As we update Pregnancy, Childbirth and the Newborn, I will post here about major updates in each section since our 2010 edition. Here’s what’s new in thoughts about cesarean.
Key resources to be aware of
Barber, et al. Indications Contributing to the Increasing Cesarean Delivery Rate. OBGYN VOL. 118, NO. 1, JULY 2011. Reviews records of over 32,000 births at Yale-New Haven hospital between 2003 and 2009, when the cesarean rate increased from 26% to 36.5%. Factors that contributed the most to the increase were, in order:
- An increase in the diagnosis of nonreassuring fetal heart rates and failure to progress in labor. [Note: These are somewhat subjective diagnoses. It is possible that the rates of problems did not change much, but that caregivers began to lower the threshold at which they would decide cesarean was indicated.]
- Multiple gestation. The rate of twins increased slightly, but it also became more common to do a cesarean for multiples rather than attempting a vaginal delivery.
- Suspected macrosomia. Although more cesareans were done because it was thought the baby was too big, the actual size of babies delivered did not increase.
- Preeclampsia. The average age of mothers has increased, and more women are obese prior to pregnancy, and this has led to an increase in gestational hypertension. Also, caregivers are becoming more likely to use cesarean rather than induction for women with preeclampsia.
- Maternal request. A very small (less than 1%), but increasing, percentage of women requested a cesarean.
A 2011 journal article by Zhang, et al for the Consortium on Safe Labor, titled Contemporary Cesarean Delivery Practice in the US summarizes current trends. Some of the data from this article figured strongly in the ACOG / SMFM statement discussed below.
ACOG Committee Opinion on Cesarean Delivery on Maternal Request, 2013. They estimate 2.5% of all U.S. births are elective cesareans without medical indication. Their summary recommendation was: ” in the absence of maternal or fetal indications for cesarean delivery, a plan for vaginal delivery is safe and appropriate and should be recommended to patients. In cases in which cesarean delivery on maternal request is planned, delivery should not be performed before a gestational age of 39 weeks. Cesarean delivery on maternal request should not be motivated by the unavailability of effective pain management. Cesarean delivery on maternal request particularly is not recommended for women desiring several children, given that the risks of placenta previa, placenta accreta, and gravid hysterectomy increase with each cesarean delivery.”
Consensus statement from ACOG and Society for Maternal-Fetal Medicine. Safe Prevention of the Primary Cesarean Delivery. 2014. This statement has the potential of a huge impact on maternity care practices and should be read by all childbirth educators and other birth professionals. From the abstract, with my emphasis added: “The rapid increase in cesarean birth rates from 1996 to 2011 without clear evidence of concomitant decreases in maternal or neonatal morbidity or mortality raises significant concern that cesarean delivery is overused. Variation in the rates of nulliparous, term, singleton, vertex cesarean births also indicates that clinical practice patterns affect the number of cesarean births performed. The most common indications for primary cesarean delivery include, in order of frequency, labor dystocia, abnormal or indeterminate (formerly, nonreassuring) fetal heart rate tracing, fetal malpresentation, multiple gestation, and suspected fetal macrosomia. Safe reduction of the rate of primary cesarean deliveries will require different approaches for each of these, as well as other, indications. For example, it may be necessary to revisit the definition of labor dystocia because recent data show that contemporary labor progresses at a rate substantially slower than what was historically taught. Additionally, improved and standardized fetal heart rate interpretation and management may have an effect. Increasing women’s access to nonmedical interventions during labor, such as continuous labor and delivery support, also has been shown to reduce cesarean birth rates. External cephalic version for breech presentation and a trial of labor for women with twin gestations when the first twin is in cephalic presentation are other of several examples of interventions that can contribute to the safe lowering of the primary cesarean delivery rate.
What does this all mean?
It can take a long time for practice recommendations to become wide-spread practice in the “real world” of obstetrics. They will likely be adopted more quickly in university teaching hospitals in major urban areas than in rural hospitals.
I think these are the messages we give our students about cesarean:
For a parent who has not had a previous cesarean, your chance of having a cesarean with this birth is about 23%. It is much higher if you are carrying twins (47%), if you are older, obese (44% at BMI of 35+), or if your labor is induced (about twice as likely). Rates vary greatly by hospital, so it’s good to research your options.
If you are carrying multiples, and the first baby is head-down when it is time for the birth, vaginal birth is better than cesarean.
If your baby is breech at 35 weeks, try chiropractic, acupuncture / moxibustion and other techniques to turn baby. Ask for a version at week 37.
If a care provider tells you your baby is looking big, and recommends an ultrasound in late pregnancy to assess size, or recommends induction / cesarean to treat: know that a) late-term ultrasounds are not a precise way to measure size, b) macrosomia is not considered a reason for induction, and c) macrosomia should only be considered an indication for cesarean if baby is believed to be at least 5000 grams (11 pounds) in a woman without diabetes, and at least 4500 grams (9 pounds, 14.7 ounces) in a woman with diabetes.
The most common reasons for cesarean are repeat cesareans, failure to progress in labor and concerns about baby’s heart rate that arise during labor.
For most women with prior cesareans, VBAC is a safe option and should be pursued.
Failure to progress in labor. See my post on what should be considered prolonged labor. Also, talk to your clients about all the ways that we promote labor progress.
For baby’s heart rate: If there are concerns, ask how concerning it is – does it warrant immediate intervention, or is it possible to try other things. Some options are: changing mom’s position, IV fluids or oxygen for mom, amnioinfusion for baby, turning down Pitocin, letting narcotics wear off, giving tocolytics to gentle the contractions. She can also request that they use fetal scalp stimulation to check baby’s response.