliveries
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 "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.
The guidelines authors have disclosed no relevant financial relationships.
Obstet Gynecol. 2014;123:693-711.