as breech birth. Each instance requires a different solution, ACOG says. Under traditional best practices, if the
cervix fails to change dilation for two hours or more, a physician could diag- nose active phase arrest. CSL is now say- ing labor arrest should not be diagnosed before 6 cm. of dilation. Before physicians diagnose labor ar-
rest, ACOG recommends they ensure the patient has been pushing for at least two hours if she has previously given birth and at least three hours if she has never given birth. ACOG guidelines state pa- tients in active phase labor arrest should have a C-section once they have reached at least 6 cm. of dilation and have failed to progress for four to six hours.
Worth the risk? According to the National Institutes of Health, cesarean delivery is the safest path in certain instances, such as pla- centa previa and uterine rupture. Houston neonatologist and TMA Past
President Michael Speer, MD, says the cesarean section is an appropriate op- tion in an emergency, but cesareans per- formed for the wrong reasons must be controlled. “You need to have a reason,” he said. “It’s not good to muck around with Moth- er Nature.” In Texas, more than 35 percent of de- liveries were cesarean in 2010, slightly more than the national average of about 33 percent, the AJOG study shows. Dr. Speer says in his 38 years practicing medicine, he has seen firsthand the in- creasing number of cesarean sections and the subsequent increased need for newborn intensive care. “Anything that can decrease unwar- ranted cesarean sections is good, and I think that these guidelines are long over- due,” he said.
Obstetricians who are reluctant to say no to an uncomfortable expecting mother contribute to the high number of cesarean deliveries, Dr. Speer says. “Unfortunately, some mothers believe that delivery at 34 weeks is perfectly fine, as opposed to waiting until 40 weeks,” he said. Dr. Speer says nonmedically indicat- ed cesarean sections can yield disastrous
results. According to ACOG’s report, the risk of severe maternal morbidities, such as hemorrhaging that requires hysterec- tomy or blood transfusion, shock, car- diac arrest, or major infection, was 2.7 percent for a planned cesarean delivery, as opposed to 0.9 percent for a vaginal delivery. That’s a threefold increase. The chances of placental abnormali- ties in future pregnancies increase with each subsequent cesarean delivery, ACOG says. But data from the study show the number of women who de- livered vaginally after a prior cesarean delivery plummeted from nearly 30 per- cent in the mid-1990s to less than 10 percent in 2011. Dr. Speer says maternal deaths in the United States are at epidemic propor- tions. (Read “Preserving Mother’s Day,” September 2013 Texas Medicine, pages 53–57, or visit
www.texmed.org/Moth ersDay.) “The greatest risk to both the mother
and infant is not the initial cesarean sec- tion, but those that follow,” he said. Dr. Speer says if a woman does not have a cesarean delivery with her first child, the chances are she will not have a cesarean in subsequent deliveries. “The trick is stopping the first cesar-
ean,” he said. Another reason for the rise in cesar- ean deliveries could be financial, Dr. Speer says. According to “Physicians Treating Physicians: Information and Incentives in Childbirth,” a paper published by the Social Science Research Network last July, some payers gave physicians a few hundred dollars more for a cesarean sec- tion than for a vaginal delivery; some payers awarded hospitals a few thou- sand dollars more for the procedure. Dr. Speer says Medicaid pays the same amount for a cesarean as it pays for a vaginal delivery, but this might not be the case with all payers. He says pay-
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