New guidelines to decrease C-sections

The American College of Obstetricians and Gynecologists and the Society for Maternal Fetal Medicine recently developed new recommendations to help decrease the number of primary Cesarean sections (C-section).

We asked Community Physician Network OB/GYN, Dr. Indy Lane, to tell us what the new guidelines mean for soon-to-be mothers.

"A primary C-section is one performed in a woman’s first pregnancy," said Lane. "While there are many situations in which a C-section is necessary for the safety of the mother and/or baby, there are both short and long term consequences of an operative delivery versus a vaginal birth." 

The new recommendations for labor management challenge the traditional definitions of abnormal labor patterns in the hopes of reducing what is thought to be an overuse of Cesarean delivery. Currently, the most common indications for a C-section are abnormal labor progress (34%), fetal distress (23%), and abnormal fetal position (17%).

The new guidelines examined these indications and released ways physicians can provide patients with better odds of a successful vaginal delivery.

Lane explained, "Traditionally, a woman’s labor progress was considered abnormal if she labored longer than 14-20 hours during the early stage of labor. New data suggest that it is reasonable for a woman to labor beyond 20 hours in the early stage if there is at least some cervical change."

Historically, it was considered abnormal if the rate of cervical change did not accelerate after four centimeters of dilation. New data suggests that abnormal labor progress cannot be determined until a patient has reached at least six centimeters of dilation. A mother can continue to labor in the absence of maternal or fetal indications for delivery.

Allowing patients to push longer before proceeding to C-section and scheduling inductions one week beyond the established due date may also facilitate more vaginal births.

"Physicians and nurses closely watch the fetal heart rate tracing in order to monitor the health of the fetus during labor," said Lane.

Fetal distress is the second most common indication for Cesarean births. To decrease the incidence of Cesarean deliveries due to fetal distress, physicians are encouraged to use the standardized categories for fetal heart rate tracing interpretation, and to then proceed with C-section only in patients with severely abnormal tracings.

Resuscitative measures to improve fetal heart rate patterns during labor should be performed prior to proceeding with Cesarean delivery. Approximately 3.8 percent of babies are in the breech position at 36 weeks of pregnancy. Vaginal delivery of a breech baby carries significant risk to the mother and baby. Currently, a scheduled C-section is recommended for a woman with a baby in a persistent breech presentation.

Physicians are encouraged to offer the patient an opportunity to have an external cephalic version, or an attempt to manually rotate the baby to a head down position. A successful external cephalic version would allow the patient to attempt a vaginal delivery thus decreasing the need for operative delivery.

In summary, C-sections are a vital, safe, and life saving mode of delivery for many women. Based on a concern for the possible overuse of Cesarean delivery, the new guidelines encourage doctors to be more patient during the labor process allowing more women an opportunity to deliver vaginally. We must consider contemporary definitions for abnormal labor when managing patients, which may decrease the incidence of primary C-sections.

"The new guidelines reinforce how many obstetricians already practice here in the Community Health Network," said Lane. "A woman’s labor management is individualized to provide a safe birth experience for both the mother and baby. In the absence of unnecessary risk to the mother and/or fetus, every effort should be made to provide the patient with the best opportunity to deliver vaginally," she said.