Safe Prevention of the Primary Cesarean Section

Yesterday, I was talking to one of the moms who came to us for her first check up in this pregnancy, and she said something to me that blew my mind away. She told me that in her last pregnancy, she set into labor, and that her bag of waters broke after a few hours of labor. Contractions were coming a bit faster, but still very manageable. Then comes the nurse and hooks her onto the continuous EFM machine. The baby is doing fine. But, at the peak of the contraction, the baby’s heartbeat in around 130-135 bpm, as compared to 140-150 bpm without contractions. She is looking at the monitor, she feels fine, her baby is moving well. But, the doctor says that these are early decelerations, this is fetal distress – so she is advised a C-section immediately!! This time, she wants to try for a normal delivery. As I counsel her, I find it hard to believe that 130s heartbeat is thought of a deceleration, and just not as a normal response of the baby during a contraction! How much evidence based practice do routine hospitals use in maternity care?

With the tremendous increase in Cesarean rates over the last few years, the American College of Obsetricians and Gynecologists and the Society for Maternal Fetal Medicine issued a joint Obsetric Care Consensus statement on the Safe Prevention of the Primary Cesarean Section. This statement provides fantastic guidelines in the way maternity care should be delivered, and in the way hospitals and doctors should look at progression of labor, electronic fetal monitoring, breech presentations and twin pregnancies. All of this, in an effort to reduce that first C-section!

The Consensus Statement first establishes that vaginal birth in most cases is less risky and more beneficial for most mothers and their babies: “Childbirth by its very nature carries potential risks for the woman and her baby, regardless of the route of delivery. The National Institutes of Health has commissioned evidence-based reports over recent years to examine the risks and benefits of cesarean and vaginal delivery. For certain clinical conditions––such as placenta previa or uterine rupture––cesarean delivery is firmly established as the safest route of delivery. However, for most pregnancies, which are low-risk, cesarean delivery appears to pose greater risk of maternal morbidity and mortality than vaginal delivery.

Table 1. Risk of Adverse Maternal and Neonatal Outcomes by Mode of Delivery
Outcome Risk
Maternal Vaginal Delivery Cesarean Delivery
Overall severe morbidity and mortality*† 8.6% 9.2%*
0.9% 2.7%
Maternal mortality 3.6:100,000 13.3:100,000
Amniotic fluid embolism§ 3.3–7.7:100,000 15.8:100,000
Third-degree or fourth-degree perineal laceration|| 1.0–3.0% NA (scheduled delivery)
Placental abnormalities Increased with prior cesarean delivery versus vaginal delivery, and risk continues to increase with each subsequent cesarean delivery.
Urinary incontinence# No difference between cesarean delivery and vaginal delivery at 2 years.
Postpartum depression|| No difference between cesarean delivery and vaginal delivery.
Neonatal Vaginal Delivery Cesarean Delivery
Laceration** NA 1.0–2.0%
Respiratory morbidity** < 1.0% 1.0–4.0% (without labor)
Shoulder dystocia 1.0–2.0% 0%

So, what are some of the recommendations for prevention of the Primary Cesarean Section?

1) Slow, but progressive labor in the first stage of labor should not be an indication for a C-section. As long as mother and baby are doing well, cervical dilation of 6 cms should be the threshold for active phase of labor.

2) Adverse neonatal outcomes have not been associated with the duration of the second stage of labor (pushing stage). Therefore, at least giving 3 hours of pushing to a first time mother, and minimum 2 hours of pushing to a women with previous children, is recommended. Cochrane database considers spontaneous bearing down as the beginning of second stage of labor. So just using complete dilation as start of second stage is not recommended, and this itself can lead to decreased C-sections for non-progression of second stage of labor.

3) Instrument delivery can reduce the need for Cesarean section. The authors note with concern that many obsetricians do not feel competent using forceps for delivery.

4) Now for some real good observations: Recurrent variable decelerations appear to be a physiologic response to repetitive compressions of the umbilical cord and are not pathologic. The guideline goes on to have some good in-depth discussion about how to monitor fetal heart rate patterns, and what are some of the other solutions available, other than jumping into a C-section for variable decelerations. This in turn has the potential to remarkably reduce Cesarean rates!

5) Induction of labor can increase the risk of a C-section! Induction is not recommended prior to 41 completed weeks, unless there are compelling maternal/fetal indications. Cervical ripening with induction can reduce the need for a C-section. Only after 24 hours of induction with Pitocin/Syntocinon and ruptured membranes can induction be considered as a failure! Obviously this gives so much more time to the laboring mother!

6) Neither chorioamnionitis (infection of the maternal/fetal membranes) nor its duration should be an absolute indication for a C-section. In other words, as long as mother and baby are well, and are being monitored, and other interventions as needed being provided, a C-section can and should be the last option.

7) Late pregnancy ultrasounds is associated with an increase in cesareans with no evidence of neonatal benefit! Macrosomia (a big baby) is not an indication for a C-section.

8) External Cephalic Version for breech presentation, can lower the C-section rate. The recommendation for breech vaginal birth is that the parents should be told of the risks involved (perinatal/neonatal morbidity/mortality), but should be given a choice to birth their baby vaginally, with a good informed consent being provided for the procedure.

9) Outcomes for twin gestations, especially when the first twin is cephalic (head down) are NOT improved by a Cesarean delivery. Hence, the recommendation is that a trial of labor should be given to the mom in this circumstance.

10) Continuous Labor Support is one of the most effective ways to reduce Cesarean rates! The authors note that this resource is probably underused.

As Judith Lothian points out in her article in the Journal of Perinatal Education, “These guidelines offer great promise in lowering the cesarean rate and making labor and birth safer for mothers and babies. They also suggest an emerging respect for and understanding of women’s ability to give birth and a more hands off approach to the management of labor. Women will be allowed to have longer labors. Obstetricians will need to be patient as nature guides the process of birth. Hospitals will have to plan for longer stays in labor and delivery. And women will need to have more confidence in their ability to give birth. Childbirth educators can play a key role here. The prize will be safer birth and healthier mothers and babies.”

All of the above is no surprise to us at Healthy Mother. When mothers are provided with a safe space to birth their babies, when they are supported and monitored in labor, when they have been given adequate antenatal support, advice and preparation, nature has its way of guiding the process of birth. Midwives around the world have low interventions and C-section rates since they respect the woman’s body and the innate intricacy of maternal/fetal hormones that drive labor and birth. It is satisfying to see that these recommendations from ACOG are slowly aligning with good birth practices.

So, how does your hospital and care-provider measure up when it comes to using evidence-based practices in pregnancy, labor and birth? It may be good for you to invest time and energy to find out, so that you can have a safe, healthy and optimal birthing experience!

Bibiography:

http://www.acog.org/Resources-And-Publications/Obstetric-Care-Consensus-Series/Safe-Prevention-of-the-Primary-Cesarean-Delivery