Full Circle Midwifery

Reprinted from Childbirth Connection

What Pregnant Women Need to Know

MARCH 2014

In March 2014, the two leading obstetric professional organizations in the United States issued a landmark joint consensus statement. The statement says that cesarean birth is overused in the United States. More and more cesareans – now one in three births – have not led to better health for mothers and babies. While this procedure offers clear benefits in some situations, it appears to pose greater risk for quite a few problems in women and babies in low-risk pregnancies. The American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine identify many ways to safely reduce the chance of cesarean birth. They focus on preventing “primary” or initial cesareans in pregnant women who have never had a cesarean.

The focus on preventing cesareans that offer no clear benefit is good for women and babies. When hospitals and maternity care providers reliably follow the recommendations in this welcome statement, our high cesarean rate will fall. But, health care practice changes slowly. All parties, including women, have a role in ensuring that the best care is provided. To help pregnant women prepare to talk with their maternity care providers and make good care decisions, this guide summarizes the new recommendations. It also adds a few more practices that can reduce the chance of cesarean and gives links for learning more.

Recommended practices. The new recommendations emphasize ensuring that your body is ready for labor, being patient with labor, and having good support during labor. The

statement recommends the following ways to reduce your likelihood of having a cesarean, noting that these may not be appropriate in all cases:

Labor induction

• Labor induction (using drugs or other methods to try to cause labor to start) before the 41st week of pregnancy should be done for medical reasons.
•  Before inducing labor, if a woman’s cervix is not soft and ready to open, drugs or devices for “cervical ripening” should be used to help prepare it for labor.
•  Cesarean should not be used for unsuccessful labor induction (“failed induction”) until at least 24 hours of labor have passed without reaching a cervical opening (“dilation”) of 6 centimeters.
•  If membranes are broken, cesarean should not be used for unsuccessful labor induction (“failed induction”) until synthetic oxytocin (“Pitocin,” a drug that is used to start labor) has been used for at least 12 to 18 hours.

Labor before the pushing phase

•  Labor before the cervix is open 6 centimeters is known as “latent” labor. Cesarean is not appropriate when latent labor is “prolonged,” that is, has gone on for more than 20 hours in first-time mothers or more than 14 hours in experienced mothers.
•  Labor after the cervix is open 6 centimeters is known as “active” labor. Cesarean should only be done for poor progress in active labor if 1) membranes are broken and there have been 4 hours of contractions with no progress or 2) synthetic oxytocin (“Pitocin,” a drug that is used to strengthen contractions) has been used for 6 hours with no progress.
• Cesarean is not appropriate before the pushing phase of labor if labor is slow but progressing.Labor during the pushing phase

•  There is no fixed upper time limit for the pushing phase of labor.
• Intervention should not be used for lack of progress (“arrested” labor) until first-time moms have pushed for at least 3 hours and experienced moms for at least 2 hours. More time may be appropriate, e.g., if the woman is using epidural pain relief or the baby is not well-positioned for passing through the pelvis, so long as some progress is being made.
• When the baby is not well-positioned for passing through the pelvis, having a provider use a hand to move the head to a better position (“manual rotation”) may avoid the need for “assisted” vaginal birth (with vacuum extractor or forceps) or cesarean birth.
• When intervention is needed during the pushing phase of labor, a provider’s skilled, experienced use of a vacuum extractor or forceps is a safe alternative to cesarean birth.Other

•   Continuous labor support, such as labor doula care, reduces risk of cesarean.
•   Cesarean is not appropriate for most babies that are estimated to be large near the endof pregnancy (estimates are often wrong, and many large babies are born vaginally). It may be appropriate if the baby is estimated to be at least 4,500 grams in women with diabetes and at least 5,000 grams in other women (5,000 grams, or 11 pounds, is rare).
•   If a baby is breech (buttocks- or feet-first) at about 36 weeks of pregnancy, hands-to- belly movements to turn babies head-first (“external cephalic version”) should be offered.
•   Women with twins and the first twin head-first should be encouraged to plan a vaginal birth.
•   Women who have had herpes simplex virus should consider using acyclovir, a medication to prevent a late-pregnancy outbreak, and should plan a vaginal birth if the virus is inactive at labor.
•   Counseling women about avoiding excess pregnancy weight gain may avoid cesareans.Other ways you can lower your chance of having a cesarean. While not included in the new statement, research suggests that the following also reduce your chance of cesarean section:
• Choose a care provider or group and birth setting with relatively low cesarean rates.
•   Work with care providers to delay going to the hospital until labor is well under way.

•   Ask for “intermittent auscultation” – periodic listening with various devices – to monitor fetal heart patterns rather than continuous electronic fetal monitoring during labor.
•   Stay upright and move around in labor before the pushing phase. This is especially possible without or before the use of epidural pain relief.Being fit and well-rested at the end of pregnancy could increase your stamina for labor, including a longer labor that may prevent the use of cesarean section.

  Resources. Childbirth Connection Programs at the National Partnership for Women & Families provide many resources with more information about cesarean birth and planning for a safe and healthy birth. These include:
   Understanding & Navigating the Maternity Care System

•   What Every Pregnant Woman Needs to Know About Cesarean Section
•   Why is the National U.S. Cesarean Section Rate So High?
•   Graph and table of national cesarean trends and rates
•   Factors driving the use of cesarean section – what Listening to Mothers surveyparticipants told us about their views and experiences with cesarean and vaginal birth.

  Childbirth Connection has joined forces with and become a core program of the National Partnership for Women & Families. Together, we will continue transforming maternity care in the United States. More information is available at www.ChildbirthConnection.org and www.NationalPartnership.org.

  © 2014 National Partnership for Women & Families. All rights reserved.