Decreasing C-section Rates

Maternal morbidity and mortality are still on the rise in the United States. In fact, severe maternal morbidity has risen over 200% in the United States since 1993 (Centers for Disease Control and Prevention [CDC], 2023). There are some known reasons for this increase (Mahadik, 2019):

1. Increases in maternal age
2. Pre-pregnancy obesity
3. Preexisting chronic medical conditions
4. Cesarean delivery

Cesarean sections (c-sections) are one probable cause of maternal morbidity, and the rate of these procedures have drastically increased in the United States. The other variables of morbidity and mortality, such as age, obesity, and preexisting medical conditions, are difficult, if not impossible, to change. In order to improve maternal outcomes, the cesarean section rate must be decreased.

Through the years, the cesarean section rate has continued to climb. Primary cesarean rates account for 50% of the overall increased rate. There are a few causes for this increased rate. More of the reasons for primary c-sections are for non-reassuring fetal status and arrest of dilation than more objective indications such as malpresentation, maternal-fetal, and obstetric conditions, as seen in a woman who has delivered a baby vaginally before a c-section (Mahadik, 2019).

Malpresentation, maternal-fetal, and obstetric reasons cannot be argued. Some conditions require c-sections, such as:

• A woman with active herpes
• A placental abruption
• Cardiac disease
• A cord prolapse
• A fetus with certain birth defects
• A breech or transverse baby

Non-reassuring fetal heart rate is a reason for a cesarean if it is truly non-reassuring. Concerns of medical malpractice have led to quicker decisions for c-sections.

Labor dystocia is one reason for a c-section that needs to be improved. Labor dystocia is a generic term used to describe labor that is not following a “normal” curve. Friedman published the original labor curve in the 1950s. It was not until the 1990s that this labor curve was questioned. Obstetricians and midwives have not completely moved their practice to this new labor curve. Not all patients, especially with changes in patient demographics, such as age, weight, and co-morbidities, fall into a curve. Labor arrest is another term that can describe labor that is not effective. A woman having her first baby is no longer considered in labor until she is at least 6cm dilated. Therefore, the arrest of labor cannot be diagnosed prior to 6 cm. The arrest of descent is defined as a fully dilated woman (10 cm) and pushing, but the head is not descending to deliver.

Myers et al. (2020) reviewed labor dystocia. The findings were that low-risk nulliparous women appear to labor for longer and that labor progress is variable from woman to woman. This makes the diagnosis of labor dystocia difficult to make and vague. One study showed that the number of cesareans performed for the arrest of descent has increased and could be due to the increased average newborn size at delivery (Kugelman et al., 2020). This means that more providers are letting the woman labor longer and reach 10 cm, or fully dilated, but then performing a c-section because the baby has not descended, or “come down the pelvis” to deliver. Therefore, the increased average newborn size at delivery and an arrest of descent into the pelvis are possible reasons for increased c-section rates.

Another study showed that delayed admission until the onset of active labor, continuous supportive care, supporting adequate hydration, use of upright positioning, immediate pushing when 10 cm dilated, and low-dose rather than high-dose oxytocin during labor all have some biological plausibility for facilitating vaginal birth via support for physiological labor and possibly preventing c-sections  (LeFevre et al., 2021).

An additional study showed that preventing a patient's first c-section is complex and requires teamwork among the physicians, midwives, nurses, and patients. Low intervention management of labor can encourage labor progress (American College of Obstetricians and Gynecologists [ACOG], 2019a).

Obstetricians and midwives work all hours of the day. Sometimes they want to get home, which may influence their decision to do a cesarean section. The electronic fetal heart tracing may be questionable. Even with the improvement in the fetal heart after interventions, the obstetrician may continue to worry about the tracing. If the nurse caring for that patient keeps questioning the doctor, that doctor may also be more likely to perform a cesarean because they start to worry more. Another reason for a c-section could be that a doctor may have been sued because of a bad outcome, leading them to perform a c-section quicker because they worry more. There are many reasons why doctors and midwives may decide on a c-section. It is always easy to see why they should not have done the c-section when reviewing the case, but that does not look at the big picture of what the doctor and midwife are dealing with at the time of the c-section.

There are many reasons for cesarean sections. Changes in patient demographics, such as age and co-morbidities, are factors that doctors, nurses, and midwives cannot change. Many variables, however, can be changed. Labor support and low interventions have both been proven to lower the rate. Nurses can give more labor support. Labor dystocia is one area that needs to be addressed. Women today cannot have their labor compared with women of the 1950s who were younger, lighter, and possibly healthier. Most importantly, teamwork and communication are the best ways to decrease the c-section rate. Doctors, midwives, and nurses all need to discuss each patient and develop the best plan of care.

Hospital-level policies may be a powerful tool for reducing medically unnecessary c-sections. Performance improvement committees can review all primary c-sections performed and require the doctor to present the case. This may discourage doctors from performing unnecessary c-sections. Identifying individual physician c-section rates at a department meeting is another means of discouraging it. It is vital to demonstrate the importance of lowering the c-section rate to all providers.

Non-reassuring fetal heart rate cannot always be fixed, but all doctors, midwives, and nurses need to be adequately educated on fetal heart monitoring, speak the same language, and perform interventions when indicated. It is acceptable for obstetricians to consult with other obstetricians when looking at a questionable fetal heart tracing.

The first step to overcoming labor dystocia would be educating the patients about labor and letting them labor longer at home. Midwives are much more likely to have their patients stay home longer. If the patient insists on coming to the office or hospital and is contracting but is not at least 5 cm dilated for a nulliparous woman, she should be discharged home.A checklist with labor dystocia guidelines has been shown in one study to help make the diagnosis (Crosland, 2018). Women need to labor longer if the fetal heart tracing is normal. A woman who is less than 6 cm dilated should not receive a c-section for the arrest of labor because she is not technically “in labor”(ACOG, 2014). These women also need to have adequate contractions with oxytocin, if not progressing, before an arrest of labor is considered. A woman giving birth to her first baby who is pushing and not making progress should not be diagnosed as failure to descend until she has pushed for at least 3 hours (and possibly 4 hours if she has an epidural) (Kawakita et al. 2021).

Women who are at low risk do not need continuous fetal monitoring. Intermittent fetal monitoring is acceptable and even preferred, giving the woman more freedom to move. Continuous fetal monitoring in low-risk pregnancies has not been shown to improve fetal outcomes. Labor and delivery nurses who are trained in fetal monitoring should advocate for using it. Low-risk patients generally include those with:

• No meconium fluid
• No oxytocin use
• No intrapartum bleeding
• No abnormal fetal testing
• No risk for intrauterine growth restriction
• No risk for fetal congenital anomalies
• No maternal conditions that could affect the fetus (i.e. prior c-section, diabetes, hypertension)

Telemetry fetal monitoring is another intervention used for women who need continuous fetal monitoring. These monitors allow women the freedom to move around while being monitored without being connected by wires. Many small interventions can impact the final result, but the providers must ultimately alter their practices.

Women who have had c-sections may be able to have a vaginal birth. Most women who have had one c-section and did not have a classical uterine incision are candidates for a trial of labor after a c-section. Even women who have had two c-sections without a classical uterine incision may be candidates (ACOG, 2019b).

Amniotomy alone has not been proven to reduce time to delivery, but also has not been shown to increase any additional risks such as umbilical cord prolapse or abnormal fetal heart tracings. Amniotomy combined with oxytocin has been associated with a small decrease in duration of the first stage of labor (ACOG, 2019a).

Jenna is a 24-year-old G1P0 at 40 weeks gestation.

Jenna was admitted to the hospital on 11/2 at 0800. She was 3 cm dilated. The provider admitted her because it was her due date, and she was tired. Twelve hours later (8 pm), she was 4 cm dilated, and the provider started Pitocin and ordered an epidural for pain relief. Jenna received the epidural and then had to stay in bed. She slept through the night, so the RN left her alone.

The next morning (11/3) at 8 am, the patient was still 4 cm, and the provider decided to perform a c-section for labor dystocia.

Let’s consider some questions about Jenna’s case:

1. Was this an appropriate c-section?
2. What else could have/should have been done by the RN for this patient?
3. What risks are there to this patient?

This c-section was not appropriate at this time. Jenna was not yet in active labor at only 4 cm. She could have been sent home until she was in active labor. Alternatively, if she wanted to stay, she should have been encouraged to walk, move, get in the shower, and try other techniques to manage pain. Once she got the epidural, the RN should have continued moving the patient and using a peanut ball. This patient has all of the risks of someone who had a c-section. She is only 24, and this is her first baby. Now she has uterine scarring, which could cause future complications.

The rising c-section rate is a concern for all women of child-bearing age in the United States. There are many causes of c-sections. There is no single solution to fix the problem. Nurses, doctors, and midwives all need to be speaking the same language and following the latest evidence-based practice, which includes allowing the woman to labor longer and provide labor support. Nurses can perform the role of labor support when appropriately trained. Low interventions can also help to decrease c-section rates. One low intervention is performing intermittent fetal heart monitoring instead of continuous monitoring. Implementing evidence-based practices into all aspects of labor and delivery should also decrease the rate.

• American College of Obstetricians and Gynecologists. (ACOG). (2019a). ACOG committee opinion no. 766: Approaches to limit intervention during labor and birth. Obstetrics & Gynecology, 133(2), e164-e173. Visit Source.
• American College of Obstetricians and Gynecologists. (ACOG). (2019b). ACOG practice bulletin no. 205: Vaginal birth after cesarean delivery. Obstetrics & Gynecology, 133(2), e110-e127. Visit Source.
• American College of Obstetricians and Gynecologists. (ACOG). (2014). Obstetric care consensus no. 1. Obstetrics & Gynecology, 123(3), 693-711. Visit Source.
• Centers for Disease Control and Prevention. (CDC). (2023). Severe maternal morbidity in the United States. Centers for Disease Control and Prevention (CDC). Visit Source.
• Crosland, A., Wu, E., Oakes, M., Seet, E., Westermann, M., Clair, K., & Chan, K. (2018). 354: Effects of a labor dystocia checklist: Safely raising the bar with contemporary guidelines. American Journal of Obstetrics & Gynecology, 218(1). Visit Source.
• Kawakita, T., Gold, S.L., Huang, J.C., & Iqbal, S.N. (2021). Refining the clinical definition of active phase arrest of dilation in nulliparous women to consider degree of cervical dilation as well as duration of arrest. American Journal of Obstetrics & Gynecology, 225(3), 294.e1-294.e14. Visit Source.
• Kugelman, N., Sagi-Dain, L., Kleifeld, S., Kedar, R., Bardicef, M., Toledano-Hacohen, M., & Damti, A. (2020). Can recurrent cesarean section due to arrest of descent be predicted by newborn weight difference? European Journal of Obstetrics & Gynecology and Reproductive Biology, 245, 73-76. Visit Source.
• LeFevre, N.M., Krumm, E., & Cobb, W.J. (2021). Labor dystocia in nulliparous patients. American Family Physician, 103(2), 90-96. Visit Source.
• Mahadik, K. (2019). Rising cesarean rates: Are primary sections overused? The Journal of Obstetrics and Gynecology of India, 69(6), 483-489. Visit Source.
• Myers, E.R., Sanders, G.D., Coeytaux, R.R., McElligott, K.A., Moorman, P.G., Hicklin, K., Grotegut, C., Villers, M., Goode, A., Campbell, H., Befus, D., McBroom, A.J., Davis, J.K., Lallinger, K., Fortman, R., & Kosinski, A. (2020). Labor dystocia. Comparative Effectiveness review no. 226. (Prepared by the Duke Evidence-based Practice Center under Contract No. 290-2015-00004-I.) AHRQ Publication No. 29-EHC007. Agency for Healthcare Research and Quality. Visit Source.