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Preventing the First Cesarean Delivery: How Best to Change Current Practice

Summary and Comment |
July 22, 2013

Preventing the First Cesarean Delivery: How Best to Change Current Practice

  1. Diane J. Angelini, EdD, CNM, FACNM, FAAN, NEA-BC

Failure to progress, the most common indication, is not always clearly defined.

  1. Diane J. Angelini, EdD, CNM, FACNM, FAAN, NEA-BC

The U.S. has one of the highest cesarean delivery rates in the world, and safely lowering this rate is an explicit objective of the Department of Health and Human Services. In a retrospective study of data from the Consortium on Safe Labor involving >38,000 primary cesarean deliveries (PCDs), researchers sought to delineate the factors that underlie this rate.

The PCD rate was 31% for primiparous women and 12% for multiparous women. The most common indications for PCD were failure to progress (35%), nonreassuring fetal heart rate tracings (27%), and fetal malpresentation (18%). Among women with failure to progress, 41% never attained cervical dilation beyond 5 cm. Of women who did reach second-stage labor, 17% underwent PCD for arrest of descent before 2 hours, and only 1% had a trial of operative vaginal delivery. Among PCDs for suspected fetal macrosomia, 97% of infants weighed <5000 gm (i.e., below the recommended threshold weight for offspring of nondiabetic mothers).

Comment

Failure to progress is the predominant surgical indication propelling the rising incidence of primary cesarean deliveries in the U.S., yet this study shows that accepted definitions of this condition are not always observed. For example, many women underwent primary cesarean delivery before reaching 6 cm dilation (which has been suggested as the cutoff for the beginning of active labor (NEJM JW Womens Health Dec 16 2010). Allowing more time for labor could substantially lower the PCD rate (the American College of Obstetricians and Gynecologists recommends allowing as long as 3 hours for the second stage). Other effective actions include adhering to ACOG's macrosomia guidelines, offering external cephalic version more commonly, training physicians in the delivery of noncephalic second twins, and incorporating innovations such as night-float schedules (NEJM JW Womens Health Jan 12 2011). Understanding the factors that drive PCD rates will strengthen efforts to support vaginal birth.

  • Disclosures for Diane J. Angelini, EdD, CNM, FACNM, FAAN, NEA-BC at time of publication Editorial boards Journal of Perinatal and Neonatal Nursing

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Reader Comments (1)

DR GANGAMBIKA NISTY Physician, Obstetrics/Gynecology, M.R.MEDICAL COLLEGE,GULBARGA

I HAVE PRIVATE PRACTICE ALSO, SO FOR REF. I NEED TO WATCH JOURNALS

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