Wednesday, February 25, 2015

Reducing Primary Cesareans (Part 2)

Click here to read Part 1: The Primary Cesarean Reduction Movement

I just listened to an interesting webinar on Preventing Primary Cesareans! The presenter explored much of the research and data supporting the recommendations behind the SMFM and ACOG Statement Safe Prevention of the Primary Cesarean Delivery. I found a few of the points interesting enough to share them here.

Ideally the primary cesarean reduction issue would be addressed through a systems approach, where hospitals, payors, patients, and OB providers are all working to improve primary cesarean rates. This presentation mainly focused on the obstetrics areas that can be influenced to make change.

The presenter noted that the Healthy People 2020 target cesarean rate for low risk, full term, singleton, vertex pregnancies is 23.9%, BUT that the goal in 2010 was 15%. Clearly, the government had to lower its expectations.

Malpresentation contributes to 17% of pre-labor cesareans, and is a highly modifiable obstetric indication for preventing the first cesarean. For example, research shows that an external cephalic version at greater than 36 weeks has a success rate ranging from 35-86%. Care providers and hospitals should be offering and encouraging this procedure. Furthermore, more clinicians need to be trained in how to vaginally deliver breech babies. The presenter only recommended this when the second twin is breech. Vaginal breech delivery of the second twin does not increase morbidity when done by an experienced provider.

Failure to progress (or CPD) accounts for about 34 - 47% of intrapartum cesareans (the majority first stage arrest), and nonreassuring fetal status (heart rate tracing interpretation) accounts for about 10 - 27% of intrapartum cesareans. These are additional modifiable areas to prevent cesareans. 

A big one is Failure to Progress, aka labor arrest, aka cephalopelvic disproportion. This can be diagnosed during either first stage or second stage (pushing). We joke in the doula world that this is often "failure to wait." Many OB's are taught that labor progresses according to the Friedman's Curve. This curve is one of my biggest birth pet peeves. This curve basically says that during active labor, a primiparous woman should dilate about 1 centimeter per hour, and that (on average) the entire first stage should last about 13 hours. This is based on a 1955 study with a sample size of 500 primips. It looks like this:

A 2010 multicenter study of more than 200,000 deliveries looked at primips and multips. This study found that the 95th% was about 20 hours for the first stage, with a mean of 8.4. (Keep in mind that half of the women received pitocin and 80% of the women had an epidural). Here is the curve from this study. It shows that multiparous mothers generally have shorter labors and that active labor may not really get going for them until about 6 cm dilation. Then, the curve is quick. For first time moms, however, there is no definite "turning point," and the curve is more gradual. 

This is a reason for the big change to starting "Active Labor" at about 6 centimeters dilation and not diagnosing labor arrest unless the mother is not having cervical change for 4 or more hours after they are at least 6 cm dilated. Moreover, diagnosis of labor arrest in the second stage has also changed due to this study, which found longer pushing stages for first time mothers as well as for mothers who had an epidural. Much research has shown that no neonatal morbidities were (statistically) significantly increased as length of second stage increased. Some maternal morbidities were found to increase (statistically) significantly as pushing time increased (e.g. uterine atony).

Another important point is that we need to give women who are induced more time to labor! There are few adverse outcomes associated with increased patience for inductions. The recommendation is at least 24 hours of pitocin + no regular contractions + no cervical change = arrest. 

The presenter suggested that to addressing variation in diagnosis of nonreassuring fetal heart tones, we should really emphasize that moderate fetal heart rate variability is reassuring, as is FHR acceleration after fetal scalp stimulation.

I'm going to share her slide here so you can see what she lists as the non-medical factors in the hospital and among care providers that influence cesarean rates.

I liked that she addressed that the hospital has trouble with allowing women to labor longer on L&D, that OR staff often go home at about 8pm so many Cesareans are scheduled before then so no one has to come back to the hospital at night, and that nurses are very busy and have competing priorities. Physicians of course have their own personal reasons for "diagnosing" a cesarean, among them financial incentives to deliver the child themselves so they will get paid and not someone else! Research shows that hospitals that have salaried MDs (e.g. laborists; can also be midwives) have less variability in the time of day when diagnoses of fetal distress are made. 

She touches on myths among patients (labor is bad for the baby, long labor is bad, induced labor is the same as spontaneous labor, operative vaginal delivery is worse than cesareans, etc). This is something that childbirth educators and doulas try to impress on the public, but physicians need to be doing this education, too. 

She did not cover medical legal issues due to time constraint (understandable - it is a major topic)! I would have liked to hear, though, ways that nurses can be involved in preventing the first cesarean. I work with a hospital that shared that they are getting their nurses educated and involved in educating and working with patients on how position changes can help the baby descend, pelvis open, and reduce first and second stage labor time (and nonreassuring fetal heart rates). I think this is a great initiative!

The presenter did mention doulas when prompted, praising their involvement, and the involvement of midwives, but did not touch on how they can make a difference in reducing primary cesareans. 

If you'd like to see the entire slide set or check the references, you can download the slide set from the National Perinatal Information Center website when they become available.

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