“The greatest risk to both the mother and infant is not the initial cesarean section, but those that follow.”
Changing tide ACOG President John Jennings, MD, chair of the Texas Medicine Editorial Board, says maternal obesity and an increase in the average age of mothers have contributed to the rise in cesarean sections since 1996. He says ACOG no- ticed the spike and decided to change the tide. “This revision of the traditional labor
curve is based on good science. Our phy- sicians need to pay attention to these changes,” he said. Dr. Jennings says the rate of cesar- ean sections will fall gradually as more physicians opt to follow the recommen- dations and perform operative vaginal deliveries when possible. “The use of forceps is a lost art,” he
The authors used data from National Vital Statistics to determine one in three women who gave birth in the United States in 2011 did so by cesarean deliv- ery. Cesarean deliveries rose 60 percent from 1996 to 2009, according to the Centers for Disease Control and Preven- tion’s (CDC’s) National Center for Health Statistics.
The authors of the ACOG study say despite the rise in cesarean delivery, no evidence suggests the increase has re- duced maternal or neonatal morbidity or mortality. According to the study, the data raise significant concern that doctors perform cesareans when other paths, such as less invasive operative vaginal delivery, could be taken.
If the birth is not spontaneous and an operation is necessary, ACOG now recommends operative vaginal delivery over cesarean delivery. “Training in and ongoing maintenance of practical skills related to operative vaginal delivery should be encouraged,” the report states. To read the full set of recommenda- tions, visit
http://bit.ly/SafeCSection. The recommendations will likely
mean more training for physicians in res- idency and more refresher courses and simulations for practicing obstetricians, says Houston obstetrician-gynecologist Carla Ortique, MD. According to the study, the rate of op-
42 TEXAS MEDICINE June 2014
erative vaginal delivery has fallen signifi- cantly in the past 15 years. Dr. Ortique, chair of TMA’s Committee on Maternal and Perinatal Health, says the ACOG recommendations are an important first step in changing patients’ and physicians’ attitudes toward cesarean sections. “An operative vaginal delivery, in the
appropriate clinic setting, over the long term is more beneficial to the mother,” she said. “She may accept greater risk from having a C-section.” But, Dr. Ortique says, one of the rea-
sons for the rise in cesarean rates is that many obstetricians lack experience and practice using common operative vagi- nal delivery tools such as forceps and vacuums. “If they’re not trained, they are obvi- ously not going to do those things,” she said. “So they have to do C-sections.” Risks associated with operative vagi- nal delivery include damage to the vagi- nal tract, extensive blood loss, and dam- age to the fetus, especially when a doc- tor’s skills have not been honed because of lack of practice, Dr. Ortique says. Of the new findings, she says, “My hope is that they don’t compel practic- ing obstetricians to practice outside their level of expertise and comfort.” If physicians are well-trained in op- erative vaginal delivery, when used in the appropriate clinical setting, the risk to both the mother and the child is low, she adds.
said. “It’s going to take a while before the trends change.”
That’s because physicians have long based the duration of labor on the Fried- man Curve, which plots the typical rate of cervical dilation and fetal descent. “We have good research that shows our traditional Friedman Curve is prob- ably inaccurate,” he said. The active phase of labor, during which the cervix becomes fully dilated, has traditionally been considered ab- normal when cervical dilation is less than 1.2 centimeters (cm.) an hour for women who have never given birth and 1.5 cm. an hour for women who have given birth. According to ACOG’s study, new data
from the Consortium on Safe Labor (CSL) indicate women dilate more slow- ly than historically thought, regardless of whether the woman has previously given birth. ACOG now recommends physi- cians consider cervical dilation of 6 cm. the beginning of the active phase. The second stage of labor begins when the cervix is fully dilated and ends with delivery.
Use of epidural analgesia, maternal
obesity, and increased birth weight have all been shown to lengthen the second stage of labor, ACOG says. The study outlines several reasons for
cesarean deliveries. Seventy-four percent are the result of either labor arrest, ab- normal or indeterminate fetal heart rate tracing, or fetal malpresentation, such
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