Saturday, April 12, 2014

Preventing the First Cesarean: Don't Go to the Hospital Too Early

Dark line with squares is overall cesarean rate,
Light line with triangles is primary cesarean rate,
Line with diamonds that goes up and then plummets is the VBAC rate

As part of Cesarean Awareness Month, we are discussing the long-term implications of a high cesarean rate, as well as how to lower the sky-high cesarean rate in women of size.

One of the important parts of lowering the overall cesarean rate is preventing the first (or "primary") cesarean.

As you can see from the chart, the primary cesarean rate (middle line) has risen over the years pretty much in parallel with the overall cesarean rate, even as the VBAC (Vaginal Birth After Cesarean) rate has drastically declined.

The VBAC rate has declined so strongly because many places have VBAC bans in place. Once a woman has that first cesarean, she usually has repeat cesareans thereafter, unless she is one of the lucky ones who can find a provider that is truly willing to support VBAC.

Thus the first step to lowering the high overall cesarean rate is to prevent the very first cesarean from happening whenever possible.

And one important step in preventing primary cesareans is not going to the hospital too early in labor. 

Research has shown that when women are admitted early in labor ("latent" labor), they have a much greater chance of having a cesarean than if they get to the hospital a bit later, when contractions are consistent and dilation starts to change more quickly ("active" labor).

In fact, a recent consensus statement from the American Congress of Obstetricians and Gynecologists and the Society for Fetal-Maternal Medicine suggests that the definition of "active" labor be changed from 4 cm to 6 cm.

Lamaze International has highlighted this with their related discussions on "Six is the New Four."

This proposed change is based on research that suggests that labor tends to progress more slowly in the early stages of labor than recognized in previous guidelines, and that many "failure to progress" cesareans might be prevented by being just a little bit more patient during labor.

Below is yet another study that confirms the importance of not going into the hospital until labor is well-established and "active."

In this study, more than half the women were admitted during "preactive" labor, and those that were had more than twice the c-section rate of those who were admitted in active labor.

If half of women are regularly being admitted into the hospital during latent labor, this strongly suggests that delaying admission to the hospital until labor is truly in the "active" phase might help lower the primary cesarean rate significantly.

This may be a particularly important consideration for women of size. Some research suggests that "overweight" and "obese" women have longer labors, especially in the stage just before transition. Although no one has actually studied yet whether delaying admission until 6 cm in obese women would lower cesarean rates in that group, it certainly seems like a logical conclusion.

In combination with lowering unnecessary induction rates and being more patient in labor, delaying hospital admission until 6 cm might really help impact the cesarean rate in obese women.


The take-home message for mothers is that if you plan to birth in the hospital, don't rush to the hospital in early labor.

Obviously, if there is something that is concerning you or doesn't feel right, it's important to be evaluated, and you should not hesitate to go in and ask for evaluation. Certain other medical situations, of course, might also call for early evaluation; your care provider will help you determine the situations to be cautious about.

However, most of the time, there is no need to be in the hospital right away if labor has started. The sooner you go in, the more likely you are to have interventions like oxytocin augmentation and cesareans.

The take-home message for hospitals is to have stricter admissions policies, given that around half of women are being admitted in early labor. The secondary message is to allow more time in labor before moving to a cesarean (barring fetal distress); a "failure to progress" cesarean is too often a "failure to wait" cesarean.

Bottom line: To lower the rate of primary cesareans, wait till labor is well-established before going to the hospital, and practice more patience during labor before moving to a cesarean if all else is well. 


J Midwifery Womens Health. 2014 Jan;59(1):28-34. doi: 10.1111/jmwh.12160. Epub 2014 Feb 11. Outcomes of nulliparous women with spontaneous labor onset admitted to hospitals in preactive versus active labor. Neal JL, Lamp JM, Buck JS, Lowe NK, Gillespie SL, Ryan SL. PMID: 24512265
INTRODUCTION: The timing of when a woman is admitted to the hospital for labor care following spontaneous contraction onset may be among the most important decisions that labor attendants make because it can influence care patterns and birth outcomes. The aims of this study were to estimate the percentage of low-risk, nulliparous women at term who are admitted to labor units prior to active labor and to evaluate the effects of the timing of admission (ie, preactive vs active labor) on labor interventions and mode of birth. METHODS: Data from low-risk, nulliparous women with spontaneous labor onset at term gestation were merged from 2 prospective studies conducted at 3 large Midwestern hospitals...RESULTS: Of the sample of 216 low-risk nulliparous women, 114 (52.8%) were admitted in preactive labor and 102 (47.2%) were admitted in active labor. Women who were admitted in preactive labor were more likely to undergo oxytocin augmentation (84.2% and 45.1%, respectively; odds ratio [OR], 6.5; 95% confidence interval [CI], 3.43-12.27) but not amniotomy (55.3% and 61.8%, respectively; OR, 0.8; 95% CI, 0.44-1.32) when compared to women admitted in active labor. The likelihood of cesarean birth was higher for women admitted before active labor onset (15.8% and 6.9%, respectively; OR, 2.6; 95% CI, 1.02-6.37). DISCUSSION: Many low-risk nulliparous women with regular, spontaneous uterine contractions are admitted to labor units before active labor onset, which increases their likelihood of receiving oxytocin and giving birth via cesarean. An evidence-based, standardized approach for labor admission decision making is recommended to decrease inadvertent admissions of women in preactive labor. When active labor cannot be diagnosed with relative certainty, observation before admission to the birthing unit is warranted.
Previous Research on Early Admission in Labor

Midwifery. 2013 Dec;29(12):1297-302. doi: 10.1016/j.midw.2013.05.014. Epub 2013 Jul 24.
Influence of timing of admission in labour and management of labour on method of birth: results from a randomised controlled trial of caseload midwifery (COSMOS trial). Davey MA1, McLachlan HL, Forster D, Flood M. PMID: 23890679
OBJECTIVE: to explore the relationship between the degree to which labour is established on admission to hospital and method of birth...SETTING: a large tertiary-level maternity service in Melbourne, Australia. PARTICIPANTS: English-speaking women with no previous caesarean section at low risk of complications in pregnancy were recruited to a randomised controlled trial. Trial participants whose management did not include a planned caesarean and who were admitted to hospital in spontaneous labour were included in this secondary analysis of trial data (n=1532)... RESULTS: ...Pooling the two randomised groups of nulliparous women, and after adjusting for randomised group, maternal age and maternal body mass index, early admission to hospital was strongly associated with caesarean section. Admission before the cervix was 5 cm dilated increased the odds 2.4-fold (95%CI 1.4, 4.0; p=0.001). Augmentation of labour and use of epidural analgesia were each strongly associated with caesarean section (adjusted odds ratios 3.10 (95%CI 2.1, 4.5) and 5.77 (95%CI 4.0, 8.4) respectively. CONCLUSION: these findings that women allocated to caseload care were admitted to hospital later in labour, and that earlier admission was strongly associated with birth by caesarean section, suggest that remaining at home somewhat longer in labour may be one of the mechanisms by which caseload care was effective in reducing caesarean section in the COSMOS trial.
J Obstet Gynecol Neonatal Nurs. 2003 Mar-Apr;32(2):147-57; discussion 158-60.
Impact of collaborative management and early admission in labor on method of delivery.
Jackson DJ1, Lang JM, Ecker J, Swartz WH, Heeren T. PMID: 12685666
OBJECTIVE: This study compared the effects of early admission in labor and perinatal care provider on delivery method. Higher spontaneous vaginal delivery rates for certified nurse midwives as compared with physicians have been reported in observational studies and randomized clinical trials. Certified nurse midwives, with their more expectant approach to labor management, would be expected to admit women later in labor than obstetricians. METHODS: Prospective cohort study of 2,196 low-risk pregnancies, with singleton, vertex infants admitted in spontaneous labor. Independent and joint effects of perinatal care provider and cervical dilation at admission on delivery method were evaluated... RESULTS: Fewer (23.4%) women in collaborative care were admitted in early labor (< 4 cm cervical dilation) than women managed by obstetricians (95% CI = -27.6 to -19.2). Obstetrician care had 9% to 30% fewer spontaneous vaginal deliveries. Women admitted early in labor also had 6% to 34% fewer spontaneous vaginal deliveries. Evaluation of joint effects suggested that interaction between obstetrician provider and earlier admission increased the risk of operative delivery. CONCLUSION:
Later admission in labor (at 4 cm or greater cervical dilation) and management of perinatal care by certified nurse midwives in collaboration with obstetricians increased the rate of spontaneous vaginal delivery in low-risk women.


Cassandra said...

I have mixed feelings about your bottom line. Women should be in control of when they go into the hospital. Too many times a woman has been checked at just a few centimeters, and then maybe an hour or less later, she's pushing. Rare, sure, but it happens. It's well known that the cervix can open and close rapidly and it varies by woman. While a hospital policy against early admission would help, shouldn't the bigger issue be that because early admissions cause a cascade of interventions, that means they're giving unnecessary interventions? That if they're not needed if women stayed home and waited, that means the hospital should just keep their hands off and wait too? Sure advise women to stay home and wait, but I don't think hospitals should be advised to alter policies to turn women away who feel a need to be there. Their hospital policies should be advised that no interventions are necessary until much farther into labor, if ever.

Well-Rounded Mama said...

All excellent points, Cassandra.

I tried to address some of that with the paragraph that if a woman feels she needs to be there, by all means she should go. In the end, she's the best judge of her needs.

But you're right, the real bottom line is that the hospital should not do so many interventions, especially early in labor.