1. Preventing the First Cesarean Delivery
Katharine D. Wenstrom, MD
Director of Maternal-Fetal Medicine
Women and Infants Hospital of RI
Warren Alpert Medical School, Brown University

2. I have no conflicts to disclose

3. Discuss current data on the “normal” progression of labor.
Objectives:
Describe medical and social factors that contribute to the high cesarean rate in the US.
Discuss current data on the “normal” progression of labor.
Describe evidence-based management approaches to preventing the first cesarean.
Describe how hospital polices, practitioner schedules, financial issues, medical legal concerns, and other factors all influence the management of labor.

4. Important Recent Literature Reviews/Guidelines:
Preventing the first cesarean: Summary of a joint SMFM, NICHD, ACOG Workshop. Spong CY, Berghella V, Wenstrom K, Mercer BM, Saade GR. Obstet Gynecol 2012; 120:
Safe Prevention of the Primary Cesarean Delivery Obstetric Care Concensus by ACOG and SMFM Obstetrics and Gynecology 2014; 123(3): 693

5. Source: CDC/NCHS, National Vital Statistics System.

6. US Total Cesarean Delivery Rates by State, 2010
Data from Martin et al.77
ACOG. Safe prevention of primary cesarean delivery. Am J Obstet Gynecol 2014.

8. Cesarean Delivery, by Gestational Age: United States,
Final and Preliminary 2011
NOTES: Singletons only. Early preterm is less than 34 weeks of gestation; late preterm is weeks; early term is weeks; full term is weeks. Access data table for above at:
Source: CDC/NCHS, National Vital Statistics System.

9. US Delivery Rates, 1989 through 2011
CD, cesarean delivery; VBAC, vaginal birth after cesarean delivery.
*Percent of women who have VBAC; yRate based on total number of deliveries.
Data from National Vital Statistics and from Martin et al.77
ACOG. Safe prevention of primary cesarean delivery. Am J Obstet Gynecol 2014.

10. Repeat Cesarean Rate

11. 50% of the increasing CS rate
Primary cesareans account for
50% of the increasing CS rate

12. Neonatal Risk of Adverse Outcomes by Mode of Delivery
Vaginal Cesarean
Laceration NA – 2.0 %
Resp Morbidity < 1.0 % – 4.0 %
Shoulder Dystocia – 2.0 % %
AJOG 2014; 123:

13. Maternal Risk of Adverse Outcomes by Mode of Delivery
Vaginal Cesarean
Morbidity and Mortality* % %
Severe M and M** % %
Maternal Mortality :100, : 100,000
Amn Fluid Embolism :100, : 100,000
3rd or 4th° Laceration – 3.0% NA
Placental Abnormalities Increased with cesarean;
Risk goes up with each cesarean
Urinary Incontinence No difference
Postpartum Depression No difference
AJOG 2014; 123:
* Cochrane Review 2011, 12 ** CMAJ 2007;176:455

14. Compared With the First Cesarean Delivery
Complications of Subsequent Cesarean Deliveries
Compared With the First Cesarean Delivery
Cesarean Placenta Cesarean
Delivery Accreta OR (95% CI) Hysterectomy OR (95% CI)
First* % — % —
2nd % (0.7–2.3) % (0.4–0.97)
3rd % (1.3–4.3) % (0.9–2.1)
4th % (4.8–16.7) % (2.4–6.0)
5th % (3.8–25.5) % (2.7–11.6)
≥ % (11.3–78.7) % (6.9–33.5)
Silver et al Obstet Gynecol 2006; 107: 1226

15. Target Cesarean Rate Healthy People 2020
Low risk, full term, singleton, vertex: 23.9%*
*Healthy People 2010 : 15%

16. Core Issues Provider practices Induction of labor
Diagnosis of labor arrest
Fetal Intolerance of Labor
Provider practice preferences, workload, financial incentives/disincentives
Patient perceptions/education and societal attitudes
(Medical-Legal Issues)

17. Systems Based Approaches
Primary cesarean incidence
Hospitals
Payors
OB Providers
Patients

18. Consortium on Safe Labor
L and D data from 228,668 deliveries at ≥ 23 weeks, at 19 US hospitals, : • First delivery in database selected: 206,969 women • Overall CS rate = 30.5% (Nullips = 31.2%) Zhang et al Am J Obstet Gynecol 2010; 203: 326

19. Non -Obstetric Factors Influencing Cesarean Rate
Maternal age (age < 20 = 21%; age ≥ 35 = 42%)
Obesity (BMI <25 = 22.3%; BMI ≥ 35 = 43.7%)
Multifetal Gestation (65.9%)
Zhang et al Am J Obstet Gynecol 2010; 203: 326

20. Birth Rates, by Selected Age of Mother:
USA, Final and Preliminary 2013

21. Trends in Overweight and Obesity Among Adults, United States, 1962–2010
■ Overweight     ■ Obesity     ■ Extreme obesity

22. Percent of Women with Cesarean Deliveries by BMI: Nulliparas
Deliveries Cesareans(%)
TOTAL ,
BMI Category
< ,
25.0 – ,
30.0 – ,
35.0 – ,
≥ ,
Kominiarek et al
AJOG, 2010; 203:126 e1

23. Percent of Women with Cesarean Deliveries, by BMI: Multips, Prior CS
Deliveries Cesareans(%)
TOTAL ,
BMI Category
<
25.0 – ,
30.0 – ,
35.0 – ≥
Kominiarek et al
AJOG, 2010; 203:126 e1

26. Obstetric Factors Influencing the Cesarean Rate
Pre-Labor Cesarean:
Previous cesarean (45.1%)
Elective* (26.4%)
Malpresentation (17.1%)
Intrapartum:
FTP or CPD (47.1%)
Nonreassuring fetal status (27.3%)
*Declined TOL, AMA, muliparity, post term, diabetes, chorio,
chronic HTN, PROM, HPV, GBS, polyhydramnios, IUFD,
desires TL, social/religious
Zhang et al Am J Obstet Gynecol 2010; 203: 326

27. Potentially Modifiable Obstetric Indications for the First Cesarean
Diagnostic Effect on Pre-Labor Maternal Indication Accuracy Preventing CS Preeclampsia High Small Prior shoulder dystocia Limited Small Prior myomectomy Limited Small Prior third-degree or 4th-degree High Small laceration, prior breakdown of repair, fistula Marginal and low-lying High Small placentation

28. Potentially Modifiable Maternal Indications for the First Cesarean
Diagnostic Effect on Pre-Labor Maternal Indication Accuracy Preventing CS Obesity (BMI>30) High Small Infection ( HSV, HCV, HIV) High Small Cardiovascular Disease High Small (HTN crisis, cardiomyopathy, pulmonary HTN, CVA or aneurysm) Inadequate Pelvis Limited Small Maternal Request NA Small

29. Potentially Modifiable Fetal Indications for the First Cesarean
Pre-Labor Diagnostic Effect on Fetal Indication Accuracy Preventing CS Malpresentation High Large Multiple gestation High Small Macrosomia Limited Small Malformations Moderate Small (eg NTD, hydrops)

30. Major Indications for Primary Cesarean Delivery
Stage Indication % Prelabor Malpresentation 10–15* Multiple gestation 3 Hypertensive disorders 3 Macrosomia 3 Maternal request 2–8

31. • Breech extraction and vaginal delivery of the
Malpresentation
External Cephalic Version at ≥ 36 weeks:
• Success Rate 58% (35-86%)
Breech Delivery of Second Twin:
In experienced hands:
• Breech extraction and vaginal delivery of the
nonvertex second twin does not increase
morbidity
• Attempted external cephalic version is a reasonable
alternative
Boggess and Chisholm. Obstet Gynecol Surv, 1997; 52(12):728

32. Major Indications for Primary Cesarean Delivery
Stage Indication % In labor First-stage arrest 15–30* Second-stage arrest 10–25 Failed induction 10 Nonreassuring FHR 10

33. FIGURE 3 Indications for primary cesarean delivery
Data from Barber et al.16
ACOG. Safe prevention of primary cesarean delivery. Am J Obstet Gynecol 2014.

34. Potentially Modifiable Intrapartum Indications for the First Cesarean
Diagnostic Effect on Labor Indication Accuracy Preventing CS Failed induction Limited Large Arrest of labor Limited Large Nonreassuring ante- Moderate Large or intrapartum fetal surveillance

35. Friedman’s Curve

36. Friedman’s Curve 500 Primips at term with complete data:
• 70% age 20 – 30 (range 13-42)
• 67% had gynecoid pelvis
•13.8% required pitocin (18% for induction)
• 98.2% delivered vaginally
Obstet Gynecol 1955; 5: 567

37. Friedman’s Curve Latent Phase 8.6 Active Phase 4.9 First Stage 13.3
Stage Mean (Hours)
Latent Phase
Active Phase
First Stage
Second Stage
Obstet Gynecol 1955; 5: 567

38. Consortium on Safe Labor
Multicenter retrospective study of 228,668 deliveries
62,415 parturients selected:
Term, singleton, vertex, spontaneous labor,
spontaneous vaginal delivery, normal outcome
Zhang et al; Obstet Gynecol 2010; 116(6): 1281

39. Consortium on Safe Labor

40. Consortium on Safe Labor

41. Friedman’s Curve

42. Consortium on Safe Labor
Stage Mean th percentile
Latent Phase hrs hrs
First Stage hrs hrs
Zhang et al; Obstet Gynecol 2010; 116(6): 1281

43. Friedman’s Curve
Stage Mean ± SD* 1 SD* 2 SDs* Latent Phase 8.6 ± Active Phase 4.9 ± First Stage 13.3 ± Second Stage 0.95 ± *Hours Obstet Gynecol 1955; 5: 567

44. Friedman’s Curve Protracted Latent Phase
27 women has latent phase > 20 hours;
2 delivered by CS (7%)
Failure to Progress (“Inertia”)
46 patients had First Stage = ± 1.8 hours
Second Stage = 1.6 ± 0.22 hours;
6 delivered by CS (13%)
Obstet Gynecol 1955; 5: 567

45. Friedman’s “Ideal” Curve, Based on 200 “Ideal” Labors
Stage Mean ± SD* 1 SD* 2 SDs* Latent Phase 7.1 ± Active Phase 3.4 ± First Stage 10.6 ± Second Stage 0.76 ± *Hours Obstet Gynecol 1955; 5: 567

46. Consortium on Safe Labor
Stage Mean* 95th%* [Friedman 2SD**]
Latent Phase [15.2]
First Stage [19.8]
* Hours after admission at cm
** “Ideal” Labor
Zhang et al; Obstet Gynecol 2010; 116(6): 1281

47. Definitions of Failed Induction and Arrest Disorders
First-Stage Arrest
6 cm or greater dilation with membrane rupture and
no cervical change for:
4 h or more of adequate contractions
(eg, 200 Montevideo units) or
6 h or more if contractions inadequate
Obstet Gynecol 2012; 120:1181
AJOG 2014;123(3): 693

48. Consortium on Safe Labor

49. Second Stage Duration in Nulliparas
Rouse et al:
4,126 women enrolled in the Pulse Ox trial who reached the second stage:
Hours in Second Stage
< 1 hr 1 to < to < to < to <5 ≥ 5
SVD % % % % % %
Op Vag 13% % % % % %
CS % % % % % %
AJOG 2009; 201: 357

50. Second Stage Duration in Nulliparas
Neonatal Morbidity
Hours in Second Stage
< 1 hr to < to < to < to <5 ≥ 5
pH< % % % % % %
NICU % % % % % %
Intubation % % % % % %
Sepsis % % % % % %
Brach Inj * % % % % % %
Composite % % % % % %
* AOR 1.78[ ]
Am J Obstet Gynecol 2009; 201: 357

51. Second Stage Duration in Nulliparas
Maternal Morbidity
Hours in Second Stage
< 1 hr 1 to < to < to < to <5 ≥ 5
Chorio* % % % % % %
Endometritis 1% % % % % %
3rd /4th ** % % % % % %
Atony *** % % % % % %
Transfusion 1% % % % % %
*AOR 1.60 [ ]
** AOR 1.44 [ ]
*** AOR 1.31 [ ]
Am J Obstet Gynecol 2009; 201: 357

52. Second Stage Duration Similar findings reported by:
Moon et al. J Reprod Med, 1990; 35(3): 229
Retrospective review of1432 women with second
stage > 2 hours
No adverse neonatal outcomes
Cheng et al. AJOG 2004; 191: 933
Retrospective review of 15,759 multips
No adverse neonatal outcomes; maternal morbidity
increased after 4 hours

53. Definitions of Failed Induction and Arrest Disorders
Second-Stage Arrest
No progress (descent or rotation) for:
2 h or more in multiparous women without an epidural
3 h or more in nulliparous women without an epidural
[ 3 h or more in multiparous women with an epidural ]*
[ 4 h or more in nulliparous women with an epidural ]*
Obstet Gynecol 2012; 120:1181*
AJOG 2014;123(3): 693

55. Effect of Delivery Route on Neonatal Injury
Delivery Method Death ICH Other
Spont Vag Del :5, :1, :216
CS no labor :1, :2, :105
CS during labor :1, : :71
Vacuum :3, : :122
Forceps :2, : :76
Towner et al N Engl J Med 1999;341: 1709

56. Operative Vaginal Delivery
Maternal outcomes:
• Pelvic floor injury related to episiotomy, prolonged second stage, large fetus
• Pelvic floor dysfunction similar one year after operative vag delivery versus cesarean for nd Stage Arrest
• UI rates similar after ≥ 2 deliveries or in older women regardless of CS vs vaginal
Demisse K et al BMJ 2004; 329:24
Seidman DS et al Lancet 1992; 33: 1583
Crane AK. Female Pelvic Med Reconstr Surg 2013;19:13

57. Consortium on Safe Labor
Rate of Labor Induction:
36.2% (All)
43.8% (Women Attempting SVD)
Zhang et al; Obstet Gynecol 2010; 116(6): 1281

58. What is the Definition of a Failed Induction?

59. Rouse, et al. Failed Labor Induction: Toward an Objective Diagnosis
1,347 nullips at ≥ 36 weeks’; cervix no more than 2 cm, <100% effaced, ≤ 2 station:
● Active phase = 4 cm and 100%, or 5 cm
● Outcomes based on time of ROM and oxytocin
(● 50% got cervical ripening)
Obstet Gynecol 2011;117:267

60. Length of Latent Phase with ROM
ROM with Pitocin Vaginal Cesarean
0 to > 3 hours % %
3 to < 6 hours % %
6 to < 9 hours % %
9 to <12 hours % %
≥ 12 hours % %
Obstet Gynecol 2011;117:267

61. Fetal Outcomes ROM / Pit Time n NICU NICU>48° Composite*
0 to < 3 hours 1, % % %
3 to < 6 hours % % %
6 to < 9 hours % % %
9 to < 12 hours % % %
≥ 12 hours % % %
*5 min Apgar < 4; UA pH < 7.0; seizures;
intubation in DR; death, NICU > 48 hours
Obstet Gynecol 2011;117:267

62. Maternal Outcomes ROM /Pit Time n Infection 3rd /4th Lac Atony
0 to < 3 hours , % % %
3 to < 6 hours % % %
6 to < 9 hours % % %
9 to < 12 hours % % %
≥ 12 hours % % %
Obstet Gynecol 2011;117:267

63. • Harper et al. Obstet Gynecol 2012; 119: 1113
Induction of Labor
Simon et al. Obstet Gynecol 2005; 105: 705
397 Nullips undergoing induction of labor
Only latent phase > 18 hours increased rate of CS,
chorio, hemorrhage
No adverse neonatal outcomes
• Harper et al. Obstet Gynecol 2012; 119: 1113
5388 women laboring at term (1647 undergoing IOL)
Time required for each cm of cervical change in
latent phase was 2.0 – 5.5 hours longer in induced
labor

64. Definitions of Failed Induction and Arrest Disorders
Arrest of Labor
Failure to generate regular (eg, every 3 min)
contractions and cervical change:
● After at least 24 h of oxytocin administration,
and
● At least hours after ROM
Obstet Gynecol 2012; 120:118
AJOG 2014;123(3): 693

66. Management of FHR Tracings

67. Moderate FHR variability is reassuring
FHR acceleration after fetal scalp stimulation is reassuring

68. Non-Medical Factors Influencing Cesarean Rate
Institutional Factors:
Time constraints for scheduling in L and D
OR staff availability
Inability to support prolonged inductions
Physician Factors:
Fatigue, workload, anticipated sleep deprivation
Financial incentives and disincentives

69. Financial Incentives/ Disincentives for Cesarean
Spetz et al:
Birth certificate and hospital financial data from >500,000 births in California, 1995
Cesarean rates for patients with Kaiser
(salaried MDs, profit sharing, standard shifts for MDs, utilization review / education / guidelines)
versus
Other HMOs, private insurance, Medicaid, other payment forms
Medical Care 2001; 39(6): 536

71. Strategies to Reduce Cesarean Rates
Aggressive Laboring Techniques
Evidence Based Protocols
Confidential Provider Feedback on CS Rate
Perinatal Outcomes Feedback
Second Opinion /Peer Review
Review of Facilities. Staffing, Medical Care

72. Common Myths Among Patients
Cesarean is better for my baby
Operative vaginal delivery is bad
Labor is bad for the baby
Normal labor is a relatively short & predictable process
Long labor is bad for you and your baby
Induced labor is the same as spontaneous labor

73. Patient Perceptions/Education
More realistic patient expectations of labor onset, understanding the differences between spontaneous vs. induced labor, and inability to predict timing or provider
Improve patient’s understanding of labor benefits; labor can be/is safe and beneficial for both mother & baby
Help patients understand that cesarean has risks for both mother & baby

74. Medical Legal Issues!

75. Quality Measures to Track and Provide Feedback for Each Ob –Gyne
Rate of non-medically indicated cesarean delivery
Rate of non-medically indicated induction
Rate of labor arrest or failed induction diagnosed without meeting accepted criteria
Rate of cesarean deliveries for nonreassuring fetal heart rate (by NICHD category)

76. Summary
A cesarean performed without an accepted indication should be labeled “nonindicated”
Labor induction should be performed only for medical indications
Diagnosis of failed induction should be made only after an adequate attempt
Adequate time for normal latent, first, and second stages should be allowed

77. Summary
If maternal and fetal status is reassuring, diagnosis of arrest of labor should be made only after adequate time has elapsed
Medically indicated operative vaginal delivery is acceptable
When discussing the first cesarean, its effects on subsequent pregnancy should be explained
Financial incentives to limit the time spent managing labor should be eliminated