Why is reducing the Cesarean Delivery rate so important?
The answer is patient safety. The maternal mortality rate in the United States has remained among the highest of developed countries and has not been decreasing. The risk of maternal mortality with Cesarean delivery is 3.6 times higher than with vaginal delivery. Given the perceived safety of this mode of delivery, providers and patients often take for granted that Cesarean delivery is a major surgical procedure, associated with risks of infection, higher blood loss, operative injury, anesthesia complications, risks of blood clot formation, etc. Moreover, having a Cesarean delivery puts a patient at higher risk of complications in future pregnancies, including the risk of placenta accreta, hysterectomy, uterine rupture, or difficulty delivering baby due to scar formation. More than 90% of women who require an initial Cesarean delivery will have a repeat Cesarean in their subsequent pregnancy. This makes lowering the primary Cesarean delivery rate that much more important.
What can patients do to help in achieving this goal?
The best thing patients can do is to play an active role in their healthcare. Ask questions of your provider and encourage your provider to explain the medical reasons of any test or procedure he or she may recommend. Do your research in choosing your labor care provider and inquire about their own Cesarean delivery rate and their labor management style. Another key strategy patients can use is to await spontaneous labor. Induced labor is not as successful in achieving vaginal delivery, thus awaiting spontaneous labor is one of the best things patients can do to decrease their chances of requiring a Cesarean delivery. If, in fact, you do require a Cesarean delivery, talk to your provider about the specific indications and inquire if you would be a candidate for a trial of vaginal delivery in the future. Just remember, you are your own advocate in your healthcare.
What is Wasatch OB/GYN doing to help?
Our providers function as a team in caring for patients. Our call structure is such that lifestyle factors and time constraints do not influence the way we manage laboring patients. We are also employed physicians, thus eliminating financial disincentives to awaiting a vaginal delivery. Our physicians do not practice in such a way to encourage elective inductions, especially in our first-time mothers; labor inductions are performed for medical reasons. We promote spontaneous labor, always with the goal of achieving a vaginal delivery. As such, our group Cesarean delivery rate is around 15%, well below the Healthy People 2020 goal.
How can this goal be achieved?
In a joint workshop of 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, an evaluation of ways to reduce the primary Cesarean delivery rate revealed that some of the major contributing factors were: failed induction of labor, arrest of labor, non-reassuring fetal status, and malpresentation. Therefore, the following key points were identified:
• Labor induction should be performed for medical reasons only.
• If elective, labor induction should only be performed after 39 weeks gestational age, and in the setting of a favorable cervix (typically 2-3 cm dilated)
• Providers should adhere to appropriate definitions of failed induction and arrest of labor, allowing adequate time for labor to progress, as long as mom and baby are doing well.
• Less aggressive means at furthering labor along should be used whenever possible to ensure the well-being of mom and baby.
• External cephalic version (rotating the baby to head down) should be considered in the setting of breech presentation whenever possible.
• Operative vaginal delivery (vacuum or forceps) should be considered an acceptable birth method when feasible.
• Prior to proceeding with Cesarean delivery, patients should be adequately counseled about the risks and implications for future pregnancies.
• Non-medical factors such as provider time constraints and financial incentives or disincentives should be limited by instituting practice management strategies that promote allowing adequate time for vaginal delivery.