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Starting at the Very Beginning: Preventing the First Cesarean Delivery

Guideline Watch |
March 18, 2014

Starting at the Very Beginning: Preventing the First Cesarean Delivery

  1. Allison Bryant, MD, MPH

Two obstetric professional societies collaborate in recommendations aimed at lowering primary cesarean delivery rates.

  1. Allison Bryant, MD, MPH

Sponsoring Organizations: American College of Obstetricians and Gynecologists, Society for Maternal Fetal Medicine

Target Population: Obstetric care providers

Background and Objective

Rising rates of primary and repeat cesarean deliveries have sharpened the focus on policies to prevent the first cesarean delivery. The American College of Obstetricians and Gynecologists and the Society for Maternal Fetal Medicine have released a consensus statement with guidelines for the safe prevention of the first cesarean. The leading indications for primary cesarean are labor dystocia, abnormal fetal heart rate tracings, malpresentation, and multiple gestations (NEJM JW Womens Health Jul 22 2013).

Key Recommendations

Labor Dystocia

  • A prolonged latent phase (>20 hours in nulliparous women or >14 hours in multiparous women) is not an indication for cesarean delivery.

  • Active labor typically begins at 6 cm of cervical dilation; therefore, cesarean delivery for active phase arrest in the first stage should only be considered when the cervix is >6 cm dilated, membranes are ruptured, and no progress has occurred during >4 hours of adequate uterine contractions.

  • Slow but steady progress during the first stage is not an indication for cesarean delivery.

  • Active phase arrest during the second stage should not be declared before 3 hours of pushing in nulliparous women and 2 hours of pushing in multiparous women; allowing women to push longer is reasonable if progress is being made and maternal and fetal well-being are assured.

  • Operative vaginal delivery, when appropriate, should be encouraged as an alternative to cesarean delivery.

Abnormal or Indeterminate Fetal Heart Rate Tracings

  • When suspicion of abnormal fetal heart rate tracings arises, fetal scalp stimulation may be used to assess the likelihood of fetal acidemia.

  • Amnioinfusion should be considered as an alternative to cesarean delivery in the setting of repetitive variable decelerations.

Malpresentation

  • Clinicians should assess fetal position starting at 36 completed weeks; external cephalic version should be offered for malpresentation if appropriate.

Multiple Gestations

  • Women having twin pregnancies with a cephalic presenting first fetus should be encouraged to undergo trial of labor.

Labor Induction

  • Recent data do not support previously held notions that labor induction raises risk for primary cesarean delivery.

  • Labor induction before 41 completed weeks' gestation should be performed based on maternal and fetal indications.

  • Cesarean delivery for failed induction should be performed only when active labor is not achieved within 24 hours despite oxytocin administration and membrane rupture for at least 12 to 18 hours.

Comment

In making these recommendations, the American College of Obstetricians and Gynecologists and the Society for Maternal Fetal Medicine rightly recognize the need for systems-level setting of agendas to encourage appropriate training and cultural shifts to enable these practices. Without this participation from the top — and without creation of clinician incentives for vaginal delivery — these evidence-based recommendations are unlikely to take hold.

  • Disclosures for Allison Bryant, MD, MPH at time of publication Nothing to disclose

Citation(s):

Reader Comments (1)

Roshan Zeirideen MBBS MRCOG Other, Obstetrics/Gynecology, Homerton Hospital Lonfon

I think preventing the first caesarean is the key to reduce the number of cohort of women who will have high impact of morbidity and financial implications in future. Second stage Caesarean sections and maternal request CS are slowly rising. Trainees and the future consultants needs to be confident and competed in performing instrumental deliveries and set uniform guidelines has to be in place to manage maternal request CS to reduce or prevent this massive potential future problems relating to Caesarean sections ie rupture, abnormal placentations etc and the fetal and maternal mortality and morbidity

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