On February 19, the American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine (SMFM) issued joint guidelines to reduce the rate of cesarean sections. The guidelines recommend allowing most women with low-risk pregnancies labor longer in the first sage (the time taken for the cervix to completely dilate); the authors claim that this could reduce the number of unnecessary cesarean sections. The new guidelines are focused on preventing women from having a cesarean section with their first delivery; thus, 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,” explained Aaron B. Caughey, MD, a member of The College’s Committee on Obstetric Practice who participated in the development of the new guidelines. He added, “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.”
The guideline authors note that in 2011, one in three US women delivered by a cesarean section, marking a 60% increase since 1996. Currently, about 60% of all cesarean deliveries occur among women with their first birth (primary cesareans). They explain that a cesarean birth can be life-saving for the infant and/or the mother; however, the rapid increase in cesarean birth rates raises significant concern that cesarean delivery is overused without any clear proof of improved maternal or newborn outcomes.
- The guidelines, entitled “Safe Prevention of the Primary Cesarean Delivery” present strategies 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 is their first delivery, and even longer in some situations (e.g., with an epidural).
- Using techniques to assist with vaginal delivery, which is the preferred method when possible. For example, this may include the use of forceps.
- 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,” explained SMFM President Vincenzo Berghella, MD, who participated in the development of the new guidelines. He added, “But for most pregnancies that are low-risk, cesarean delivery may pose greater risk than vaginal delivery, especially risks related to future pregnancies.”
Both ACOG and SMFM encourage physicians, organizations, and governing bodies to conduct research focused on providing a better knowledge base to guide decisions regarding cesarean delivery and encouraging policy changes that safely lower the rate of primary cesarean delivery. The new guidelines are the first in a new Obstetric Care Consensus series from ACOG and SMFM. The series are focused on providing high-quality, consistent, and concise clinical recommendations for practicing obstetricians and maternal-fetal medicine subspecialists.