ACOG/SMFM Consensus
ACOG/SMFM obstetric care consensus
Safe prevention of the primary cesarean delivery

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In 2011, 1 in 3 women who gave birth in the United States did so by cesarean delivery. Cesarean birth can be lifesaving for the fetus, the mother, or both in certain cases. However, the rapid increase in cesarean birth rates from 1996 through 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.

Section snippets

Background

In 2011, 1 in 3 women who gave birth in the United States did so by cesarean delivery.1 Even though the rates of primary and total cesarean delivery have plateaued recently, there was a rapid increase in cesarean rates from 1996 through 2011 (Figure 1). Although cesarean delivery can be lifesaving for the fetus, the mother, or both in certain cases, the rapid increase in the rate of cesarean births without evidence of concomitant decreases in maternal or neonatal morbidity or mortality raises

Balancing risks and benefits

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 delivery3 (Table 1). 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

Indications for primary cesarean

There is great regional variation by state in the rate of total cesarean delivery across the United States, ranging from a low of 23% to a high of nearly 40% (Figure 2). Variation in the rates of nulliparous term singleton vertex cesarean births indicates that clinical practice patterns affect the number of cesarean births performed. There also is substantial hospital-level variation. Studies have shown a 10-fold variation in the cesarean delivery rate across hospitals in the United States,

Definition of abnormal first-stage labor

The first stage of labor has been historically divided into the latent phase and the active phase based on the work by Friedman in the 1950s and beyond. The latent phase of labor is defined as beginning with maternal perception of regular contractions.17 On the basis of the 95th percentile threshold, historically, the latent phase has been defined as prolonged when it is >20 hours in nulliparous women and >14 hours in multiparous women.18 The active phase of labor has been defined as the point

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    The information reflects emerging clinical and scientific advances as of the date issued, is subject to change, and should not be construed as dictating an exclusive course of treatment or procedure. Variations in practice may be warranted based on the needs of the individual patient, resources, and limitations unique to the institution or type of practice.

    The authors report no conflict of interest.

    This article is being published concurrently in the March 2014 issue of Obstetrics & Gynecology (Obstet Gynecol 2014;123:693-711).

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