Clinical Context

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).

Study Synopsis and Perspective

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

• Permit 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).
• Permit more time for labor to progress in the active phase.
• Permit 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 decrease cesarean birth rates.
• Perform external cephalic version for breech presentation.
• Permit 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 "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.

Guideline Highlights

• Cesarean delivery is not indicated for prolonged latent phase (> 20 hours in nulliparous women and > 14 hours in multiparous women) in the first stage of labor.
• Cesarean delivery is not indicated for slow but progressive labor in the first stage of labor.
• The threshold for the active phase of most women in labor should be considered to be a cervical dilation of 6 cm.
• Standards of active-phase progress should not be applied before 6 cm of dilation is achieved.
• Only women at or beyond 6 cm of dilation 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, should undergo cesarean delivery for active-phase arrest in the first stage of labor.
• Experts have not yet identified a specific absolute maximal length of time spent in the second stage of labor beyond which all women should undergo cesarean delivery.
• Labor arrest in the second stage of labor should not be diagnosed without pushing for at least 2 hours in multiparous women, or for at least 3 hours in nulliparous women, if maternal and fetal conditions permit.
• As long as progress continues, longer durations of labor may be appropriate on an individualized basis (eg, with the use of epidural analgesia or with fetal malposition).
• In the second stage of labor, a safe, acceptable alternative to cesarean delivery is operative vaginal delivery by experienced and well-trained clinicians who maintain their practical skills in this procedure.
• Before moving to operative vaginal delivery or cesarean delivery in the setting of fetal malposition in the second stage of labor, manual rotation of the fetal occiput may be a reasonable alternative.
• The fetal position in the second stage of labor should be evaluated, particularly in the setting of abnormal fetal descent, to safely prevent cesarean deliveries when malposition is present.
• For repetitive variable fetal heart rate decelerations, amnioinfusion may safely decrease the rate of cesarean delivery.
• When abnormal or indeterminate fetal heart patterns are present, scalp stimulation can be used to evaluate fetal acid–base status.
• Labor should be induced before 41-0/7 weeks of gestation only if needed based on maternal and fetal medical indications.
• At 41-0/7 weeks of gestation and beyond, labor should be induced to reduce the risks for cesarean delivery and perinatal morbidity and mortality.
• Cervical ripening methods are recommended when labor is induced in women with an unfavorable cervix.
• If the maternal and fetal status permit, cesarean deliveries for failed induction of labor in the latent phase can be reduced by permitting longer durations of the latent phase (≥ 24 hours) and requiring that oxytocin be administered for at least 12 to 18 hours after membrane rupture before the induction is considered to be a failure.

Clinical Implications

• 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 joint guidelines from ACOG and SMFM.
• Specific recommendations for fetal heart rate monitoring and labor induction may also help avoid unnecessary cesarean deliveries, according to joint guidelines from ACOG and SMFM.

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