In an effort to lower the two-decade surge in cesarean sections, two prominent groups representing obstetricians-gynecologists issued new guidelines on Wednesday calling for doctors to put off the surgery in first-time mothers, allowing them to labor longer and push harder to see if more babies can be delivered vaginally. That’s based on recent studies showing that the rise in cesarean sections hasn’t led to better health outcomes for women or babies like lower mortality rates.
“C-sections save lives,” said Dr. Vincenzo Berghella, president of the Society for Maternal-Fetal Medicine, the organization that issued the new recommendation along with the American College of Obstetricians and Gynecologists. “But we also know that some C-sections can be safely prevented and that having multiple surgical deliveries raises the risk of placenta abnormalities, hysterectomies, and bladder and bowel injuries making them dangerous for mothers and babies.”
The new guidelines aim to prevent unnecessary cesarean in first-time mothers by recommending that they not be considered to be in active labor until they get to 6 centimeters of dilation, rather than the 4 centimeters many doctors learned in their training.
Dr. Allison Bryant Mantha, an obstetrician-gynecologist at Massachusetts General Hospital, said she and her colleagues shifted over to this new way of thinking a few years ago. “Six centimeters has become part of common parlance to define active labor,” she said, “because we understand that often C-sections are performed due to slow or prolonged labor.” Doctors need to allow women a little bit of extra time to labor, she added, and not be “quite so rigid about when a pregnancy needs to be over” if they want to see their surgery rates decline.
Some obstetricians, though, may resist the new advice to allow their patients more time to dilate during labor, to let first-time mothers push for three hours or even longer, and to use forceps to get the baby out vaginally. “We are paid a little bit more to perform a C-section, but the bigger reason for doctors to do them is that they’re more convenient and quicker than vaginal labor,” said guideline co-author Dr. Aaron Caughey, chair of obstetrics and gynecology at Oregon Health & Science University.
“These recommendations are of absolutely no to benefit an ob-gyn’s work-life balance nor pocketbook,” Caughey added, “but this never came up when we were writing them or having them reviewed by colleagues.”
The movement to reduce the cesarean rate—1 in 3 women now have the surgery in Massachusetts compared to 1 in 5 in 1997—has been growing stronger over the past few years in this state and elsewhere. Individual states have wide variations in rates for the surgery ranging from 23 percent to nearly 40 percent of all births, according to the latest 2010 statistics from the federal government.
Even individual hospitals within Massachusetts have a wide varation in their rates of caesarean section. A 2011 Department of Public Health report showed that the 2009 cesarean rates for first-time mothers with low-risk pregnancies ranged from 10 to 35 percent.
“There isn’t a magic number to define an ideal C-section rate for hospitals,” Caughey said, since a mother’s advanced age, excess weight, low income, or ethnicity can all play a role in increasing her risk. Still, he added, “we think we’re somewhere above where we should be.”