Preventing the Primary Cesarean Section

This mega-episode was inspired by a two-part Grand Rounds series written by our PGY-4 Brown OBGYN class. We’ll dive into some of the history of cesarean, the challenges and data with respect to deciding on cesarean delivery, and current evidence-based strategies to reduce the risk of primary cesarean in low-risk women.

Cesarean sections have been around for a long time, the very first of which was documented around 1750 BC. However, surgery was originally performed only on a dead or dying mom with the hope of saving the child, or so the infant could be buried separately from mom per religious edicts. And then for the first 3000 years of cesarean, the mortality rate for women was… 100%. And it stayed this way until the mid-18th century! Anesthesia was introduced in 1846 with the discovery of ether, and as the 19th century progressed sutures and antibiotics became live-saving measures that allowed women to survive cesarean.

With the urbanization of the western world through this time period, more women began to deliver in hospitals as cesarean became a viable alternative, rather than delivering at home. In the USA, by 1955, 99% of births occurred in hospital. The rate of cesarean in the US stayed low until the 1970s, which coincided with the introduction of electronic fetal monitoring. A cesarean rate of <10% prior to EFM increased to 17% by 1980, 25% by 1988, and 31.9% in 2016.

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Now with the increased use of cesarean, we should expect some benefit to it. And there certainly are! There are life-saving implications for both mother and baby, and when needed, the surgery is absolutely a necessary tool for an obstetrician. That said, cesarean does not come without its own risks. For mothers, cesarean is associated with more risk of bleeding, infection, thrombosis, increased pain, worse satisfaction with the birth experience, and risks to future pregnancy such as increased risk of repeat cesarean and risk of placenta accreta spectrum (PAS) disorders. For infants, cesarean carries slightly higher risks of respiratory difficulty during the transition, breastfeeding difficulty, and intracranial hemorrhage (if laboring prior to cesarean; rates of IVH between SVD and non-laboring cesarean are about equal).

One of the criticisms of cesarean delivery are that its use does not seem standardized. There is a high level of variation between countries, and in the US, there is high variation between states, cities, and even hospitals in the same city! As an example, here are the nulliparous term singleton vertex (NTSV) cesarean rates between US states for 2016:

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While no rate of cesarean has proven to be the “optimal” or “ideal” amount, some observational data may provide some clues. The WHO has compared countries’ rates of cesarean with respect to both maternal and neonatal mortality, and also attempted to normalize these countries’ resources by demonstrating their relative wealth. For both maternal and neonatal mortality benefit, the rate seems to sit around 20% — you can see these graphs from the WHO below.

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In order to safely choose our use of cesarean delivery, there are evidence-based guidelines to recall. The ACOG/SMFM Obstetric Care Consensus #1 on safe prevention of the primary cesarean delivery is one such tool. In this document, there are three important thresholds to remember. This is nicely outlined in checklist format by the folks at the California Maternal Health Quality Collaborative (CMQCC):

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The use of partographs also has some limited data to support their use to help monitor labor progress. While one version over another hasn’t been shown to be superior, in a before-and-after study, the presence of their use helped to reduce cesarean rates, likely because of the closer attention to normal labor progress that was effected by them.

We additionally came across some other exciting ways to try to help reduce cesarean rates or examine cesarean utilization. Some of these things include:

• Open Access to Cesarean Data 

  • Beth Israel Deaconess’ NTSV rate was a target of a large, stepwise quality project, with a decrease from 35% to 21% over 8 years. However, their single best year of improvement was from 2014-2015, when cesarean data was fully unmasked and shared amongst all physicians who practiced there. Similar findings have been demonstrated in the CMQCC hospitals. Simply put, no one likes to be an outlier amongst their peers!

• Cesarean Audit Committees

  • These committees meet to review all unplanned cesarean delivery, prepare and interpret data, and look for opportunities for improvement in terms of physician/midwife, nurse, or patient education.

    • These committees offer the advantage of individualized feedback for improvement of practice based on more nuanced classifications that adjust for risk in population than just “NTSV.” 

    • Meta-analyses have demonstrated reduced cesarean rates stemming from a cesarean audit in concert with multifaceted programs to reduce cesarean delivery.

• Utilizing Labor Dystocia Checklists

  • Several quality collaborative groups use checklists, such as the one from CMQCC above; these are evidence-based, objective, and don’t call into question a provider’s interpretation of labor progress. 

    • Overall decrease PCS by preventing premature C/S for indications of labor dystocia. 

    • Some institutions have gone as far as to institute “double doctor” reviews for cesarean for labor arrest, allowing for a second opinion, particularly regarding the feasibility of operative vaginal delivery.

• Improved, transparent team communication 

  • Improved communication between physician or midwife, bedside nurse, patient, and support persons allows for appropriate expectations for labor or induction, and allows all members of the team to “be on the same page.”

  • At our institution, we are trialing using a whiteboard to document the partograph in the labor room; this allows the patient to compare patient to where they are on partograph compared to “standard labor progress.”

Have a technique you’re using at your hospital to help reduce primary cesarean delivery? Share it with us! We’d love to hear from you via email or the comments section of the website.