Obstetricians Call for Fewer Cesarean Sections

You know when a professional association recommends doing fewer procedures for which its members get paid, there’s probably a good reason. That’s the case with delivering a child by cesarean section.

The American Congress of Obstetricians and gynecologists (ACOG) recently called on its members and all medical practitioners to stop doing so many C-sections. As explained by the Associated Press (AP), new guidelines direct doctors to give otherwise healthy women more time to deliver their babies vaginally before assuming that labor has stalled.

It’s the latest news in a years-long effort to prevent unnecessary C-sections, which have become increasingly popular, often for reasons of convenience more than good medicine.

According to the Centers for Disease Control and Prevention (CDC), nearly 1 in 3 women in the U.S. gives birth by cesarean.

Sometimes, the procedure is necessary to save the life of the mother or the baby. Sometimes, it’s necessary because labor was unwisely induced with oxytocin (Pitocin), a hormone that stimulates uterine contractions. Sometimes, it’s a matter of parents trying to squeeze child birth into the schedule of life events. And sometimes, it’s about doctors fearful of being sued if someone thinks they waited too long for vaginal delivery.

In crafting the guidelines, ACOG and the Society for Maternal-Fetal Medicine found that a primary reason for a first-time C-section is labor that’s progressing too slowly. But slow is not the same as troubled, at least not always. Performing a C-section has definite risks, and the procedure greatly raises the chances of a subsequent pregnancy also ending in a C-section. Like any surgery, if it isn’t medically necessary, it’s a bad idea.

As noted in our C-section backgrounder, the risks of C-section include premature delivery (thanks to Pitocin); injury to the mother’s ureters (tubes that carry urine from the kidneys to the bladder), bowels or other pelvic organs; a higher likelihood of uterine rupture in future pregnancies.

Common sense and a reordering of priorities is the best defense against parents whose timetable is more important than good health care, but in the case of obstetricians overly concerned about making mistakes, well, these guidelines are the latest “best evidence” that labor can take longer than you want. Provided the practitioner is monitoring the mother and the fetus for serious distress resolved only by surgery, being sued for making a waiting mistake isn’t a reasonable concern.

”Labor takes a little longer than we may have thought,” Dr. Aaron Caughey told AP. He’s a co-author of the guidelines.

Caughey told AP that when it comes to labor, every woman is different. ”My patients ask this every day,” he said, and that the answer can ”run the gamut from six hours long, start to finish, to three and four days,” and any woman who endures that should win a medal.

Complicating the answer to “when is a long time too long a time?” is that the art of assessing the progress of labor might have advanced since many doctors learned about the different stages of labor in medical school.

According to the AP, a study from the National Institutes of Health in 2012 found that one stage can take 2½ hours longer now than it did in the 1960s, when many labor definitions were set.

That might be because today’s mothers are older and weigh more, but also because of changes in obstetric practice, such as more use of pain medicine, which can slow labor.

Considering these changes and the world we live in, for pregnancies that involve otherwise low-risk mothers and fetuses:

  • Obstetricians should not order a C-section just because the first and longest phase of labor is prolonged. That’s when contractions are mild and far apart, and the mother’s cervix is barely dilated. Doctors used to consider it stalled if it lasted longer than 20 hours for a first-time mom, or 14 hours for returning mothers.
  • Obstetricians should consider that “active labor” begins later than once thought – not until the cervix is dilated 6 centimeters instead of the outdated 4 centimeters. That’s when contractions become stronger and more frequent, and the cervix begins to dilate more rapidly until the woman eventually is ready to push.

    It’s a key change because many doctors won’t admit women to the hospital until they’re in active labor, unless they need more care for another reason.

  • Obstetricians should allow women, if they’re not too tired, to push at least two hours if they have delivered before, three hours if it’s their first baby. They may push longer if they had an epidural (pain medicine), as long as the doctor can see progress.
  • Obstetricians should consider using forceps as a safe alternative to certain cesareans if they’re used by an experienced, well-trained physician. Few physicians today undergo the training.

Find out what a doctor’s cesarean rate is before choosing an obstetric practice. Discuss vaginal delivery versus C-section with your obstetrician long before your due date. Ask if he or she is familiar with the new guidelines, and what he or she considers as “normal labor.”

Long before you’re in the delivery room, you should know how the doctor supports women in labor, what he or she considers too long and agree about both. If your doctor says labor has stalled, ask if either you or the baby is in danger if you continue waiting.

No one wants to prolong labor. But neither does anyone want an adverse outcome, for this pregnancy or one you’re yet to experience.

Tragic cases of babies being born with brain damage do happen because of malpractice by either the doctor or nurses in not carefully monitoring the baby’s heartbeat and responding quickly when the baby shows signs of distress from not getting enough oxygen. These are the types of situations the Patrick Malone law firm confronts each year. Our firm website has extensive resources for parents of children with birth injuries.

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