New guidelines urge fewer caesarean births

In an effort to curtail caesarean sections, two prominent medical groups issued guidelines Wednesday calling for doctors to let first-time mothers remain in labor longer, and push harder, to see if more babies can be delivered vaginally.

The recommendation was driven by recent studies showing that the rise over the past decade in caesarean sections hasn’t led to better health outcomes for women or babies, such as lower mortality rates.

“C-sections save lives” when used in certain emergency situations, said Dr. Vincenzo Berghella, president of the Society for Maternal-Fetal Medicine, the organization that issued the new recommendation along with the American College of Obstetricians and Gynecologists.

“But we also know that some can be safely prevented and that having multiple surgical deliveries raises the risk of placenta abnormalities, hysterectomies, and bladder and bowel injuries, making them dangerous for mothers and babies.”

Some obstetricians, though, may resist the advice, which includes allowing patients more time to dilate during labor, letting first-time mothers push for three hours or even longer, and using forceps to get the baby out vaginally.

“We are paid a little bit more to perform C-sections, but the bigger reason for doctors to do them is that they’re more convenient and quicker than vaginal labor,” said guideline co-author Dr. Aaron Caughey, chairman of obstetrics and gynecology at Oregon Health and Science University.

“These recommendations are of absolutely no benefit to an ob-gyn’s work-life balance nor pocketbook,” Caughey added, “but this never came up when we were writing them or having them reviewed by colleagues.”

The movement to reduce the caesarean rate — 1 in 3 women now have the surgery in Massachusetts, compared with 1 in 5 in 1997 — has been growing stronger over the past few years in Massachusetts and elsewhere. Rates vary widely among states, ranging from 23 percent to 40 percent of all births, according to the latest statistics from the federal government.

The same is true among hospitals in Massachusetts. A 2011 Department of Public Health report showed that the 2009 caesarean rates for first-time mothers with low-risk pregnancies ranged from 10 percent to 35 percent.

“There isn’t a magic number to define an ideal C-section rate for hospitals,” Caughey said, because a mother’s age, weight, income, or ethnicity can play a role in increasing the likelihood of surgery.

Still, he added, “we think we’re somewhere above where we should be.”

The new guidelines aim to prevent unnecessary caesareans in first-time mothers, in part, by recommending that women not be considered to be in active labor until they reach 6 centimeters of dilation, rather than the previous standard of 4 centimeters, which most gynecologists over age 40 learned in their training.

Dr. Allison Bryant Mantha, an obstetrician-gynecologist at Massachusetts General Hospital, said she and her colleagues shifted over to the new standard a few years ago.

“Six centimeters has become part of common parlance to define active labor,” she said, “because we understand that often C-sections are performed unnecessarily due to worries about slow or prolonged labor” in which women take hours to get from 4 centimeters to 6 centimeters.

The guideline authors pointed to several studies suggesting no increase in bad outcomes among infants born to women who had a longer duration of this middle stage of labor or who engaged in prolonged active pushing at the end.

One large Canadian study also found that mothers who delivered vaginally fared better, with fewer than 1 percent experiencing a life-threatening complication, such as a serious infection or excessive bleeding or uterine rupture that required a hysterectomy, compared with nearly 3 percent of those who had caesarean deliveries.

Doctors were told to counsel women about gaining an appropriate amount of weight during their pregnancies to prevent obesity, a caesarean risk factor; the guidelines also recommended that doctors attempt to turn breech babies into a head-down position about a month before the due date. Most breech babies require surgical deliveries to ensure that the head does not get stuck in the pelvis.

“These recommendations are all in synch with what we’ve been advocating,” said Michele Ondeck, a nurse and president of Lamaze International, a natural childbirth organization.

“Doctors are being asked to evaluate their birth practices and to consider making changes if their C-section rate is at the higher end.”

Expectant mothers can take steps as well to minimize their risk of a surgical birth. “They can ask about the hospital caesarean rate,” Ondeck added, “and if there’s a plan for quality measures to reduce unnecessary surgeries.”