Conference Coverage
WASHINGTON – Longer labors lead to fewer cesarean sections.
That’s according to the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine who have jointly issued the Obstetric Care Consensus guideline, urging physicians to allow women with low-risk pregnancies to remain in latent labor longer before elevating their delivery to surgical status. The report and the consensus guideline appear in the March issue of Obstetrics & Gynecology (Obstet. Gynecol. 2014;123:693-711).
"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," Dr. Aaron B. Caughey, a member of ACOG’s Committee on Obstetric Practice, said in a statement.
The document calls on physicians to consider that active labor has begun at 6 cm of cervical dilation, rather than 4, and stresses that doctors should allow more time for progression of labor during the active phase. Whether a woman chooses to use an epidural should also be factored into laboring times because the analgesia can slow contractions.
Although no absolute specific time for allowing a woman to remain in the active labor phase has been determined, the document states that women who have never delivered should be given at least 3 hours to push, while women who have delivered previously should be given a minimum of 2 hours.
‘Fear and convenience’
The recommendations are specifically concerned with avoiding the primary cesarean section because more than one-third of all births in the United States are cesarean deliveries, two-thirds of which are among nulliparous women. Avoiding the first cesarean section is important, "because if the woman labors with a scar from a previous C-section, there is a risk that the uterus will rupture," SMFM president Dr. Vincenzo Berghella, director of maternal-fetal medicine at Thomas Jefferson Medical Center in Philadelphia, said in an interview. "It only happens one-half to one percent [of the time], but it can be catastrophic. The baby could even die. A lot of women, understandably, are afraid of [that]."
In addition, sometimes the procedure is medically indicated, as in the case of placenta previa or uterine rupture. However, according to the document, in most pregnancies, which are typically low risk, cesarean delivery carries with it greater overall severe morbidity and mortality risks for the mother compared with vaginal delivery: 9.2% vs. 8.6% and 2.7% vs. 0.9%, respectively.
A combination of fear of being sued for malpractice, convenience, and lack of manpower, are partially responsible for the astronomical rise in C-sections, now the most common surgical procedure performed in the United States, according to the Centers for Disease Control and Prevention.
Dr. Berghella said a scenario that plays out in a physician’s mind could run along the lines of, "You know what, maybe 99% of things are fine here, but I am just worried a little bit here. So I am just going to do a C-section just to cover my behind."
In the past, solo practitioners also were pressed in ways that today’s doctors who belong to an entire practice are not, said Dr. Berghella.
"There are many, many factors that can lead to a longer labor," Dr. Berghella said, adding it was his "hope" that the document will help doctors make decisions based on the patient and how she presents as an individual. "This is to empower doctors, and reassure everyone on the team, including that patient, that if everything is going well, there is no rush."
Redefining active labor and ‘failed’ induction
The use of alternative methods to assist with stalled labors, such as vaginally delivering the baby with forceps or vacuum, is no longer as common as it once was. So residents were taught these techniques less and less. But now Dr. Berghella and his colleagues at the college and the society are urging residency training programs to offer more training in these techniques, including with vacuum birth simulations. "It’s better to do it the first time on a simulator than to try it out on the patient and put the woman at risk. But [residents] need to learn how to do these things," he said.
Physicians also are urged in the statement to reconsider whether there is a failed induction, noting that if the maternal and fetal status allow, cesarean deliveries should be postponed up to 24 hours or longer, and that "oxytocin [should] be administered for at least 12-18 hours after membrane rupture before deeming induction a failure"
A commonly held misperception is that induction and C-section rates are positively correlated, according to the document. "That is a big, big change. The better data seem to say that if you get to 39 weeks, if you do an induction, it actually decreases the chance for a cesarean," said Dr. Berghella. "It was painted as a terrible thing, but if you do it at the right time, it is beneficial."
Into practice
Prenatal counseling should stress weight maintenance, because more than a third of women of reproductive age in the United States are obese, a factor that Dr. Berghella said contributes to the rise in C-sections. Infection risk is higher in this population, and the abundance of adipose tissues makes it harder for the baby to be delivered vaginally. "The higher your weight, the higher your chance of C-section," said Dr. Berghella.
In addition to tort reform, which the document states is "necessary" to prompt physicians to overcome their fears of being sued in case of an adverse event during vaginal delivery, Dr. Berghella said that the culture change rests on communication between office-based obstetricians, midwives, nurse practitioners, and their patients. "Doing a better job of educating women [prenatally] about labor in general, including that it can take a while, will prepare them and help avoid frustration and impatience because they will know what is going on," he said, noting that even a woman who has given birth before can have a completely different experience the next time.
Dr. Berghella said he had no relevant financial disclosures.