ACOG Guidelines Focus on Reducing Primary Cesarean Deliveries — Physician’s First Watch

Medical News |
February 20, 2014

ACOG Guidelines Focus on Reducing Primary Cesarean Deliveries

By Kelly Young

To reduce the number of first-time cesarean deliveries, women should be encouraged to undergo longer labor, according to new guidelines from the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine.

Here are some of the key recommendations:

  • Prolonged latent phase labor (>20 hours in nulliparous women, >14 hours in multiparous women) is not an indication for cesarean delivery.

  • Cervical dilation of 6 cm should be considered the start of active labor. Previously, the threshold was 4 cm.

  • Multiparous women should be allowed to push for 2 hours and nulliparous women for 3 before arrest of labor is diagnosed. Longer durations are permissible, particularly with an epidural.

  • Vaginal delivery with vacuum or forceps in the second stage is an alternative to cesarean delivery, although clinicians need more training.

OB/GYN Allison Bryant, with NEJM Journal Watch, comments: "This evidence-based blueprint is much welcomed, emphasizing safe means to reduce first cesareans; the greatest yield will require rethinking longstanding paradigms of labor disorders and fetal heart rate abnormalities."

Reader Comments (5)

Arun Moray MD Physician, Obstetrics/Gynecology, India

Main reasons for increase in the CS rate is fear in obstetrician's mind about medicolegal implications , lack of training about instrumental delivery and daytime obstetrics. Guidelines should be formed in consultation with judiciary, women right activists and obstetrician's organization.

Esther Tumim Preventive Medicine

This study does not mention the pH of fetal blood after 3 hours of pushing as compared to 19 minutes? How about acid base deficit? Maybe the answer to preventing C-sections would be in preventing epidural anesthesia?

Zeferino Pina Other, Obstetrics/Gynecology, Nelio Mendonça Hospital - Madeira/Portugal

The guideline is ofcourse not the last one.
I think its very important one for all and its a guide for all the docter who work with pregnent women or in delivery room ar work!

MD, FRCOG, FRCPI, Accr SOG, DScMed Physician, Obstetrics/Gynecology, University Hospital

When the active management of labour was introduced with the use of the partogram [criteria were then evidence-based], the aim was to reduce foetal and maternal morbidity and mortality. At the time the Caesarean section rate was about 10% or less. This proposal started the alert line at 3 cm provided the patient was getting strong and regular contractions. Reaching the action line after four DID NOT MEAN performing a caesarean section but making a clinical decision, even if this was simply masterly inactivity. Are we now proposing to "ignor" women until they are 6 cm dilated!!! I hope not.

Prolongation of the second stage should not be managed by CS unless there are definite signs of CPD. People are simply afraid today, because of medicolegal issues, to actually do something other than a CS and use a method of operative vaginal delivery where this is indicated. I wonder what the women themselves have to say about being asked to push for two to three hours as proposed. I will remind you of Rebecca in the Old testament and Queen Charlotte in the 19th century. Those are the consequences of a prolonged second stage of labour.

Our role as obstetricians is to make pregnancy and labour as safe as possible for both mother and child. Letting nature take its course is sometimes not an option. Nature does kill!


We delivered up to 70% of patients by C-section. I am glad to see an attempt at a better approach

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