Evidence-Based Research on How to Safely Reduce Cesarean Births
Hello Fellow Birth Professionals and Parents,
I put together an easy to read evidenced-based research checklist from ACOG March 2014 Edition on how to safely reduce cesarean births.
This would be great to have with you in your birth bag!
Please share this with your clients, family, partner, friends, and loved ones who are pregnant and interested in making an educated and informed decision on how to safely reduce their chances of a cesarean birth.
Receiving Continuous Support from a Midwife, RN, Doula, or Birth Partner:
A Cochrane meta-analysis of 12 trials and more than 15,000 women demonstrated that the presence of continuous one-on-one support during labor and delivery was associated with improved patient satisfaction and a statistically significant reduction in the rate of cesarean delivery.
How to Safely Reduce your Risk of a Cesarean Birth During the First Stage of Labor:
A prolonged latent phase greater than 20 hours in nulliparous women and greater than 14 hours in multiparous women should not be an indication for cesarean delivery.
Slow but progressive labor in the first stage of labor should not be an indication for cesarean delivery.
When the first stage of labor is protracted or arrested, pitocin is commonly recommended.
Several studies have evaluated the optimal duration of pitocin augmentation in the face of labor protraction or arrest.
Research has shown that an additional 4 hours (for a total of 8 hours) in patients who were dilated at least 3 cm and had unsatisfactory progress (either protraction or arrest) after an initial 4-hour augmentation period of pitocin had lower cesarean birth of only 18 percent, versus women who only received only the 4 hour of augmentation, which had a two-fold increase in having a cesarean birth.
Labor Arrest in the first stage of labor should not be identified until mother is at 6cm not 4cm.
If there is no immediate risk to you and your baby, delay getting pitocin will reduce your chances of a cesarean birth.
Cesarean delivery for labor arrest (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 pitocin administration with inadequate uterine activity and no cervical change.
Rouse DJ, Owen J, Hauth JC. Active-phase labor arrest: oxytocin augmentation for at least 4 hours. Obstet Gynecol 1999;93:323–8.
How to Safely Reduce your Risk of a Cesarean Birth During the Second Stage of Labor:
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.
Before diagnosing arrest of labor in the second stage, if the maternal and fetal conditions permit, allow for the following: a) At least 2 hours of pushing in multiparous women, b) At least 3 hours of pushing in nulliparous women, c) Longer durations may be appropriate on an individualized basis (eg, with the use of epidural analgesia or with fetal malposition) as long as progress is being documented.
Make sure you get a doctor that has experience in manual rotation of the fetal occiput in the setting of fetal malposition in the second stage of labor is a reasonable intervention to consider before moving to operative vaginal delivery or cesarean delivery.
Ask your doc if he/she has received ongoing training or education on operative vaginally deliveries.
Forceps-assisted vaginal deliveries were associated with a reduced risk of the combined outcome of seizure, intraventricular hemorrhage, or subdural hemorrhage as compared with either vacuum-assisted vaginal delivery or cesarean delivery.
Werner EF, Janevic TM, Illuzzi J, Funai EF, Savitz DA, Lipkind HS. Mode of delivery in nulliparous women and neonatal intracranial injury. Obstet Gynecol 2011;118:1239–46.
In order to safely prevent cesarean deliveries in the setting of malposition, it is important to assess the fetal position in the second stage of labor, particularly in the setting of abnormal fetal descent.
How to Safely Reduce your Risk of a Cesarean Birth for Occiput Posterior or Transverse Baby:
Occiput posterior and occiput transverse positions are associated with an increase in cesarean delivery and neonatal complications.
Historically, forceps rotation of the fetal occiput from occiput posterior or occiput transverse was common practice. Today this procedure, although still considered a reasonable management approach, has fallen out of favor and is rarely taught in the United States.
An alternative approach is manual rotation of the fetal occiput, which has been associated with a safe reduction in the risk of cesarean delivery.
In order to consider an intervention for a fetal malposition, the proper assessment of fetal position must be made. Intrapartum ultrasonography has been used to increase the accurate diagnosis of fetal position when the digital examination results are uncertain.
How to Safely Reduce your Risk of a Cesarean Birth for Fetal Heart Monitoring:
Amnioinfusion for repetitive variable fetal heart rate decelerations may safely reduce the rate of cesarean delivery. Amnioinfusion with normal saline also has been demonstrated to resolve variable fetal heart rate decelerations and reduce the incidence of cesarean delivery for a nonreassuring fetal heart rate pattern.
Scalp stimulation can be used as a means of assessing fetal acid–base status when abnormal or indeterminate (formerly, nonreassuring) fetal heart patterns (eg, minimal variability) are present and is a safe alternative to cesarean delivery in this setting. Scalp stimulation to elicit a fetal heart rate acceleration is an easily employed tool when the cervix is dilated and can offer clinician reassurance that the fetus is not acidotic. Spontaneous or elicited heart rate accelerations are associated with a normal umbilical cord arterial pH (7.20 or greater).
Recurrent variable decelerations, thought to be a physiologic response to repetitive compression of the umbilical cord, are not themselves pathologic.
However, if frequent and persistent, they can lead to fetal acidemia over time. Conservative measures, such as position change, may improve this pattern.
How to Safely Reduce your Risk of a Cesarean Birth For Induction of Labor:
Before 41 0/7 weeks of gestation, induction of labor generally should be performed based on maternal and fetal medical indications.
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.
Cervical ripening methods should be used when labor is induced in women with an unfavorable cervix.
Numerous studies have found that the use of cervical ripening methods––such as misoprostol, dinoprostone, prostaglandin E2 gel, Foley bulbs, and laminaria tents––lead to lower rates of cesarean delivery than induction of labor without cervical ripening.
There is data to support the use of more than one of these methods sequentially or in combination, such as misoprostol and a Foley bulb, to facilitate cervical ripening.
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 or longer) and requiring that oxytocin be administered for at least 12–18 hours after membrane rupture before deeming the induction a failure.
Evidenced-Based Research Guidelines on How to Safely Reduce your Risk of a Cesarean Birth For Suspected Large for Gestational Age Baby (Macrosomia)
If you, a family member, partner, friend, or client has told you that they recently got an ultrasound and there doc told them that they have a Large for Gestational Age Baby (Macrosomnia) and wants to schedule a medical induction before 42 weeks have them do their BRAIN! (Benefits, Risks, Alternatives, Intuition and Now?)
According to the ACOG March 2014 study, it shows that low-risk nulliparous mothers who have been suspected of having a large for gestational age baby are at only a 4 percent risk of having labor complications that would ultimately result in having a cesarean birth!
Research has shown that when a mother is medically induced it puts her at a 27-50 percent risk of having a cesarean birth and creates additional risk to mother and baby (death, postpartum bleeding, genital tract injury; wound disruption, wound infection, or both; systemic infection)
Gregory KD, Jackson S, Korst L, Fridman M. Cesarean versus vaginal delivery: whose risks? Whose benefits? Am J Perinatol 2012;29:7–18.
Make sure you share this evidence based information with your doc and tell him/her that the risks outweigh the benefits of getting medically induced and that you would rather attempt to go into labor naturally. Tell your doc if for some reason the baby is too big to fit through the birth canal then let him/her know that you would be open to Plan B if there , which would be a cesarean birth.
Cesarean delivery to avoid potential birth trauma should be limited to estimated fetal weights of at least 5,000 g in women without diabetes and at least 4,500 g in women with diabetes. The prevalence of birth weight of 5,000 g or more is rare, and patients should be counseled that estimates of fetal weight, particularly late in gestation, are imprecise.
How to Safely Reduce your Risk of a Cesarean Birth For Twin Gestation:
The rate of cesarean deliveries among women with twin gestations increased from 53% in 1995 to 75% in 2008.
Perinatal outcomes for twin gestations in which the first twin is in cephalic presentation are not improved by cesarean delivery.
Thus, women with either cephalic/cephalic-presenting twins or cephalic/noncephalic presenting twins should be counseled to attempt vaginal delivery.
Ask your doctor if he has experience and has received ongoing training with twin vaginal deliveries.
How to Safely Reduce your Risk of a Cesarean Birth By Doing Audits and Feedback in the Hospital Setting:
Change the local culture and attitudes of obstetric care providers regarding the issues involved in cesarean delivery reduction can be challenging.
A 2007 review found that the cesarean delivery rate was reduced by 13% when audit and feedback were used exclusively but decreased by 27% when audit and feedback were used as part of a multifaceted intervention in the hospital setting, which involved second opinions and culture change.
How to Safely Reduce You or Your Client’s Risk of a Cesarean Birth By Taking Additional Workshops or Classes as a Birth Professional or Birth Partner.
Acupressure Workshop for Midwives, Doulas, and Childbirth Educators
This workshop will give you the necessary tools to minimize your client’s pregnancy-related concerns, facilitate a more efficient and less painful labor in order to promote a natural unmedicated childbirth, and minimize your client’s postpartum-related concerns.
Please contact Nick Olow, L.Ac.at 619-405-5282 for an updated listing of classes in your area.
Acupressure Workshop for Birth Partners:
This hand's on practical workshop that will show you how to safely and effectively provide comfort measures to minimize your wife or partner’s pregnancy-related concerns and also facilitate a more efficient and less pain labor in order to promote a positive and natural childbirth experience.
Please contact Nick Olow, L.Ac.at 619-405-5282 for an updated listing of classes in your area.
Lamaze International promotes a natural, healthy and safe approach to pregnancy, childbirth and early parenting practices.
To find classes in your area, or for more information visit: www.lamaze.org.
The Bradley Method® classes teach families how to have natural births
To find classes in your area, or for more information visit: http://www.bradleybirth.com/
Hypnobirthing will teach you how to use your natural birthing instincts for a calm, serene and comfortable birth in order to promote a natural childbirth.
To find classes in your area, or for more information visit: http://hypnobirthing.com/
Belonging to ImprovingBirth.org, www.ican-online.org, and taking a VBAC facts workshop http://vbacfacts.com/ are great resources to help you or your client's make educated and informed decisions how to safely reduce your chances of having a cesarean birth.
Risk Factor associated with having repeated Cesarean Births:
An increasing number of prior cesareans is associated with the morbidity of placental previa: after three cesarean deliveries, the risk that a placenta previa will be complicated by placenta accreta is nearly 40%.
With placenta accrete, the placenta usually has difficulty separating from the uterine wall and puts the mother at risk for hemorrhaging during manual attempts to detach the placenta. Severe hemorrhaging can be life threatening. Other concerns involve damage to the uterus or other organs (percreta) during removal of the placenta. Hysterectomy is a common therapeutic intervention, but the results involve the loss of the uterus and the ability to conceive.
Research has shown that the initial cesarean delivery is associated with some increases in morbidity and mortality, but the downstream effects are even greater because of the risks from repeat cesareans in future pregnancies.
If you can please share this information with your clients, family, partner, friends, and loved ones who are pregnant and interested in making an educated and informed decision on how to safely reduce their chances of a cesarean birth that would great!
Nicholas Olow, BA, MS, L.Ac.
Board Certified and Licensed Acupuncturist
DONA and ACNM Approved CEU Provider
Specializing in Pregnancy Care, Labor Support, Postpartum Care, and Pain Management
Founder and Director of AcuMassage Therapy Center
4417 30th Street, Suite 111
San Diego, CA 92116