Safe Prevention of the Primary Cesarean Delivery
Safe prevention of the primary cesarean delivery is a matter deserving international attention. The following document discusses strategies for safely reducing the rate of primary cesarean deliveries. According to the ACOG/SMFM OBSTETRIC CARE CONSENSUS, 2014, it is vital to focus on the safe prevention of primary cesarean delivery by balancing risks and benefits.
Balancing Risks and Benefits
CS can be lifesaving for the fetus, the mother, or both in certain cases. For example, for placenta previa or uterine rupture: CS is firmly established as the safest route of delivery. However, for low risk pregnancies: CS has greater risk of maternal morbidity and mortality than VD.
Maternal and Neonatal Risks
Data suggests that the risk of severe maternal morbidities—including hge that requires hysterectomy or transfusion, uterine rupture, and anesthetic complications such as shock, cardiac arrest, acute renal failure, or assisted ventilation—was increased 3-fold for CS as compared with VD (2.7% vs 0.9%, respectively). Other risks include venous thromboembolism, major infection, or in-hospital wound disruption or hematomae.
Furthermore, there are significant long-term risks associated with CS, specifically regarding placental abnormalities. Placenta previa, in future pregnancies, increases with each subsequent CS, from 1% with 1 prior CS to almost 3% with 3 prior CS. After 3 CS, the risk that a placenta previa will be complicated by placenta accreta is nearly 40%. Additionally, neonatal complications may occur, such as neonatal intensive care unit admission and perinatal death.
Trends in Cesarean Section Rates (CSR)
There has been a rapid increase in CSR from 1996 through 2011 without clear evidence of concomitant decreases in maternal or neonatal morbidity or mortality: this raises significant concern that CS is overused. The following data highlights the variations across different regions:
- USA: 23% in 1991 to 32% in 2007.
- Canada: 18% in 1991 to 31% in 2008.
- Australia: 14% in 1995 to 29% in 2005.
- Italy: In Campania, 60% of 2008 births; in Rome, 44%-85% in some private clinics.
- Brazil: Up to 80%.
- Arab countries: Ranging from a low of 15% to a high of nearly 55%.
It is noted that maternal characteristics such as age, weight, and ethnicity do not account fully for increase in the CSR or its regional variations. Other factors likely contribute to the increasing CSR, including patient preferences and practice variation among hospitals, systems, and health care providers.
Common Indications and Strategies for Prevention
The document finds that the most common indications for primary c-sections are labor dystocia, abnormal fetal heart rate tracings, fetal malpresentation, multiple gestation, and suspected macrosomia. Indications for primary CS, in order of frequency, are as follows:
- Labor dystocia: 34%
- Abnormal or indeterminate fetal heart rate tracing: 23%
- Fetal malpresentation: 17%
- Multiple gestation: 7%
- Suspected fetal macrosomia.
Safe reduction of c-section rates will require different approaches tailored to each of these indications. Some strategies discussed include:
- Revising the definition of labor dystocia.
- Improving interpretation of fetal heart rate monitoring.
- Increasing access to support during labor.
- Attempting external cephalic version for breech babies.
- Allowing trial of labor for some twin pregnancies.
Ultimately, the document emphasizes using evidence-based guidelines and a multifaceted approach at the organizational and regional levels to manage the epidemic of CS.