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Initiatives and Guidelines to Reduce the Rate of Cesarean Births

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C-sections are one of the most common procedures performed in hospitals and rates have continued to rise. Learn more about how to reduce the rate of Cesarean births, improve quality, and promote risk management, including the revised labor guidelines from the American College of Obstetrics and Gynecology.

As we discussed in our last post, the rates of C-section versus vaginal births has continued to rise yet varies widely from hospital to hospital, as much as 20%.  The California Maternal Quality Care Collaborative (CMQCC) has focused on reducing the rate of Cesarean birth for nulliparous term singleton vertex (NTSV) births (first labor, full-term, single births) due to the fact that preventing a C-section for a woman’s first labor results in a 90% rate of vaginal births for subsequent labor.

The American College of Obstetrician and Gynecologists (ACOG) has joined with CMQCC to promote this initiative.  Greater clinical patience is the main focus of many of the recommendations in the ACOG Obstetric Care Consensus on Safe Prevention of the Primary Cesarean Delivery.    This includes changing the definition of active labor.  ACOG’s revised labor guidelines now state that active labor does not occur until 6 cm of dilation, compared to the previous 4 cm guideline.  The guidelines further state that before 6 cm of dilation is achieved, standard of active phase progress should not be applied.

This is because over the past years, women have been getting admitted earlier and earlier and often when labor is not seen to be progressing, a C-section is performed.  Based on ACOG’s guidelines, many of these C-sections may have been unnecessary as prior to 6 cm of dilation, the lack of progression is due primarily to the fact that the woman was not in active labor not due to arrest.

The guidelines go further to state that Cesarean delivery for active phase arrest in the first stage of labor should be reserved for women at or beyond 6 cm of dilation with ruptured membranes who fail to progress despite 4 hours of adequate uterine activity, or at least 6 hours of oxytocin administration with inadequate uterine activity and no cervical change.

Based on these guidelines, one hospital in California has given their labor nurses buttons to wear that say “6 is the new 4”.  This is a reminder to both the nursing staff and the patients to stick with the labor process, remain patient, and do everything possible to promote vaginal birth.

Along with the rise in the rate of C-section, the rate of non-medically indicated labor inductions has gone up.  In response to these rising rates, ACOG’s revised guidelines state that before 41 0/7 weeks of gestation, induction of labor generally should be performed based on maternal and fetal medical indications.  Furthermore, inductions at 41 0/7 weeks of gestation and beyond should be performed to reduce the risk of Cesarean delivery and the risk of perinatal morbidity and mortality.

They also state that if the maternal and fetal status allow, Cesarean deliveries for failed induction of labor in the latent phase can be avoided by allowing longer durations of the latent phase (up to 24 hours longer) and requiring that oxytocin be administered for at least 12-18 hours after membrane rupture before deeming the induction a failure.

Close adherence to these revised guidelines along with quality improvement and safety efforts help to decrease liability for institutions by making sure only indicated Cesareans are performed.  Utilizing evidence-based best practice protocols that follow national consensus and expert-vetted standardized approaches for labor and fetal heart rate abnormalities is vital.  Communication techniques which engage the patient in “shared decision making” also creates a strong deterrence to lawsuits and reducing primary Cesareans protects against post-Cesarean complications and poor outcomes during future care.  In our next post, we will discuss best practices to support vaginal births and manage labor abnormalities.

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