Preventing the first cesarean delivery: summary of a joint Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, and American College of Obstetricians and Gynecologists Workshop

Abstract

With more than one third of pregnancies in the United States being delivered by cesarean and the growing knowledge of morbidities associated with repeat cesarean deliveries, the Eunice Kennedy Shriver National Institute of Child Health and Human Development, the Society for Maternal-Fetal Medicine, and the American College of Obstetricians and Gynecologists convened a workshop to address the concept of preventing the first cesarean delivery. The available information on maternal and fetal factors, labor management and induction, and nonmedical factors leading to the first cesarean delivery was reviewed as well as the implications of the first cesarean delivery on future reproductive health. Key points were identified to assist with reduction in cesarean delivery rates including that labor induction should be performed primarily for medical indication; if done for nonmedical indications, the gestational age should be at least 39 weeks or more and the cervix should be favorable, especially in the nulliparous patient. Review of the current literature demonstrates the importance of adhering to appropriate definitions for failed induction and arrest of labor progress. The diagnosis of "failed induction" should only be made after an adequate attempt. Adequate time for normal latent and active phases of the first stage, and for the second stage, should be allowed as long as the maternal and fetal conditions permit. The adequate time for each of these stages appears to be longer than traditionally estimated. Operative vaginal delivery is an acceptable birth method when indicated and can safely prevent cesarean delivery. Given the progressively declining use, it is critical that training and experience in operative vaginal delivery are facilitated and encouraged. When discussing the first cesarean delivery with a patient, counseling should include its effect on future reproductive health.

Figure 1

Algorithm for induced labor.

Figure 2

Algorithm for spontaneous labor. *Try not to admit unless at least 3 cm dilated. †Expectant management; no need for intervention.

Figure 3

Assessment of intrapartum fetal heart rate monitoring. *Given the wide variation of fetal heart rate (FHR) tracings in Category II, this algorithm is not meant to represent assessment and management of all potential FHR tracings, but provide an action template for common clinical situations. † Intrauterine resuscitative measures may include oxygen supplementation, position change, intravenous fluids, stopping oxytocin, tocolysis, amnioinfusion, etc. ‡Timing and mode of delivery based on feasibility and maternal-fetal status. Modified from ACOG Practice Bulletin No. 116. Assessment of intrapartum fetal heart rate tracings. Obstet Gynecol 2010;116:1232–40.