Management of Labor and Delivery, An Issue of Obstetrics

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iv Contributors

SARAH E. LITTLE, MD, MPH

Assistant Professor, Division of Maternal-Fetal Medicine, Brigham and Women’s
Hospital, Harvard Medical School, Boston, Massachusetts

STEPHANIE MELKA, MD
Maternal-Fetal Medicine Associates, PLLC, Department of Obstetrics, Gynecology, and
Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, New York

JAMES MILLER, MD
Maternal-Fetal Medicine Associates, PLLC, Department of Obstetrics, Gynecology, and
Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, New York

CHRISTINA A. PENFIELD, MD, MPH

Clinical Instructor and Maternal-Fetal Medicine Fellow, Department of Obstetrics and
Gynecology, School of Medicine, University of California, Irvine, Orange, California

RACHEL A. PILLIOD, MD
Clinical Fellow, Department of Obstetrics and Gynecology, Division of Maternal-Fetal
Medicine, Oregon Health & Science University, Portland, Oregon

NANDINI RAGHURAMAN, MD, MS

Maternal-Fetal Medicine Fellow, Department of Obstetrics and Gynecology, Division of
Maternal-Fetal Medicine, Washington University School of Medicine in St. Louis, St Louis,
Missouri

JANINE S. RHOADES, MD
Department of Obstetrics and Gynecology, Washington University School of Medicine in
St. Louis, St Louis, Missouri

BETHANY SABOL, MD
Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland,
Oregon

JAMES SARGENT, MD
Clinical Fellow in Maternal-Fetal Medicine, Department of Obstetrics and Gynecology,
Oregon Health & Science University, Portland, Oregon

ANTHONY SCISCIONE, DO
Director of Maternal-Fetal Medicine and the OB/Gyn Residency Program, Department of
Obstetrics and Gynecology, Christiana Care Health System, Newark, Delaware

DEBORAH A. WING, MD, MBA

Professor, Department of Obstetrics and Gynecology, School of Medicine, University of
California, Irvine, Orange, California
 Management of Labor and Delivery

Contents

Foreword: Addressing Common Management Dilemmas in Labor and Delivery xi

William F. Rayburn

Preface: Evidence-Based Management of Labor and Delivery: What Do We Still

Need to Know? xiii
Aaron B. Caughey

Evidence-Based Labor and Delivery Management: Can We Safely Reduce the

Cesarean Rate? 523
Aaron B. Caughey
This article provides an overview of the approaches that might be used to
safely reduce the cesarean rate. Although cesarean delivery may be a
safe alternative to vaginal delivery, its use in 1 in 3 women giving birth
is likely too high. The downstream impact of cesarean delivery on future
pregnancies is likely not well considered when the first cesarean is being
performed. Through quality improvement, environmental changes will
allow clinicians to adopt the range of practices described. However,
without such environmental changes, clinicians may not be able to
change their own practice patterns given environments in which they
practice.

Defining and Managing Normal and Abnormal First Stage of Labor 535
Janine S. Rhoades and Alison G. Cahill
Modern data have redefined the normal first stage of labor. Key differences
include that the latent phase of labor is much slower than was previously
thought and the transition from latent to active labor does not occur until
about 6 cm of cervical dilatation, regardless of parity or whether labor
was spontaneous or induced. Providers should have a low threshold to
use one of the safe and effective interventions to manage abnormal pro-
gression in the first stage of labor, including oxytocin, internal tocodyna-
mometry, and amniotomy.

Defining and Managing Normal and Abnormal Second Stage of Labor 547
Yvonne W. Cheng and Aaron B. Caughey
The American College of Obstetricians and Gynecologists (ACOG) Prac-
tice Bulletin No. 49 on Dystocia and Augmentation of Labor defines a pro-
longed second stage as more than 2 hours without or 3 hours with epidural
analgesia in nulliparous women, and 1 hour without or 2 hours with
epidural in multiparous women. This definition diagnoses 10% to 14% of
nulliparous and 3% to 3.5% of multiparous women as having a prolonged
second stage. Although current labor norms remained largely based on
data established by Friedman in the 1950s, modern obstetric population
and practice have evolved with time.
vi Contents

Labor Induction Techniques: Which Is the Best? 567

Christina A. Penfield and Deborah A. Wing
Induction of labor is a common procedure undertaken whenever the
benefits of prompt delivery outweigh the risks of expectant management.
Cervical assessment is essential to determine the optimal approach. Indi-
cation for induction, clinical presentation and history, safety, cost, and pa-
tient preference may factor into the selection of methods. For the
unfavorable cervix, several pharmacologic and mechanical methods are
available, each with associated advantages and disadvantages. In women
with a favorable cervix, combined use of amniotomy and intravenous
oxytocin is generally the most effective approach. The goal of labor induc-
tion is to ensure the best possible outcome for mother and newborn.

Is There a Place for Outpatient Preinduction Cervical Ripening? 583

Beth Leopold and Anthony Sciscione
Induction of labor continues to be one of the most commonly performed
tasks in obstetrics. If trials like the National Institute of Child Health and
Human Development’s ARRIVE trial show that delivery for all women at
39 weeks provides a significant advantage in pregnancy outcomes, the
number of women who require induction of labor will considerably in-
crease. Strategies to improve patient/family satisfaction, decrease
resource allocation and costs, and assure safety are paramount. Although
there are many potential candidates, it seems that outpatient preinduction
cervical ripening with the Foley catheter meets these criteria in a properly
selected group of low-risk women.

Augmentation of Labor: A Review of Oxytocin Augmentation and Active

Management of Labor 593
Annessa Kernberg and Aaron B. Caughey
Labor augmentation can be used to hasten labor, shorten the time to de-
livery, and perhaps reduce the risk of cesarean delivery. Particularly in
women with longer labors or less frequent contractions, oxytocin augmen-
tation seems to have positive impacts on these outcomes. Despite this, the
evidence for augmentation alone on the risk of cesarean delivery is
unclear, with varying evidence. More recently, oxytocin protocols have
been recommended to standardize care and ensure patient safety.

Elective Induction of Labor: What is the Impact? 601

Sarah E. Little
Elective induction of labor (ie, without a maternal or fetal indication) is
common in the United States. When using the correct comparison group
(elective induction vs expectant management), induction is not associated
with an increased risk of cesarean delivery. Moreover, elective induction
after 39 weeks seems to have maternal benefits (eg, lower infection rates)
as well as a reduction in neonatal morbidity and the potential for a
decrease in term stillbirth. However, these risks, especially stillbirth, are
low in a healthy cohort and there are potential negative impacts on
maternal satisfaction, breastfeeding, and cost/resource use that must be
considered.
 Contents vii

Update on Fetal Monitoring: Overview of Approaches and Management of

Category II Tracings 615
Nandini Raghuraman and Alison G. Cahill
Electronic fetal monitoring (EFM) is widely used to assess fetal status in
labor. Use of intrapartum continuous EFM is associated with a lower risk
of neonatal seizures but a higher risk of cesarean or operative delivery.
Category II fetal heart tracings are indeterminate in their ability to pre-
dict fetal acidemia. Certain patterns of decelerations and variability
within this category may be predictive of neonatal morbidity. Adjunct
tests of fetal well-being can be used during labor to further triage pa-
tients. Intrauterine resuscitation techniques should target the suspected
etiology of intrapartum fetal hypoxia. Clinical factors play a role in the
interpretation of EFM.

The Evolution of the Laborist 625

Allison J. Allen and Aaron B. Caughey
The laborist movement was introduced as a means to improve the
quality of care patients receive in the labor suite and decrease physi-
cian burnout and malpractice claims. This model of care has rapidly
expanded, and there is evidence of its potential role in improving
labor outcomes. This article outlines the different models of laborist
care, reviews the evidence for its potential impact on labor outcomes,
and discusses the economic impact the employment of laborists
can have.

Fetal Malpresentation and Malposition: Diagnosis and Management 631

Rachel A. Pilliod and Aaron B. Caughey
Fetal malpresentation and fetal malposition are frequently interchanged;
however, fetal malpresentation refers to a fetus with a fetal part other
than the head engaging the maternal pelvis. Fetal malposition in labor in-
cludes occiput posterior and occiput transverse positions. Both fetal
malposition and malpresentation are associated with significant maternal
and neonatal morbidity, which have significant impact on patients and pro-
viders. Accurate diagnosis of both conditions is necessary for appropriate
management. In this article, terminology, incidence, diagnosis, and man-
agement are discussed.

Labor and Delivery of Twin Pregnancies 645

Stephanie Melka, James Miller, and Nathan S. Fox
Obstetricians who care for twin pregnancies should be aware of the
challenges that may arise during the labor and delivery. With recogni-
tion of these issues and proper training, providers should be able to
help women with twin pregnancies achieve a safe delivery for them
and their babies. With the use of breech extraction of the second
twin and active management of the second stage of labor, women
with twin pregnancies can also achieve a high vaginal delivery rate of
both twins.
viii Contents

Vaginal Birth After Cesarean Trends: Which Way Is the Pendulum Swinging? 655
James Sargent and Aaron B. Caughey
The cesarean delivery rate has plateaued at 32%; concurrently, after peak-
ing in the mid-1990s, trial of labor after cesarean (TOLAC) rates have
declined. Less than 25% of women with a prior cesarean delivery attempt
a future TOLAC. This decreasing trend in TOLAC is caused by inadequate
resource availability, malpractice concerns, and lack of knowledge in pa-
tients and providers regarding the perceived risks and benefits. This article
outlines the factors influencing recent vaginal birth after cesarean trends in
addition to reviewing the maternal and neonatal outcomes associated with
TOLAC, specifically in high-risk populations.

Quality Improvement and Patient Safety on Labor and Delivery 667

Bethany Sabol and Aaron B. Caughey
There has been an emphasis on redesigning our health care system to
eliminate medical errors and create a culture of safety. The American Col-
lege of Obstetrics and Gynecologists defines a culture of safety as an envi-
ronment in which all care providers are empowered to identify errors, near
misses, risky behaviors, and broader systems issues while engaging in
active collaboration to improve and resolve processes and system failures.
This article reviews key components that promote a culture of safety and
help to implement safer, more effective, evidence-based quality care on
labor and delivery units.
 Management of Labor and Delivery ix

OBSTETRICS AND GYNECOLOGY CLINICS

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 Management of Labor and Delivery

Foreword
Addressing Common
M a n a g e m e n t D i l e m m a s in La b o r
and Delivery

William F. Rayburn, MD, MBA

Consulting Editor

This issue of the Obstetrics and Gynecology Clinics of North America deals with key
management decisions undertaken regularly in the Labor and Delivery Unit. Ably edi-
ted by Aaron Caughey, MD, the issue highlights controversies pertaining to induction
of labor, progression during the first and second stages, fetal monitoring interpretation,
reducing cesarean delivery rates, and enhancing quality care and patient safety.
Management during labor and delivery requires two views: (1) acceptance of a
normal physiologic process that most women experience, and (2) anticipation of
complications, often occurring unexpectedly and quickly. Labor onset represents
the culmination of a series of biochemical changes in the cervix and uterus. Preterm
labor, dystocia, and postterm pregnancy may result when labor is abnormal.
Induction of labor affects one in every four pregnancies, although the incidence
varies between practices. Topics covered by the authors pertain to the role of outpa-
tient preinduction cervical ripening, best techniques for labor induction, and impact of
elective induction of labor. Oxytocin for inducing or augmenting labor is common,
affecting half or more of all pregnancies undergoing a trial of labor. Use of oxytocin
for augmentation and active labor is well reviewed in this issue.
Many abnormalities may interfere with the orderly progression of fetal descent and
spontaneous vaginal delivery. Soon after admission, a rational plan for monitoring
labor can be established based on past pregnancies and current needs of the fetus
and mother. Because there are marked variations in labor lengths, precise statements
are unwise as to its anticipated duration.
Electronic measurement of uterine activity permits generalities about certain
contraction patterns and labor outcome. Uterine muscle efficiency to effect delivery
varies greatly. Abnormal progress during the first and second stages of labor is defined

Obstet Gynecol Clin N Am 44 (2017) xi–xii

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0889-8545/17/ª 2017 Published by Elsevier Inc.
xii Foreword

in this issue along with principles of management. Slow progress arises from a single
or combination of several factors: insufficiently strong or coordinated uterine contrac-
tions; fetal malpresentations or malpositioning; abnormalities of the maternal pelvis
creating a contracted pelvis; soft tissue restrictions in the lower reproductive tract;
and inadequate maternal pushing during the second stage. These abnormalities are
addressed categorically in this issue.
Electronic fetal monitoring was introduced into practice 50 years ago. The continu-
ously recorded fetal heart rate pattern is potentially diagnostic in assessing patho-
physiologic events. Accurate information provided by this monitoring remains a
matter of debate, however, despite most American women now being monitored elec-
tronically during labor. The authors focus on category II tracings, which include those
characterized as being neither normal (category I) nor abnormal (category III). A sys-
tematic analysis of the baseline rate, baseline variability, accelerations, and periodic
or episodic decelerations is described.
Also, over the past 50 years, the cesarean delivery rate in the United States rose from
5% to 33%. This rate declined temporarily, mostly from a significant increase of vaginal
births after cesarean (VBAC), and to a closely mirrored decrease in primary cesareans.
Reasons for this high cesarean rate relate to the following conditions: common perfor-
mance of a repeat cesarean; use of electronic monitoring with a resultant higher
suspicion of “fetal distress”; breech-presenting fetus delivered by cesarean; operative
vaginal deliveries being performed less; labor induction being more common, espe-
cially among nulliparas; maternal obesity being observed frequently; more cesareans
being performed for women with preeclampsia; lower VBAC rates; elective cesarean
deliveries to avoid pelvic floor injury or reduce fetal risk or upon maternal request;
and fear of litigation. Many of these conditions are covered in this issue.
The authors emphasize the growing need for quality improvement and patient safety
on labor and delivery and how it may be measured for a variety of conditions. This
trend was accompanied by the evolution of the laborist movement in the United
States. Much of this has arisen to provide care that is more standard and accessible.
The American College of Obstetricians and Gynecologists and the American Academy
of Pediatrics continue to collaborate in the development of guidelines for optimal care
in labor and delivery. These efforts are intended to improve interdisciplinary commu-
nication, increase team-based effort with clarified expectations, and increase engage-
ment in decision-making with the patient and family. While these guidelines apply to all
pregnancies, they are especially relevant to twin pregnancies as covered in this issue.
Management strategies addressed here should be helpful to the obstetrician during
labor and delivery. Dr Caughey did well in selecting an accomplished group of authors
with proven clinical and research experience in their field. Evidence-based
approaches imparted in this collection are greatly appreciated for immediate use
and future direction.

William F. Rayburn, MD, MBA

Continuing Medical Education &
Professional Development
MSC 10 5580, 1 University of New Mexico
Albuquerque, NM 87131-0001, USA
E-mail address:
[email protected]
 Management of Labor and Delivery

Preface
Evidence-Based Management of
L a b o r a n d D e l i v e r y : W h a t D o We
Still Need to Know?

Aaron B. Caughey, MD, PhD

Editor

In the United States, there are four million births each year, and the large majority of
them occur in hospitals on labor and delivery units.1 These specialized locations are
so specific that really only pregnant women can use this space, and an enormous
amount of resources is dedicated to the care of pregnant women going through the
birth process. Why would we have women who are experiencing a normal physiologic
event in the majority of cases, do so in the hospital? Predominantly this is because of
the small, but specific, inherent risk that accompanies childbirth, both to mothers and
to babies. Over the twentieth century, a number of interventions were developed and
refined to reduce the morbidity and mortality for mothers and babies, including blood
banking, antibiotics, and more specifically, fetal heart rate monitoring and operative
obstetrics, notably the cesarean delivery.
At this point in the twenty-first century, there are more than 1.2 million cesarean
deliveries each year in the United States.2 While a cesarean rate above 15% to 20%
appears to be associated with lower maternal and neonatal mortality, a benefit by
increasing the cesarean rate up to the current 32% in the United States has not
been demonstrated.3 The divide between these two thresholds has been a focus for
the past decade. One of the drivers identified to safely reduce the primary cesarean
rate is the use of more evidence-based labor and delivery management.4
The collection of articles in this issue of Obstetrics and Gynecology Clinics of North
America deals with just that, the evidence-based management of labor and delivery.
While many are framed with the focus on mode of delivery and the potential for
reducing the cesarean rate, the intent is to provide the most up-to-date evidence to
guide practice, research, and contemplation of obstetric management. The articles
include more general management of labor and fetal heart rate monitoring as well as

Obstet Gynecol Clin N Am 44 (2017) xiii–xiv

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0889-8545/17/ª 2017 Published by Elsevier Inc.
xiv Preface

more specific articles on twins, malposition, and malpresentation. There are also
pieces on laborist models and quality improvement on labor and delivery. Throughout
them all, I think you will see that while there has been an increasing amount of evi-
dence produced over the past several decades, there is a great need for much
more evidence to be accumulated on specifics of labor and delivery care.
So, if you have a passion for labor and delivery as I do, I hope you enjoy this collec-
tion of pieces and will be inspired after reading to identify some holes in the existing
research and start a research project to address a question or begin a quality improve-
ment project to improve outcomes. Enjoy, and I hope to see you on L&D!

Aaron B. Caughey, MD, PhD

Department of Obstetrics and Gynecology
Oregon Health & Science University
3181 SW Sam Jackson Park Road
Portland, OR 97239, USA
E-mail address:
[email protected]

REFERENCES

1. MacDorman MF, Matthews TJ, Declercq E. Trends in out-of-hospital births in the

United States, 1990-2012. NCHS Data Brief 2014;(144):1–8.
2. Martin JA, Hamilton BE, Osterman MJ, et al. Births: final data for 2015. Natl Vital
Stat Rep 2017;66(1):1.
3. Molina G, Weiser TG, Lipsitz SR, et al. Relationship between cesarean delivery rate
and maternal and neonatal mortality. JAMA 2015;314(21):2263–70.
4. American College of Obstetricians and Gynecologists (College); Society for
Maternal-Fetal Medicine, Caughey AB, Cahill AG, Guise JM, et al. Safe prevention
of the primary cesarean delivery. Am J Obstet Gynecol 2014;210(3):179–93.
E v i d e n c e - B a s e d La b o r a n d
Delivery Management
Can We Safely Reduce the Cesarean Rate?

Aaron B. Caughey, MD, PhD

KEYWORDS
 Evidence-based  Labor  Delivery  Management  Safety  Cesarean rate

KEY POINTS
 Although cesarean delivery may be an increasingly safe alternative to vaginal delivery, its
use in 1 in 3 women giving birth is likely too high.
 Furthermore, the downstream impact of cesarean delivery on future pregnancies is likely
not well-considered when the first cesarean is being performed.
 There are a range of practices that have become standard that should be carefully ques-
tioned and replaced by standardized, evidence-based practices to decrease the rate of
cesarean deliveries safely.
 Through quality improvement efforts such as perinatal quality collaboratives, the environ-
mental changes will allow clinicians to adopt the range of practices described.
 Without environmental changes, clinicians may not be able to change practice patterns
that have been encouraged by the given environments in which they practice.

INTRODUCTION

More than 100 years ago, the normal physiologic process of birth began to be moved
into hospitals. Although those initial moves were likely not specifically designed to
improve pregnancy outcomes, it has led to dramatic reductions in both the maternal
and neonatal mortality rates.1,2 It also provided the opportunity to better understand
the birth process through epidemiologic study and clinical trials that can examine
the impact of interventions. In one of the earliest cohort studies, Dr Emmanuel Fried-
man prospectively studied the labor and delivery process and reported out labor
norms.3 Unfortunately, instead of an increasing number of studies, these norms
were used to establish specific labor guidelines that have been shown to increase in-
terventions without clear evidence of benefit. One of the biggest impacts of having
birth in a hospital in combination with specific labor guidelines has been the increasing
increase in cesarean deliveries.

Department of Obstetrics and Gynecology, Oregon Health & Science University, 3181 Southwest
Sam Jackson Road, Mail Code: L-466, Portland, OR 97239, USA
E-mail address: [email protected]

Obstet Gynecol Clin N Am 44 (2017) 523–533

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0889-8545/17/ª 2017 Elsevier Inc. All rights reserved.
524 Caughey

In 2015, the cesarean rate in the United States was 32.0%, meaning that more than
1.2 million women delivered via cesarean.4 Although this rate remains high, there has
been a modest reduction in the rate of cesarean births, decreasing from 32.9% to
32.0%. This nearly 1% reduction means that there are 40,000 fewer cesarean deliv-
eries each year. Unfortunately, previously, from 1996 to 2009, the cesarean rate
increased from 20.7% to 32.9%, a more than 50% increase, which was nearly
500,000 more cesarean deliveries each year.5 This increase occurred despite guid-
ance from Healthy People 2010 and Healthy People 2020 that set the primary cesar-
ean rate at 15% and the primary cesarean rate in term, nulliparous women at 23.9%.6
Furthermore, it does not seem that there is any benefit to a cesarean delivery above
20%. In a study of 179 countries around the globe, researchers found that although
both maternal and neonatal mortality rates were reduced as cesarean rates increased
to 19%, from 20% and up, there was no further reduction of either maternal or
neonatal mortality.2
In addition to the statistics regarding the increase in cesarean deliveries, it is
compelling to note the wide variation in cesarean delivery rates between institutions.7
The rate varies between institutions, even when controlling for characteristics that
would account for indicated cesarean deliveries.8 Although such variation may
depend on additional factors that differ between institutions, the variation seems to
be too great to be based on consistent, evidence-based care at all institutions.
Thus, there is a need to develop evidence-based care and disseminate practice guide-
lines to ensure that all women are managed in a fashion that gives them the best hope
for a good outcome. Our profession needs to more rapidly develop and study ap-
proaches to manage labor and delivery and reduce both maternal and neonatal
morbidity and mortality, but at the same time safely reduce the use of cesarean
deliveries.
This article provides an overview considering what approaches might be used to
safely reduce the cesarean rate. These concepts are simply meant to touch on a num-
ber of labor and delivery management areas. Most of these are discussed in much
greater depth by the articles included in this issue of Obstetrics and Gynecology
Clinics of North America. Specifically, the papers delve into the management of the
first and second stages of labor, including induction of labor, fetal heart rate moni-
toring, the management of multiple gestations, breech presentations, malposition,
women with prior cesarean deliveries, laborist models, and quality improvement mea-
sures on labor and delivery.

WHY IS THE CESAREAN RATE INCREASING?

One possible reason for the increase in the cesarean delivery rate may be that there
has simply been an increase in the need for cesarean deliveries. The most common
indication for a primary cesarean is cephalopelvic disproportion or arrest of progress
in labor. Although it is unlikely that maternal pelvis size has changed over the past 3
decades, it is possible that birthweight has increased. In fact, there is evidence that
there have been increases in the rate of macrosomia over the past 2 decades.9
Another 2 issues that contribute to increasing rates of cesarean delivery, possibly
through the mechanism of birthweight, are maternal obesity and gestational weight
gain.10,11 Without question, the proportion of obese women has increased over the
past decade12 and the even higher weight classes, such as “super obesity,” are asso-
ciated with even higher rates of cesarean deliveries.13 Additionally, increased gesta-
tional weight gain has been associated with cesarean delivery and is commonly
above standard guidelines.14
 Evidence-Based Labor and Delivery Management 525

Another reason for increasing cesarean rates may be an increase in elective

cesarean delivery, also know as cesarean delivery by maternal request (CDMR).
Because CDMR is not listed among International Classification of Disease, 9th edi-
tion, codes, it is unclear what proportion of cesarean deliveries are due to CDMR.
However, 1 recent study estimated the proportion to be as high as 4% of the
cesarean deliveries performed in the United States.15 Interestingly, CDMR is
more common in several other countries, including Brazil, Taiwan, and Chile. In
Chile, in a study that compared women receiving private care who had a cesarean
rate of greater than 40% with women receiving public care, who had a cesarean
rate of less than 20%, 8% of the women receiving private care and 11% of the
women receiving public care stated a preference toward cesarean delivery with
the vast majority preferring to deliver vaginally.16 Thus, even in this setting, it is un-
clear that maternal preferences are driving the increase in the cesarean delivery
rate. The topic of CDMR led to an National Institutes of Health State-of-the-
Science conference in 2006. The statement from this meeting concluded that future
research was necessary to examine both the, “current extent of CDMR and atti-
tudes about it.”17 More recently, a study in the United States found that the vast
majority of women would prefer to deliver vaginally, all else being equal.18
So, although some maternal demographics have changed and maternal prefer-
ences may account for a small proportion of cesarean deliveries, it seems that
much of the increase in cesarean rates may be due to cultural pressures and norms.
Some of these pressures are due to the medicolegal environment that obstetric clini-
cians face. In 1 study, surveyed physicians reported that they were more likely to
perform a cesarean delivery in a number of scenarios if they had been sued recently
or if they thought about being sued frequently.19 In another study, the amount of
tort reform was associated with cesarean deliveries, in particular, those states that
had caps on noneconomic damages in lawsuits had lower overall cesarean rates
and higher vaginal birth after cesarean (VBAC) rates.20

HOW DOES CESAREAN DELIVERY AFFECT PREGNANCY OUTCOMES?

With respect to the effect of cesarean delivery on maternal and neonatal outcomes,
much is known. Generally, there are both positive and negative effects related to
cesarean delivery on both the mother and her baby.21 With respect to the mother,
cesarean delivery has been associated with higher rates of maternal hemorrhage, infec-
tion, and even death.22 However, a cesarean delivery is protective against perineal lac-
erations.23 In turn, there is some evidence to suggest that vaginal delivery may be
associated with pelvic organ prolapse and both fecal and urinary incontinence. Impor-
tantly, there are risks from a cesarean delivery on maternal outcomes in future pregnan-
cies, such as the risk of a trial of labor after a cesarean delivery.24 In particular, the risk of
abnormal placentation that can lead to the need for a preterm delivery and/or cesarean
hysterectomy, and can be complicated by severe maternal hemorrhage, should receive
significant attention when considering the risks of a cesarean delivery.25,26
Regarding neonatal outcomes, cesarean delivery is associated with lower rates of
intrapartum hypoxic injury and neonatal mortality.27 Additionally, with vaginal delivery
there is always a risk of shoulder dystocia and permanent brachial plexus injury. Alter-
natively, neonates delivered via cesarean seem to experience higher rates of transient
tachypnea of the newborn and possibly primary pulmonary hypertension.11 Similar to
the mother, neonates in future pregnancies after a prior cesarean delivery are at
increased risk. There seems to be an increased risk of stillbirth28 and, in pregnancies
that undergo a trial of labor after cesarean (TOLAC), uterine rupture carries a risk to the
526 Caughey

neonate. Additionally, pregnancies may need to be delivered before term if compli-

cated by an abnormal placentation.

WHAT ARE THE POTENTIAL APPROACHES TO SAFELY REDUCING CESAREAN

DELIVERIES?

Although there may be components of the increase in cesarean deliveries that are due
to changing demographics of the population, it seems that much of the increase is due
to economic and medicolegal pressures on obstetric providers that have led to culture
changes on labor and delivery. As noted, the increase in cesarean deliveries from 1996
to 2009 pushed the overall cesarean rate in the United States well above the 15% to
20% threshold for benefit that has been identified and recommended. In addition to no
improvements in maternal or neonatal mortality, there are potential morbidities from
cesarean delivery, including higher risks of maternal hemorrhage and infection.22
Additionally, there are risks from a cesarean delivery on outcomes in future pregnan-
cies. There are the risks of a TOLAC,24 of course, but receiving increased interest is the
risk of abnormal placentation that can lead to the need for a preterm delivery and/or
cesarean hysterectomy, and can be complicated by severe maternal hemorrhage.25,26
Thus, the cesarean rate is at historically high levels both here in the United States
and around the globe with questionable benefits. Given this background, the National
Institutes of Health, the American College of Obstetricians and Gynecologists and the
Society for Maternal-Fetal Medicine convened a consensus conference to work on
primary prevention of cesarean delivery. Recommendations from this meeting were
summarized in a document published in 2012.29 Further, the American College of
Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine
published an Obstetric Care Consensus document that delineated a number of
approaches to safely reducing the cesarean delivery rate.30 When considering how
the cesarean rate might be safely and meaningfully lowered, it is important to consider
the most common indications for cesarean delivery, which are a prior cesarean, failed
progression in labor, and abnormal fetal heart rate tracing. Potential approaches and
frame their potential impact on the cesarean delivery rate are outlined herein.

VAGINAL BIRTH AFTER CESAREAN DELIVERY

Whereas the documents listed focus on the prevention of the primary cesarean, in the
one previous time that the cesarean rate was lowered in the United States, the focus
was on TOLAC. Unfortunately, a backlash against attempting TOLAC by many hospi-
tals and providers alike has led to a national VBAC rate that is less than 10%.4 Although
many women would not choose to undergo TOLAC, evidence suggests that more than
10% do so and that the current environment is not conducive to achieving a VBAC for
many such women. Although VBAC should likely not be universally available at every
hospital in the country, there are many hospitals where a safe TOLAC could be offered
that do not support TOLAC. Organizational changes in obstetric units such as having
laborists available around the clock as well as the availability of in-house anesthesia
have improved the safety of a TOLAC, and this remains a viable way to reduce the
cesarean delivery rate overall. Even if the VBAC rate increased back up to 25% from
the current 10%, there would be far fewer repeat cesarean deliveries.

LABOR MANAGEMENT

The bulk of indicated cesarean deliveries are performed for failed progression of labor
during the first or second stages of labor. Labor dystocia has been estimated to
 Evidence-Based Labor and Delivery Management 527

account for about one-fifth of all cesarean deliveries.28 Because the majority of these
cesarean deliveries are in women with no prior cesarean delivery, many are primary
cesarean deliveries that then lead to future cesarean deliveries because the VBAC
rate is so low. The single most common indication is for failed progression in the first
stage of labor, commonly diagnosed as active phase arrest. Failed progress in labor is
traditionally based on labor norms established more than 50 years ago from a single
study.
In 1954, Dr Emmanuel Friedman published a prospective analysis of labor norms
drawn from a relatively small cohort of approximately 500 women.3 This study pro-
vided labor thresholds such as the fifth centile of progression (the 95th centile of
length of time to achieve 1 cm of dilation) throughout labor.31 These thresholds
became universally accepted and used to ascertain when a labor was going too
long. In Friedman’s study, the first stage of labor was broken into the latent and
active phases, which were commonly demarcated by a cervical dilation of 3 to
4 cm. This threshold identified the beginning of when labor began to progress
rapidly. Thus, during the latent phase, it was understood that labor could progress
slowly but, once the onset of active labor began, generally, a progression of at least
1 cm of dilation per hour was anticipated. When progress was slower than this, a
laboring woman could be said to be “falling off of the labor curve.” Given this
threshold and with this understanding, when a woman made no progress in the
active phase for 2 hours, active phase arrest was diagnosed and became a leading
indication for cesarean delivery.
However, recent evidence refutes the use of these thresholds. For example, the
largest study of labor, the Consortium on Safe Labor, reported that the 95th centile
of progress in labor from 4 to 5 cm is 6.4 hours and from 5 to 6 cm is 3.2 hours.32
This suggests that the active phase of labor may not begin until 6 cm of dilation in
some women and a slow progression from 4 to 6 cm should be tolerated. Furthermore,
the 2-hour threshold diagnosis of active phase arrest was challenged by a prospective
study.33 In that study, the authors demonstrated that waiting for cervical change dur-
ing the active phase of labor for at least 4 hours in the setting of adequate contractions
or 6 hours without adequate contractions would lead to 60% of such women going on
to deliver vaginally without evidence of harm to either the mother or infant. In a similar
study, the investigators found not only would the cesarean rate be reduced and no
evidence of increased neonatal morbidity, but the risk of complications in women
was lowered.34
In the second stage of labor, similarly the amount of time beyond which a second
stage of labor was characterized as prolonged has likely been too short. One example
of this is that although 1 additional hour of the second stage has been traditionally
used for women with an epidural, this seems to have been based on mean or median
differences that are generally less than 1 hour.35 However, when a recent study exam-
ined the 95th centile of differences between women without epidural in the second
stage, a difference of 2 hours or more was identified in both nulliparous and multipa-
rous women.36 Thus, management in the second stage of labor should entail ongoing
assessment of progress during the second stage, but allowing for at least 2 hours of
second stage in multiparous and 3 hours of second stage in nulliparous women, and
further allowing for an additional 2 hours in women with an epidural.
In addition to increased patience during the second stage, when the fetal vertex is
engaged, operative vaginal delivery remains a beneficial adjunct to achieve vaginal
delivery, although it has declined in recent years.37 Thus, it is important that the
next generation of providers continue to be trained to perform operative vaginal
deliveries.38
528 Caughey

ABNORMAL FETAL HEART RATE TRACINGS

After abnormal progression in labor, the second most common indication for a
cesarean during labor is an abnormal or indeterminate fetal heart rate tracing.
Currently, fetal heart tracings are commonly described as belonging to 1 of 3
categories—I, II, and III. Category I tracings are entirely benign and generally of no
concern whatsoever. Category III tracings are almost always an indication for imme-
diate delivery and rarely controversial. However, a large majority of fetal heart rate
tracings are described as category II. For example, in 1 recent study, more than
90% of fetal heart rate tracings were category II during the second stage of labor.39
Category II tracings are labeled indeterminate, although they are not particularly pre-
dictive of neonatal acidemia.40 Thus, category II tracings may have some features of
concern, such as fetal heart rate decelerations, but may have other reassuring features
such as moderate variability. Thus, in an effort to prevent fetal/neonatal acidemia,
many cesarean deliveries are performed for category II fetal heart rate tracings. To
avoid unnecessary cesarean deliveries, a variety of intervening steps should be taken
before operative delivery is carried out. There are a range of resuscitative measures,
such as maternal position change, intravenous fluids, and ensuring adequate blood
pressure after obtaining regional analgesia. Additionally, in the setting of repetitive
fetal heart rate decelerations, if oxytocin augmentation is being used, this measure
can be decreased or halted if there is concern. Another approach for such repetitive
decelerations has been the use of intrauterine pressure catheter and amnioinfusion.41
Finally, if there is not moderate variability to reassure the clinician, fetal scalp stimula-
tion with a response of a fetal heart rate acceleration is quite useful to ensure a pH of
greater than 7.20.42 Despite these approaches, there are still likely too many cesarean
deliveries performed for concern about fetal heart rate tracings. Despite the ubiquitous
use of continuous fetal heart rate tracings for 40 years, there is a great ongoing need
for more clinical research to ascertain the best use of this technology.

MALPOSITION

An additional issue raised about management of patients in the second stage of labor
is for those with fetal malposition, in particular, the occiput transverse or occiput pos-
terior positions. It is estimated that persistent fetal malposition occurs in approxi-
mately 5% of laboring fetuses, is increased with epidurals, and is associated with
an increased risk of cesarean delivery and with both maternal and neonatal complica-
tions.43 One approach to fetal malposition is increased patience in both the first and
second stages of labor. Similar to the effect of the epidural on the length of second
stage of labor, fetal malposition leads to both longer first and second stages of labor.
However, it does seem that fetal malposition cannot always be overcome simply by
increasing the length of time in the first or second stage. In the second stage, rotation
of the fetal occiput is a useful obstetric skill. Historically, this was accomplished with
forceps, particularly the Kielland forceps.44 However, with a decreasing proportion of
providers being trained to perform forceps rotations, increasingly the approach taken
is manual rotation of the fetal occiput.45 This approach has been shown to significantly
reduce the risk of cesarean delivery and is relatively safe and easy to train.

MALPRESENTATION

Fetal malpresentation, most commonly breech presentation at term, is seen in approx-

imately 4% of pregnancies.46 Currently, the vast majority of such pregnancies are
delivered via cesarean delivery. Thus, the primary approach to reducing cesarean