Steps to prevent cesareans for first time mothers

In March 2014, The American American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine (SMFM) issued an “Obstetric Care Consensus” outlining safe approaches to reduce the cesarean rates for first time mothers (the primary cesarean rate). (They reaffirmed this consensus in 2023.) The consensus is thorough and it is an important article for birth professionals to read. It can, however, be a bit overwhelming for parents, so we summarized some of the key points for preventing cesareans for a healthy, normal pregnancy and birth: 

Continuous support during labor is one of the most effective ways to improve outcomes

This research is well documented. A Cochrane review looked at 22 trials involving over 15,000 women and found that women who received continuous support were more likely to have a spontaneous vaginal birth (significantly fewer had cesareans or instrumental vaginal births) and less likely to use pain medication or have a baby with a low Apgar score. Their labors were shorter and they reported greater satisfaction with their labor. In addition, the review found “that continuous support was most effective when the provider was neither part of the hospital staff nor the woman's social network...”

The bottom line: Hiring a doula or having an experienced, objective support person might be among the best things parents can do to avoid a cesarean.

Labor takes time and patience is beneficial

Labor arrest (the arrest of dilation) accounted for 34% of primary cesareans in a 2011 population-based study.  Defining “normal” labor progress is challenging. Most women with a prolonged early labor (20+ hours) will enter active labor on their own, or their labors may stop. The consensus recognizes that 6 cm is the threshold for the active phase of labor and that 4 hours with membranes ruptured is needed before diagnosing an arrest of labor. A labor that is progressing slowly is not an indication for a cesarean. An absolute maximum length of second stage has not been defined. First time mothers may push for 3 hours or more and the use of epidurals and the position of the baby may contribute to a longer pushing stage.

The bottom line:  Early labor may be 20+ hours, active labor begins at 6 cm, pushing may take 3+ hours and labor needs time and patience.

Cesareans for big babies should be limited to those weighing 11 pounds or more

Women with suspected fetal macrosomia (a birth weight of 8 lb 13 oz to 9 lb 15 oz) should not be induced nor do they need to undergo a cesarean for babies who estimated weight is less than 11 lbs (or less than 9 lbs 15 oz for women with diabetes). Furthermore, weight estimates are imprecise. Late pregnancy ultrasounds have been associated with an increase in the number of cesareans with no evidence of benefits to babies.

The bottom line: avoid late pregnancy ultrasounds unless medically necessary and avoid induction of labor or a scheduled cesarean for a suspected big baby.

In addition to these points, the article discusses the use of interventions that may reduce the cesarean rates, such as induction of labor, use of forceps/vacuum, use of amnioinfusions for abnormal fetal heart rate tracings and fetal positioning options, such as external cephalic versions. The article also recognizes the need for a more standardized approach to assessing fetal heart rate tracings, calls for a trail of labor for twins with a cephalic (head down) position of the first baby and identifies other factors that could reduce the cesarean rates. We applaud the efforts to better understand the sharp rise in cesarean rates in recent years and the steps ACOG is taking to reduce the number.

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