A Lost Art

ACOG Aims to Cut Cesarean Rates

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Public Health Feature — June 2014

Tex Med. 2014;110(6):41-44.

By Kara Nuzback
Reporter

Cesarean births can be lifesaving for a mother and her baby during a difficult delivery. But new data indicate overuse of the procedure, often putting mothers at risk of excessive blood loss and long recovery times. Medical groups are now urging physicians to allow longer labor times to cut down on the country's high cesarean section rate and to improve patient safety.

The American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine published a joint study, "Safe Prevention of the Primary Cesarean Delivery," in the March issue of the American Journal of Obstetrics and Gynecology (AJOG). 

The authors used data from National Vital Statistics to determine one in three women who gave birth in the United States in 2011 did so by cesarean delivery. Cesarean deliveries rose 60 percent from 1996 to 2009, according to the Centers for Disease Control and Prevention's (CDC's) National Center for Health Statistics.

The authors of the ACOG study say despite the rise in cesarean delivery, no evidence suggests the increase has reduced maternal or neonatal morbidity or mortality. 

According to the study, the data raise significant concern that doctors perform cesareans when other paths, such as less invasive operative vaginal delivery, could be taken.

If the birth is not spontaneous and an operation is necessary, ACOG now recommends operative vaginal delivery over cesarean delivery. 

"Training in and ongoing maintenance of practical skills related to operative vaginal delivery should be encouraged," the report states.

The recommendations will likely mean more training for physicians in residency and more refresher courses and simulations for practicing obstetricians, says Houston obstetrician-gynecologist Carla Ortique, MD.

According to the study, the rate of operative vaginal delivery has fallen significantly in the past 15 years. Dr. Ortique, chair of TMA's Committee on Maternal and Perinatal Health, says the ACOG recommendations are an important first step in changing patients' and physicians' attitudes toward cesarean sections. 

"An operative vaginal delivery, in the appropriate clinic setting, over the long term is more beneficial to the mother," she said. "She may accept greater risk from having a C-section."

But, Dr. Ortique says, one of the reasons for the rise in cesarean rates is that many obstetricians lack experience and practice using common operative vaginal delivery tools such as forceps and vacuums. 

"If they're not trained, they are obviously not going to do those things," she said. "So they have to do C-sections."

Risks associated with operative vaginal delivery include damage to the vaginal tract, extensive blood loss, and damage to the fetus, especially when a doctor's skills have not been honed because of lack of practice, Dr. Ortique says. 

Of the new findings, she says, "My hope is that they don't compel practicing obstetricians to practice outside their level of expertise and comfort."

If physicians are well-trained in operative vaginal delivery, when used in the appropriate clinical setting, the risk to both the mother and the child is low, she adds.

Changing Tide

ACOG President John Jennings, MD, chair of the Texas Medicine Editorial Board, says maternal obesity and an increase in the average age of mothers have contributed to the rise in cesarean sections since 1996. He says ACOG noticed the spike and decided to change the tide. 

"This revision of the traditional labor curve is based on good science. Our physicians need to pay attention to these changes," he said.

Dr. Jennings says the rate of cesarean sections will fall gradually as more physicians opt to follow the recommendations and perform operative vaginal deliveries when possible.

"The use of forceps is a lost art," he said. "It's going to take a while before the trends change." 

That's because physicians have long based the duration of labor on the Friedman Curve, which plots the typical rate of cervical dilation and fetal descent. 

"We have good research that shows our traditional Friedman Curve is probably inaccurate," he said.

The active phase of labor, during which the cervix becomes fully dilated, has traditionally been considered abnormal when cervical dilation is less than 1.2 centimeters (cm.) an hour for women who have never given birth and 1.5 cm. an hour for women who have given birth. 

According to ACOG's study, new data from the Consortium on Safe Labor (CSL) indicate women dilate more slowly than historically thought, regardless of whether the woman has previously given birth. ACOG now recommends physicians consider cervical dilation of 6 cm. the beginning of the active phase.

The second stage of labor begins when the cervix is fully dilated and ends with delivery. 

Use of epidural analgesia, maternal obesity, and increased birth weight have all been shown to lengthen the second stage of labor, ACOG says.

The study outlines several reasons for cesarean deliveries. Seventy-four percent are the result of either labor arrest, abnormal or indeterminate fetal heart rate tracing, or fetal malpresentation, such as breech birth. Each instance requires a different solution, ACOG says.

Under traditional best practices, if the cervix fails to change dilation for two hours or more, a physician could diagnose active phase arrest. CSL is now saying labor arrest should not be diagnosed before 6 cm. of dilation. 

Before physicians diagnose labor arrest, ACOG recommends they ensure the patient has been pushing for at least two hours if she has previously given birth and at least three hours if she has never given birth. ACOG guidelines state patients in active phase labor arrest should have a C-section once they have reached at least 6 cm. of dilation and have failed to progress for four to six hours.

Worth the Risk?

According to the National Institutes of Health, cesarean delivery is the safest path in certain instances, such as placenta previa and uterine rupture.

Houston neonatologist and TMA Immediate Past President Michael Speer, MD, says the cesarean section is an appropriate option in an emergency, but cesareans performed for the wrong reasons must be controlled. 

"You need to have a reason," he said. "It's not good to muck around with Mother Nature."

In Texas, more than 35 percent of deliveries were cesarean in 2010, slightly more than the national average of about 33 percent, the ACOG study shows. Dr. Speer says in his 38 years practicing medicine, he has seen firsthand the increasing number of cesarean sections and the subsequent increased need for newborn intensive care.

"Anything that can decrease unwarranted cesarean sections is good, and I think that these guidelines are long overdue," he said. 

Obstetricians who are reluctant to say no to an uncomfortable expecting mother contribute to the high number of cesarean deliveries, Dr. Speer says.

"Unfortunately, some mothers believe that delivery at 34 weeks is perfectly fine, as opposed to waiting until 40 weeks," he said.

Dr. Speer says nonmedically indicated cesarean sections can yield disastrous results. According to ACOG's report, the risk of severe maternal morbidities, such as hemorrhaging that requires hysterectomy or blood transfusion, shock, cardiac arrest, or major infection, was 2.7 percent for a planned cesarean delivery, as opposed to 0.9 percent for a vaginal delivery. That's a threefold increase.

The chances of placental abnormalities in future pregnancies increase with each subsequent cesarean delivery, ACOG says. But data from the study show the number of women who delivered vaginally after a prior cesarean delivery plummeted from nearly 30 percent in the mid-1990s to less than 10 percent in 2011.

Dr. Speer says maternal deaths in the United States are at epidemic proportions. (Read "Preserving Mother's Day," September 2013 Texas Medicine, pages 53-57.)

"The greatest risk to both the mother and infant is not the initial cesarean section, but those that follow," he said. 

Dr. Speer says if a woman does not have a cesarean delivery with her first child, the chances are she will not have a cesarean in subsequent deliveries.

"The trick is stopping the first cesarean," he said.

Another reason for the rise in cesarean deliveries could be financial, Dr. Speer says.

According to "Physicians Treating Physicians: Information and Incentives in Childbirth," a paper published by the Social Science Research Network last July, some payers gave physicians a few hundred dollars more for a cesarean section than for a vaginal delivery; some payers awarded hospitals a few thousand dollars more for the procedure.

Dr. Speer says Medicaid pays the same amount for a cesarean as it pays for a vaginal delivery, but this might not be the case with all payers. He says payment reform might be necessary to reduce cesareans nationwide.

According to the Texas Health and Human Services Commission, Medicaid pays for about 54 percent of all Texas births and spends $2.2 billion annually on birth- and delivery-related services for mothers and babies through the first year of life.

Supporting Patients

According to ACOG's recommendations, increasing women's access to continuous labor and delivery support, either from hospital staff or a doula, also has been shown to reduce cesarean birth rates. 

"Given that there are no associated measurable harms, this resource is probably underutilized," ACOG states.

According to the American Pregnancy Association (APA), a doula is a nonmedical professional who provides emotional, physical, and informational support to a mother who is expecting, is in labor, or has recently given birth. The doula's purpose is to help women have a safe, memorable, and empowering birthing experience, APA states.

According to "Continuous Support for Women During Childbirth," a 2012 review published in The Cochrane Library, Issue 10, women with continuous labor support were more likely to have spontaneous vaginal birth and less likely to have a cesarean or instrumental vaginal birth. When the support came from a doula, the authors of the study saw a 28-percent decrease in the risk of cesarean section and a 12-percent increase in the likelihood of a spontaneous birth.

In Dr. Ortique's experience, patients who have the professional support of a doula through labor are more likely to deliver vaginally. Because most health insurance plans do not cover the cost of doulas, she says it is often wealthier patients who hire doulas to provide support during and after childbirth.

"Our hospital has trained all delivery nurses to be doulas," she said.

However, she says, most delivery nurses have more than one patient at a time and are unable to provide continuous support. She says increased labor times will likely mean delivery nurses will be stretched more thinly. Still, she says, women in labor need support from a professional.

"Partners are wonderful support, but they do not have the training to determine what's normal and what's not," Dr. Ortique said.

She says at 35 percent, cesarean rates are clearly too high, but, she notes, not every woman can deliver vaginally. Dr. Ortique points out ACOG's recommendations are not guidelines until more data exist to support them.

"They are recommendations. They have not been established as best practices yet," she said. "They do provide a safe framework for implementation of education and the establishment of protocols to safely reduce the primary C-section rate."

Dr. Jennings says a reduction in cesarean rates might not be immediate. 

"It's sometimes hard to change habits," he said. "It'll take a while before we make that complete transition. ACOG released the recommendations because the increasing rate of C-sections unnecessarily places women at risk. There is a hazard to the mothers having repeat cesarean sections. We always want to do the best thing for our patients."

Kara Nuzback can be reached by telephone at (800) 880-1300, ext. 1393, or (512) 370-1393; by fax at (512) 370-1629; or by email.



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