The following piece appeared in Essentially MIDIRS news, vol 5, no 3, p28
In case you missed it, earlier this year the American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine (SMFM) issued a joint obstetric care consensus statement, entitled Safe prevention of the primary cesarean delivery.
This significant position statement, which was concurrently published in the March edition of Obstetrics and Gynecology (the Green Journal), made waves within the blogosphere as midwives, obstetricians, childbirth educators and women discussed the potential impact it would have on the care of women during labour. In particular, the potential that it could have to slow or reduce the rising caesarean section rate in the US. The overall caesarean section rate has plateaued at around 33% in the US since 2009, after steadily rising for more than a decade. However, there is significant regional variation, as the authors note: ‘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%’ (ACOG 2014). The authors found that clinical practice patterns, ie variation between different hospitals as well as other birth settings, affect the number of caesareans performed and argue that this is one area which could be modified to reduce the caesarean section rate. In a 2011 US population-based study (Barber et al 2011), the most common reasons for caesarean section included labour dystocia, abnormal or indeterminate fetal heart rate tracing, fetal malpresentation, multiple gestation, and suspected fetal macrosomia. ACOG and SMFM were applauded for their willingness to use evidence-based practice, despite its possible contradictions to current practice within the US. The main recommendations from the position statement included:
• allowing women to labour for longer – ie a latent phase of more than 20 hours for first-time mothers and 14 hours for multiparous women should not be an indication for caesarean section
• considering cervical dilation of 6cm as the start of the active phase of labour
• allowing women to push for at least two hours if they have given birth before, or three hours if it’s their first birth.
Notably, the statement said: ‘A specific absolute maximum length of time spent in the second stage of labor beyond which all women should undergo operative delivery has not been identified’ (ACOG 2014). The speed of cervical dilation and labour progress formed a large part of the statement, as the authors referred to recent research undertaken for the Consortium on Safe Labor (Zhang et al 2010), which they suggested should revise the current definitions: ‘Because they are contemporary and robust, it seems that the Consortium on Safe Labor data, rather than the standards proposed by Friedman, should inform evidence-based labor management’ (ACOG 2014). ACOG and SMFM ended by recommending further research to expand the evidence base and promote policy changes that could safely reduce the rate of unnecessary caesarean sections for first-time mothers. As Judith Lothian positively put it within her blog posting on the Science and Sensibility website: ‘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’ (Lothian 2014).
Hooray from all at Essentially MIDIRS!
ACOG (2014). Safe prevention of the primary cesarean delivery. http://tinyurl.com/ncgvreh [Accessed 21 February 2014].
Barber EL, Lundsberg lS, Belanger K et al (2011).Indications contributing to the increasing cesarean delivery rate. Obstetrics & Gynecology 118(2):29-38.
Lothian J (2014). Safe prevention of the primary cesarean delivery: ACOG and SMFM change the game, Science & Sensibility, 19 February. Available at:
http://www.scienceandsensibility.org/?s=cesarean [Accessed 26 February 2014].
Zhang J, Landy HJ, Branch DW et al (2010). Contemporary patterns of spontaneous labor with normal neonatal outcomes. Obstetrics & Gynecology 116(6):1281-7.