Safe Prevention of The Primary CS Delivery

The American College of
Obstetricians and Gynecologists

WOMEN’S HEALTH CARE PHYSICIANS
OBSTETRIC CARE
CONSENSUS
Number 1 • March 2014
(Reaffirmed 2019)
Safe Prevention of the Primary
Cesarean Delivery
This document was developed Abstract: In 2011, one in three women who gave birth in the United States did so by
jointly by the American cesarean delivery. Cesarean birth can be life-saving for the fetus, the mother, or both in certain
College of Obstetricians and cases. However, the rapid increase in cesarean birth rates from 1996 to 2011 without clear evi-
Gynecologists (the College) and dence of concomitant decreases in maternal or neonatal morbidity or mortality raises significant
the Society for Maternal-Fetal concern that cesarean delivery is overused. Variation in the rates of nulliparous, term, singleton,
Medicine with the assistance of vertex cesarean births also indicates that clinical practice patterns affect the number of cesarean
Aaron B. Caughey, MD, PhD; births performed. The most common indications for primary cesarean delivery include, in order
of frequency, labor dystocia, abnormal or indeterminate (formerly, nonreassuring) fetal heart rate
Alison G. Cahill, MD, MSCI;
tracing, fetal malpresentation, multiple gestation, and suspected fetal macrosomia. Safe reduc-
Jeanne-Marie Guise, MD, MPH; tion of the rate of primary cesarean deliveries will require different approaches for each of these,
and Dwight J. Rouse, MD, as well as other, indications. For example, it may be necessary to revisit the definition of labor
MSPH. The information reflects dystocia because recent data show that contemporary labor progresses at a rate substantially
emerging clinical and scientific slower than what was historically taught. Additionally, improved and standardized fetal heart rate
advances as of the date issued, interpretation and management may have an effect. Increasing women’s access to nonmedical
is subject to change, and should interventions during labor, such as continuous labor and delivery support, also has been shown
not be construed as dictating an to reduce cesarean birth rates. External cephalic version for breech presentation and a trial of
exclusive course of treatment or labor for women with twin gestations when the first twin is in cephalic presentation are other
of several examples of interventions that can contribute to the safe lowering of the primary
procedure. Variations in prac-
cesarean delivery rate.
tice may be warranted based
on the needs of the individual
patient, resources, and limita-
tions unique to the institution or Background
type of practice. In 2011, one in three women who gave birth in the United States did so by cesar-
ean delivery (1). Even though the rates of primary and total cesarean delivery have
plateaued recently, there was a rapid increase in cesarean rates from 1996 to 2011
(Fig. 1). Although cesarean delivery can be life-saving for the fetus, the mother, or
both in certain cases, the rapid increase in the rate of cesarean births without evi-
dence of concomitant decreases in maternal or neonatal morbidity or mortality raises
significant concern that cesarean delivery is overused (2). Therefore, it is important
for health care providers to understand the short-term and long-term tradeoffs
between cesarean and vaginal delivery, as well as the safe and appropriate opportuni-
ties to prevent overuse of cesarean delivery, particularly primary cesarean delivery.
Balancing Risks and Benefits
Childbirth by its very nature carries potential risks for the woman and her baby,
regardless of the route of delivery. The National Institutes of Health has commis-
sioned evidence-based reports over recent years to examine the risks and benefits
of cesarean and vaginal delivery (3) (Table 1). For certain clinical conditions––such
as placenta previa or uterine rupture––cesarean delivery is firmly established as the
safest route of delivery. However, for most pregnancies, which are low-risk, cesarean
35%
30%
25%
20%
15%
10%
5%
1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
VBAC rate* CD rate † Primary CD rate†
Fig. 1. U.S. delivery rates, 1989–2011. Data from National Vital Statistics. Abbreviations: CD, cesarean delivery; VBAC, vaginal birth after cesarean
delivery . *Percent of women who have a vaginal birth after prior cesarean delivery. †Rate based on total number of deliveries. (Data from Martin
JA, Hamilton BE, Ventura SJ, Osterman MJ, Mathews TJ. Births: final data for 2011. Natl Vital Stat Rep 2013;62(2):1–90.) ^
delivery appears to pose greater risk of maternal morbid- sion, uterine rupture, anesthetic complications, shock,
ity and mortality than vaginal delivery (4) (Table 1). cardiac arrest, acute renal failure, assisted ventilation,
It is difficult to isolate the morbidity caused spe- venous thromboembolism, major infection, or in-
cifically by route of delivery. For example, in one of the hospital wound disruption or hematoma––was increased
few randomized trials of approach to delivery, women threefold for cesarean delivery as compared with vagi-
with a breech presentation were randomized to undergo nal delivery (2.7% versus 0.9%, respectively) (7). There
planned cesarean delivery or planned vaginal delivery, also are concerns regarding the long-term risks associ-
although there was crossover in both treatment arms ated with cesarean delivery, particularly those associated
(5). In this study, at 3-month follow-up, women were with subsequent pregnancies. The incidence of placental
more likely to have urinary, but not fecal, incontinence abnormalities, such as placenta previa, in future pregnan-
if they had been randomized to the planned vaginal cies increases with each subsequent cesarean delivery,
delivery group. However, this difference was no longer from 1% with one prior cesarean delivery to almost 3%
significant at 2-year follow-up (6). Because of the size of with three or more prior cesarean deliveries. In addition,
this randomized trial, it was not powered to look at other an increasing number of prior cesareans is associated with
measures of maternal morbidity. the morbidity of placental previa: after three cesarean
A large population-based study from Canada found deliveries, the risk that a placenta previa will be compli-
that the risk of severe maternal morbidities––defined cated by placenta accreta is nearly 40% (8). This combi-
as hemorrhage that requires hysterectomy or transfu- nation of complications not only significantly increases
2 Obstetric Care Consensus No. 1

Table 1. Risk of Adverse Maternal and Neonatal Outcomes by Mode of Delivery ^
Outcome Risk
Maternal Vaginal Delivery Cesarean Delivery

Overall severe morbidity and mortality* 8.6% †
9.2%*
0.9% 2.7%†
Maternal mortality‡ 3.6:100,000 13.3:100,000
Amniotic fluid embolism§ 3.3–7.7:100,000 15.8:100,000
Third-degree or fourth-degree perineal laceration ||
1.0–3.0% NA (scheduled delivery)
Placental abnormalities¶ Increased with prior cesarean delivery versus vaginal delivery, and risk continues
to increase with each subsequent cesarean delivery.
Urinary incontinence# No difference between cesarean delivery and vaginal delivery at 2 years.
Postpartum depression ||
No difference between cesarean delivery and vaginal delivery.
Neonatal Vaginal Delivery Cesarean Delivery
Laceration** NA 1.0–2.0%
Respiratory morbidity** < 1.0% 1.0–4.0% (without labor)
Shoulder dystocia 1.0 –2.0% 0%
Abbreviations: CI, confidence interval; NA, not available; NICU, neonatal intensive care unit; OR, odds ratio; RR, relative risk.
*Overall severe morbidity and mortality defined as one or more of the following: death, postpartum bleeding, genital tract injury; wound disruption, wound infection, or both;
systemic infection. Data from Hofmeyr GJ, Barrett JF, Crowther CA. Planned caesarean section for women with a twin pregnancy. Cochrane Database of Systematic Reviews
2011, Issue 12. Art. No.: CD006553. DOI: 10.1002/14651858.CD006553.pub2.
†
Overall severe morbidity and mortality defined as any one of the following: death, hemorrhage requiring hysterectomy or transfusion; uterine rupture; anesthetic complica-
tions; shock; cardiac arrest; acute renal failure; assisted ventilation venous thromboembolic event; major infection; in-hospital wound disruption, wound hematoma, or both.
Data from Liu S, Liston RM, Joseph KS, Heaman M, Sauve R, Kramer MS. Maternal mortality and severe morbidity associated with low-risk planned cesarean delivery ver-
sus planned vaginal delivery at term. Maternal Health Study Group of the Canadian Perinatal Surveillance System. CMAJ 2007;176:455–60.
‡
Data from Deneux-Tharaux C, Carmona E, Bouvier-Colle MH, Breart G. Postpartum maternal mortality and cesarean delivery. Obstet Gynecol 2006;108:541–8.
§
Data from Abenhaim HA, Azoulay L, Kramer MS, Leduc L. Incidence and risk factors of amniotic fluid embolisms: a population-based study on 3 million births in the United
States. Am J Obstet Gynecol 2008;199:49.e1–49.e8.
||
Data from Hofmeyr GJ, Barrett JF, Crowther CA. Planned caesarean section for women with a twin pregnancy. Cochrane Database of Systematic Reviews 2011, Issue 12.
Art. No.: CD006553. DOI: 10.1002/14651858.CD006553.pub2.
¶
Silver RM, Landon MB, Rouse DJ, Leveno KJ, Spong CY, Thom EA, et al. Maternal morbidity associated with multiple repeat cesarean deliveries. National Institute of Child
Health and Human Development Maternal-Fetal Medicine Units Network. Obstet Gynecol 2006;107:1226–32.
#
Data from Hannah ME, Whyte H, Hannah WJ, Hewson S, Amankwah K, Cheng M, et al. Maternal outcomes at 2 years after planned cesarean section versus planned vagi-
nal birth for breech presentation at term: the international randomized Term Breech Trial. Term Breech Trial Collaborative Group. Am J Obstet Gynecol 2004;191:917–27.
**Data from Gregory KD, Jackson S, Korst L, Fridman M. Cesarean versus vaginal delivery: whose risks? Whose benefits? Am J Perinatol 2012;29:7–18.
maternal morbidity but also increases the risk of adverse shown a 10-fold variation in the cesarean delivery rate
neonatal outcomes, such as neonatal intensive care unit across hospitals in the United States, from 7.1% to 69.9%,
admission and perinatal death (3, 9, 10). Thus, although and a 15-fold variation among low-risk women, from
the initial cesarean delivery is associated with some 2.4% to 36.5% (12). Studies that have evaluated the role of
increases in morbidity and mortality, the downstream maternal characteristics, such as age, weight, and ethnic-
effects are even greater because of the risks from repeat ity, have consistently found these factors do not account
cesareans in future pregnancies (11). fully for the temporal increase in the cesarean delivery
rate or its regional variations (13–15). These findings
Indications for Primary Cesarean suggest that other potentially modifiable factors, such as
There is great regional variation by state in the rate of patient preferences and practice variation among hospi-
total cesarean delivery across the United States, rang- tals, systems, and health care providers, likely contribute
ing from a low of 23% to a high of nearly 40% (Fig. 2). to the escalating cesarean delivery rates.
Variation in the rates of nulliparous term singleton ver- In order to understand the degree to which cesarean
tex cesarean births indicates that clinical practice patterns deliveries may be preventable, it is important to know
affect the number of cesarean births performed. There why cesareans are performed. In a 2011 population-
also is substantial hospital-level variation. Studies have based study, the most common indications for primary
Obstetric Care Consensus No. 1 3

Fig. 2. U.S. total cesarean delivery rates by state, 2010. (Data from Martin JA, Hamilton BE, Ventura SJ, Osterman MJ, Mathews TJ. Births: final
data for 2011. Natl Vital Stat Rep 2013;62(2):1–90.) ^
cesarean delivery included, in order of frequency, labor Clinical Management Questions

dystocia, abnormal or indeterminate (formerly, non- and Answers
reassuring) fetal heart rate tracing, fetal malpresenta-
tion, multiple gestation, and suspected fetal macrosomia ◗ What is the appropriate definition of abnormally
(Fig. 3) (16). Arrest of labor and abnormal or indetermi- progressing first-stage labor?
nate fetal heart rate tracing accounted for more than one
half of all primary cesarean deliveries in the study popula- Definition of Abnormal First-Stage Labor
tion. Safe reduction of the rate of primary cesarean deliv- The first stage of labor has been historically divided into
eries will require different approaches for each of these the latent phase and the active phase based on the work
indications. For example, it may be necessary to revisit by Friedman in the 1950s and beyond. The latent phase
the definition of labor dystocia because recent data show of labor is defined as beginning with maternal perception
that contemporary labor progresses at a rate substantially of regular contractions (17). On the basis of the 95th
slower than what has been historically taught. Improved percentile threshold, historically, the latent phase has
and standardized fetal heart rate interpretation and man- been defined as prolonged when it exceeds 20 hours in
agement also may have an effect. Increasing women’s nulliparous women and 14 hours in multiparous women
access to nonmedical interventions during labor, such as (18). The active phase of labor has been defined as the
continuous labor support, also has been shown to reduce point at which the rate of change of cervical dilation sig-
cesarean birth rates. External cephalic version for breech nificantly increases.
presentation and a trial of labor for women with twin Active phase labor abnormalities can be categorized
gestations when the first twin is in cephalic presentation either as protraction disorders (slower progress than nor-
also can contribute to the safe lowering of the primary mal) or arrest disorders (complete cessation of progress).
cesarean delivery rate. Based on Friedman’s work, the traditional definition of

Preeclampsia
Other obstetric
3%
indications
4%
Nonreassuring
fetal tracing Labor arrest
23% 34%
Multiple gestation
7%
Malpresentation Macrosomia
Maternal request 17% 4%
3%
Maternal-fetal
5%
Fig. 3. Indications for primary cesarean delivery. (Data from Barber EL, Lundsberg LS, Belanger K, Pettker CM, Funai EF, Illuzzi JL. Indications con-
tributing to the increasing cesarean delivery rate. Obstet Gynecol 2011;118:29–38.) ^
a protracted active phase (based on the 95th percentile) (ie, the active phase) often did not start until at least 6
has been cervical dilatation in the active phase of less than cm. The Consortium on Safe Labor data do not directly
1.2 cm/h for nulliparous women and less than 1.5 cm/h for address an optimal duration for the diagnosis of active
multiparous women (19). Active phase arrest traditionally phase protraction or labor arrest, but do suggest that nei-
has been defined as the absence of cervical change for ther should be diagnosed before 6 cm of dilation. Because
2 hours or more in the presence of adequate uterine con- they are contemporary and robust, it seems that the
tractions and cervical dilation of at least 4 cm. Consortium on Safe Labor data, rather than the standards
However, more recent data from the Consortium on proposed by Friedman, should inform evidence-based
Safe Labor have been used to revise the definition of con- labor management.
temporary normal labor progress (20). In this retrospec-
tive study conducted at 19 U.S. hospitals, the duration ◗ How should abnormally progressing first-stage labor
of labor was analyzed in 62,415 parturient women, each be managed?
of whom delivered a singleton vertex fetus vaginally and
had a normal perinatal outcome. In this study, the 95th Management of Abnormal First-Stage Labor
percentile rate of active phase dilation was substantially Although labor management strategies predicated on the
slower than the standard rate derived from Friedman’s recent Consortium on Safe Labor information have not
work, varying from 0.5 cm/h to 0.7 cm/h for nulliparous been assessed yet, some insight into how management
women and from 0.5 cm/h to 1.3 cm/h for multiparous of abnormal first-stage labor might be optimized can be
women (the ranges reflect that at more advanced dilation, deduced from prior studies.
labor proceeded more quickly) (Table 2). The definitions of a prolonged latent phase are still
The Consortium on Safe Labor data highlight two based on data from Friedman and modern investigators
important features of contemporary labor progress have not particularly focused on the latent phase of labor.
(Fig. 4). First, from 4–6 cm, nulliparous and multiparous Most women with a prolonged latent phase ultimately
women dilated at essentially the same rate, and more will enter the active phase with expectant management.
slowly than historically described. Beyond 6 cm, multipa- With few exceptions, the remainder either will cease
rous women dilated more rapidly. Second, the maximal contracting or, with amniotomy or oxytocin (or both),
slope in the rate of change of cervical dilation over time achieve the active phase (18). Thus, a prolonged latent

Table 2. Spontaneous Labor Progress Stratified by Cervical Dilation and Parity ^
Median Elapsed Time (h)
Parity 0 Parity 1 Parity 2 or Greater

Cervical Dilation (cm) (95th percentile) (95th percentile) (95th percentile)
3–4 1.8 (8.1) –– ––
4–5 1.3 (6.4) 1.4 (7.3) 1.4 (7.0)
5–6 0.8 (3.2) 0.8 (3.4) 0.8 (3.4)
6–7 0.6 (2.2) 0.5 (1.9) 0.5 (1.8)
7–8 0.5 (1.6) 0.4 (1.3) 0.4 (1.2)
8–9 0.5 (1.4) 0.3 ( 1.0) 0.3 (0.9)
9–10 0.5 (1.8) 0.3 (0.9) 0.3 (0.8)
Modified from Zhang J, Landy HJ, Branch DW, Burkman R, Haberman S, Gregory KD, et al. Contemporary patterns of spontaneous labor with normal neonatal outcomes.
Consortium on Safe Labor. Obstet Gynecol 2010;116:1281–7.
10 P2+
P1 P0
9
8
Cervical dilation (cm
3
0 1 2 3 4 5 6 7
Time (hours)
Fig. 4. Average labor curves by parity in singleton term pregnancies with spontaneous onset of labor, vaginal delivery, and normal neonatal out-
comes. Abbreviations: P0, nulliparous women; P1, women of parity 1; P2+, women of parity 2 or higher. (Modified from Zhang J, Landy HJ, Branch
DW, Burkman R, Haberman S, Gregory KD, et al. Contemporary patterns of spontaneous labor with normal neonatal outcomes. Consortium on Safe
Labor. Obstet Gynecol 2010;116:1281–7.) ^
phase (eg, greater than 20 hours in nulliparous women The researchers found that of women who received at
and greater than 14 hours in multiparous women) should least 4 additional hours of oxytocin, 38% delivered vagi-
not be an indication for cesarean delivery (Table 3). nally, and none had neonates with 5-minute Apgar scores
When the first stage of labor is protracted or of less than 6. In nulliparous women, a period of 8 hours
arrested, oxytocin is commonly recommended. Several of augmentation resulted in an 18% cesarean delivery
studies have evaluated the optimal duration of oxytocin rate and no cases of birth injury or asphyxia, whereas if
augmentation in the face of labor protraction or arrest. A the period of augmentation had been limited to 4 hours,
prospective study of the progress of labor in 220 nullipa- the cesarean delivery rate would have been twice as high
rous women and 99 multiparous women who spontane- given the number of women who had not made signifi-
ously entered labor evaluated the benefit of prolonging cant progress at 4 hours. Thus, slow but progressive labor
oxytocin augmentation for an additional 4 hours (for a in the first stage of labor should not be an indication for
total of 8 hours) in patients who were dilated at least 3 cesarean delivery (Table 3).
cm and had unsatisfactory progress (either protraction or A study of more than 500 women found that extend-
arrest) after an initial 4-hour augmentation period (21). ing the minimum period of oxytocin augmentation for

Table 3. Recommendations for the Safe Prevention of the Primary Cesarean Delivery ^
Recommendations Grade of Recommendations

First stage of labor
A prolonged latent phase (eg, greater than 20 hours in nulliparous women and greater 1B
than 14 hours in multiparous women) should not be an indication for cesarean delivery. Strong recommendation, moderate quality evidence
Slow but progressive labor in the first stage of labor should not be an indication for 1B
cesarean delivery. Strong recommendation, moderate quality evidence
Cervical dilation of 6 cm should be considered the threshold for the active phase of 1B
most women in labor. Thus, before 6 cm of dilation is achieved, standards of active Strong recommendation, moderate quality evidence
phase progress should not be applied.
Cesarean delivery for active phase arrest in the first stage of labor should be reserved 1B
for women at or beyond 6 cm of dilation with ruptured membranes who fail to progress Strong recommendation, moderate quality evidence
despite 4 hours of adequate uterine activity, or at least 6 hours of oxytocin administra-
tion with inadequate uterine activity and no cervical change.
Second stage of labor
A specific absolute maximum length of time spent in the second stage of labor beyond 1C
which all women should undergo operative delivery has not been identified. Strong recommendation, low quality evidence
Before diagnosing arrest of labor in the second stage, if the maternal and fetal 1B
conditions permit, allow for the following: Strong recommendation, moderate quality evidence
• At least 2 hours of pushing in multiparous women (1B)
• At least 3 hours of pushing in nulliparous women (1B)
Longer durations may be appropriate on an individualized basis
(eg, with the use of epidural analgesia or with fetal malposition)
as long as progress is being documented. (1B)
Operative vaginal delivery in the second stage of labor by experienced and well trained 1B
physicians should be considered a safe, acceptable alternative to cesarean delivery. Strong recommendation, moderate quality evidence
Training in, and ongoing maintenance of, practical skills related to operative
vaginal delivery should be encouraged.
Manual rotation of the fetal occiput in the setting of fetal malposition in the 1B
second stage of labor is a reasonable intervention to consider before moving to Strong recommendation, moderate quality evidence
operative vaginal delivery or cesarean delivery. In order to safely prevent cesarean
deliveries in the setting of malposition, it is important to assess the fetal position
in the second stage of labor, particularly in the setting of abnormal fetal descent.
Fetal heart rate monitoring

Amnioinfusion for repetitive variable fetal heart rate decelerations may safely reduce 1A
the rate of cesarean delivery. Strong recommendation, high quality evidence
Scalp stimulation can be used as a means of assessing fetal acid–base status when 1C
abnormal or indeterminate (formerly, nonreassuring) fetal heart patterns (eg, minimal Strong recommendation, low quality evidence
variability) are present and is a safe alternative to cesarean delivery in this setting.
Induction of labor
Before 41 0/7 weeks of gestation, induction of labor generally should be performed 1A
based on maternal and fetal medical indications. Inductions at 41 0/7 weeks Strong recommendation, high quality evidence
of gestation and beyond should be performed to reduce the risk of cesarean
delivery and the risk of perinatal morbidity and mortality.
Cervical ripening methods should be used when labor is induced in women with an 1B
unfavorable cervix. Strong recommendation, moderate quality evidence
If the maternal and fetal status allow, cesarean deliveries for failed induction of labor 1B
in the latent phase can be avoided by allowing longer durations of the latent phase Strong recommendation, moderate quality evidence
(up to 24 hours or longer) and requiring that oxytocin be administered for at least
12–18 hours after membrane rupture before deeming the induction a failure.
(continued)

Table 3. Recommendations for the Safe Prevention of the Primary Cesarean Delivery (continued)
Recommendations Grade of Recommendations

Fetal malpresentation
Fetal presentation should be assessed and documented beginning at 36 0/7 weeks of 1C
gestation to allow for external cephalic version to be offered. Strong recommendation, low quality evidence
Suspected fetal macrosomia
Cesarean delivery to avoid potential birth trauma should be limited to estimated 2C
fetal weights of at least 5,000 g in women without diabetes and at least 4,500 g Weak recommendation, low quality evidence
in women with diabetes. The prevalence of birth weight of 5,000 g or more is
rare, and patients should be counseled that estimates of fetal weight, particularly
late in gestation, are imprecise.
Excessive maternal weight gain
Women should be counseled about the IOM maternal weight guidelines in an attempt 1B
to avoid excessive weight gain. Strong recommendation, moderate quality evidence
Twin gestations
Perinatal outcomes for twin gestations in which the first twin is in cephalic 1B
presentation are not improved by cesarean delivery. Thus, women with either Strong recommendation, moderate quality evidence
cephalic/cephalic-presenting twins or cephalic/noncephalic presenting twins should
be counseled to attempt vaginal delivery.
Other
Individuals, organizations, and governing bodies should work to ensure that research 1C
is conducted to provide a better knowledge base to guide decisions regarding Strong recommendation, low quality evidence
cesarean delivery and to encourage policy changes that safely lower the rate of
primary cesarean delivery.
Abbreviation: IOM, Institute of Medicine.
active phase arrest from 2 hours to at least 4 hours allowed (ie, evolving chorioamnionitis may predispose to longer
the majority of women who had not progressed at the labors). Thus, although this relationship needs further
2-hour mark to give birth vaginally without adversely elucidation, neither chorioamnionitis nor its duration
affecting neonatal outcome (22). The researchers defined should be an indication for cesarean delivery (25).
active phase labor arrest as 1 cm or less of labor progress Given these data, as long as fetal and maternal sta-
over 2 hours in women who entered labor spontane- tus are reassuring, cervical dilation of 6 cm should be
ously and were at least 4 cm dilated at the time arrest was considered the threshold for the active phase of most
diagnosed. The vaginal delivery rate for women who had women in labor (Box 1). Thus, before 6 cm of dilation
not progressed despite 2 hours of oxytocin augmentation is achieved, standards of active phase progress should
was 91% for multiparous women and 74% for nulliparous not be applied (Table 3). Further, cesarean delivery for
women. For women who had not progressed despite 4 active phase arrest in the first stage of labor should be
hours of oxytocin (and in whom oxytocin was continued reserved for women at or beyond 6 cm of dilation with
at the judgment of the health care provider), the vaginal ruptured membranes who fail to progress despite 4 hours
delivery rates were 88% in multiparous women and 56% of adequate uterine activity, or at least 6 hours of oxytocin
in nulliparous women. Subsequently, the researchers
validated these results in a different cohort of 501 pro-
spectively managed women (23). An additional study Box 1. Definition of Arrest of Labor
of 1,014 women conducted by different authors dem- in the First Stage ^
onstrated that using the same criteria in women with Spontaneous labor: More than or equal to 6 cm dilation
spontaneous labor or induced labor would lead to a sig- with membrane rupture and one of the following:
nificantly higher proportion of women achieving vaginal • 4 hours or more of adequate contractions (eg, more
delivery with no increase in neonatal complications (24). than 200 Montevideo units)
Of note, prolonged first stage of labor has been associated • 6 hours or more of inadequate contractions and no
with an increased risk of chorioamnionitis in the studies cervical change
listed, but whether this relationship is causal is unclear

administration with inadequate uterine activity and no A population-based study of 58,113 multiparous women
cervical change (Table 3) (22). yielded similar results when the duration of the second
stage was greater than 2 hours (31).
◗ What is the appropriate definition of abnormal A longer duration of the second stage of labor is
second-stage labor? associated with adverse maternal outcomes, such as high-
The second stage of labor begins when the cervix becomes er rates of puerperal infection, third-degree and fourth-
fully dilated and ends with delivery of the neonate. Parity, degree perineal lacerations, and postpartum hemorrhage
delayed pushing, use of epidural analgesia, maternal body (27). Moreover, for each hour of the second stage, the
mass index, birth weight, occiput posterior position, and chance for spontaneous vaginal delivery decreases pro-
fetal station at complete dilation all have been shown to gressively. Researchers have found that after a 3-hour or
affect the length of the second stage of labor (26). Further, more second stage of labor, only one in four nulliparous
it is important to consider not just the mean or median women (27) and one in three multiparous women give
duration of the second stage of labor but also the 95th birth spontaneously, whereas up to 30–50% may require
percentile duration. In the Consortium on Safe Labor operative delivery to give birth vaginally in the current
study discussed earlier, although the mean and median second stage of labor threshold environment (30).
duration of the second stage differed by 30 minutes, Thus, the literature supports that for women, lon-
the 95th percentile threshold was approximately 1 hour ger time in the second stage of labor is associated with
longer in women who received epidural analgesia than in increased risks of morbidity and a decreasing probabil-
ity of spontaneous vaginal delivery. However, this risk
those who did not (20).
increase may not be entirely related to the duration of
Defining what constitutes an appropriate dura-
the second stage per se, but rather to health care provider
tion of the second stage is not straightforward because
actions and interventions in response to it (eg, opera-
it involves a consideration of multiple short-term and
tive delivery and the associated risks of perineal trauma)
long-term maternal and neonatal outcomes––some of
(32). With appropriate monitoring, however, the abso-
them competing. Multiple investigators have examined
lute risks of adverse fetal and neonatal consequences of
the relationship between the duration of the second stage increasing second stage duration appear to be, at worst,
of labor and adverse maternal and neonatal outcomes in low and incremental. For example, in the study of 58,113
an attempt to define what should constitute a “normal” multiparous women cited earlier, although the risk of a
duration of the second stage. In the era of electronic 5-minute Apgar score of less than 7 and birth depres-
fetal monitoring, among neonates born to nulliparous sion was increased when the second stage of labor lasted
women, adverse neonatal outcomes generally have not longer than 2 hours, the absolute risk of these outcomes
been associated with the duration of the second stage of was low (less than 1.5%) with durations less than 2 hours
labor. In a secondary analysis of a multicenter random- and was not doubled even with durations greater than
ized study of fetal pulse oximetry, of 4,126 nulliparous 5 hours. Moreover, the duration of the second stage of
women who reached the second stage of labor, none of labor was unrelated to the risk of neonatal sepsis or major
the following neonatal outcomes was found to be related trauma. Thus, a specific absolute maximum length of
to the duration of the second stage, which in some cases time spent in the second stage of labor beyond which all
was 5 hours or more: 5-minute Apgar score of less women should undergo operative delivery has not been
than 4, umbilical artery pH less than 7.0, intubation in identified (Table 3). Similar to the first stage of labor,
the delivery room, need for admission to the neonatal a prolonged second stage of labor has been associated
intensive care unit, or neonatal sepsis (27). Similarly, with an increased risk of chorioamnionitis in the studies
in a secondary analysis of 1,862 women enrolled in an listed, but whether this relationship is causal is unclear
early versus delayed pushing trial, a longer duration of (ie, evolving chorioamnionitis may predispose to longer
active pushing was not associated with adverse neonatal labors). Again, neither chorioamnionitis nor its duration
outcomes, even in women who pushed for more than 3 should be an indication for cesarean delivery.
hours (28). This also was found in a large, retrospective
cohort study of 15,759 nulliparous women even in a ◗ How should abnormally progressing second-stage
group of women whose second stage progressed beyond labor be managed?
4 hours (29). Given the available literature, before diagnosing arrest
The duration of the second stage of labor and its rela- of labor in the second stage and if the maternal and
tionship to neonatal outcomes has been less extensively fetal conditions permit, at least 2 hours of pushing in
studied in multiparous women. In one retrospective multiparous women and at least 3 hours of pushing in
study of 5,158 multiparous women, when the duration nulliparous women should be allowed (Table 3). Longer
of the second stage of labor exceeded 3 hours, the risk durations may be appropriate on an individualized basis
of a 5-minute Apgar score of less than 7, admission to (eg, with the use of epidural analgesia or with fetal malpo-
the neonatal intensive care unit, and a composite of sition) as long as progress is being documented (Table 3).
neonatal morbidity were all significantly increased (30). For example, the recent Eunice Kennedy Shriver National

Institute of Child Health and Human Development safe lowering of the cesarean delivery rate (40). In sum,
document suggested allowing one additional hour in the operative vaginal delivery in the second stage of labor by
setting of an epidural, thus, at least 3 hours in multipa- experienced and well trained physicians should be con-
rous women and 4 hours in nulliparous women be used sidered a safe, acceptable alternative to cesarean delivery.
to diagnose second-stage arrest, although that document Training in, and ongoing maintenance of, practical skills
did not clarify between pushing time or total second stage related to operative vaginal delivery should be encour-
(33). aged (Table 3).
◗ What other management approaches may reduce Manual Rotation of the Fetal Occiput
cesarean deliveries in the second stage of labor? Occiput posterior and occiput transverse positions are
In addition to greater expectant management of the sec- associated with an increase in cesarean delivery and
ond stage, two other practices could potentially reduce neonatal complications (41, 42). Historically, forceps
cesarean deliveries in the second stage: 1) operative vagi- rotation of the fetal occiput from occiput posterior or
nal delivery and 2) manual rotation of the fetal occiput occiput transverse was common practice. Today this
for malposition. procedure, although still considered a reasonable man-
agement approach, has fallen out of favor and is rarely
Operative Vaginal Delivery
taught in the United States. An alternative approach
In contrast with the increasing rate of cesarean deliv- is manual rotation of the fetal occiput, which has been
ery, the rates of operative vaginal deliveries (via either associated with a safe reduction in the risk of cesarean
vacuum or forceps), have decreased significantly during delivery and is supported by the Society of Obstetricians
the past 15 years (34). Yet, comparison of the outcomes and Gynaecologists of Canada (43–45). For example, in
of operative vaginal deliveries and unplanned cesar- a small prospective trial of 61 women, those who were
ean deliveries shows no difference in serious neonatal offered a trial of manual rotation experienced a lower rate
morbidity (eg, intracerebral hemorrhage or death). In of cesarean delivery (0%) compared with those managed
a large, retrospective cohort study, the rate of intracra- without manual rotation (23%, P=.001) (46). A large,
nial hemorrhage associated with vacuum extraction did retrospective cohort study found a similar large reduction
not differ significantly from that associated with either in cesarean delivery (9% versus 41%, P< .001) associated
forceps delivery (odds ratio [OR], 1.2; 95% confidence with the use of manual rotation (43). Of the 731 women
interval [CI], 0.7–2.2) or cesarean delivery (OR, 0.9; 95% in this study who underwent manual rotation, none expe-
CI, 0.6–1.4) (35). In a more recent study, forceps-assisted rienced an umbilical cord prolapse. Further, there was
vaginal deliveries were associated with a reduced risk no difference in either birth trauma or neonatal acide-
of the combined outcome of seizure, intraventricular
mia between neonates who had experienced an attempt
hemorrhage, or subdural hemorrhage as compared with
at manual rotation versus those who had not (43). In
either vacuum-assisted vaginal delivery (OR, 0.60; 95%
order to consider an intervention for a fetal malposition,
CI, 0.40–0.90) or cesarean delivery (OR, 0.68; 95% CI,
the proper assessment of fetal position must be made.
0.48–0.97), with no significant difference between vacu-
Intrapartum ultrasonography has been used to increase
um delivery or cesarean delivery (36).
Fewer than 3% of women in whom an operative vagi- the accurate diagnosis of fetal position when the digital
nal delivery has been attempted go on to deliver by cesar- examination results are uncertain (47).
ean (37). Although attempts at operative vaginal delivery Given these data, which is limited for safety and effi-
from a mid-pelvic station (0 and +1 on the -5 to +5 scale) cacy, manual rotation of the fetal occiput in the setting of
or from an occiput transverse or occiput posterior posi- fetal malposition in the second stage of labor is a reason-
tion with rotation are reasonable in selected cases (38), able intervention to consider before moving to operative
these procedures require a higher level of skill and are vaginal delivery or cesarean delivery. In order to safely
more likely to fail than low (+2 or greater) or outlet (scalp prevent cesarean deliveries in the setting of malposition,
visible at the introitus) operative deliveries. Performing it is important to assess the fetal position in the second
low or outlet procedures in fetuses not believed to be stage of labor, particularly in the setting of abnormal fetal
macrosomic is likely to safely reduce the risk of cesarean descent (Table 3).
delivery in the second stage of labor. However, the num-
◗ Which fetal heart tracings deserve intervention, and
ber of health care providers who are adequately trained
what are these interventions?
to perform forceps and vacuum deliveries is decreasing.
In one survey, most (55%) resident physicians in train- The second most common indication for primary cesar-
ing did not feel competent to perform a forceps delivery ean is an abnormal or indeterminate fetal heart rate trac-
upon completion of residency (39). Thus, training resi- ing (Fig. 3). Given the known variation in interpretation
dent physicians in the performance of operative vaginal and management of fetal heart rate tracings, a standard-
deliveries and using simulation for retraining and ongo- ized approach is a logical potential goal for interventions
ing maintenance of practice would likely contribute to a to safely reduce the cesarean delivery rate.

Category III fetal heart rate tracings are abnormal strated to resolve variable fetal heart rate decelerations
and require intervention (48). The elements of Category (57–59) and reduce the incidence of cesarean delivery
III patterns––which include either absent fetal heart for a nonreassuring fetal heart rate pattern (59–61).
rate variability with recurrent late decelerations, recur- Similarly, other elements of Category II fetal heart rate
rent variable decelerations, or bradycardia; or a sinus- tracings that may indicate fetal acidemia, such as mini-
oidal rhythm––have been associated with abnormal mal variability or recurrent late decelerations, should be
neonatal arterial umbilical cord pH, encephalopathy, approached with in utero resuscitation (48).
and cerebral palsy (49–52). Intrauterine resuscitative Prolonged fetal heart rate decelerations (which last
efforts––including maternal repositioning and oxygen more than 2 minutes but less than 10 minutes) often
supplementation, assessment for hypotension and tachy- require intervention. They can occur after rapid cervical
systole that may be corrected, and evaluation for other change or after hypotension (ie, in the setting of regional
causes, such as umbilical cord prolapse––should be analgesia). Prolonged decelerations also may be a sign of
performed expeditiously; however, when such efforts do complications, such as abruptio placentae, umbilical cord
not quickly resolve the Category III tracing, delivery as prolapse, or uterine rupture; because of their potential
rapidly and as safely possible is indicated. The American morbidity, these complications should be considered
College of Obstetricians and Gynecologists recommends in the differential diagnosis to allow for appropriate
preparations for imminent delivery in the event that evaluation and intervention (62–64). Uterine tachysystole,
intrauterine resuscitative measures do not improve the defined as more than five contractions in 10 minutes
fetal heart rate pattern (48). averaged over 30 minutes, can occur spontaneously or
In contrast, Category I fetal heart tracings are nor- because of uterotonic agents (ie, oxytocin or prostaglan-
mal and do not require intervention other than on- dins) and can be associated with fetal heart rate changes,
going assessment with continuous or intermittent such as prolonged or late decelerations. Reduction or ces-
monitoring, given that patterns can change over time. sation of the contractile agent or administration of a uter-
Moderate variability and the presence of accelerations, ine relaxant, such as a beta-mimetic agent, can resolve
which are features of Category I patterns, have proved to uterine tachysystole and improve the fetal heart rate trac-
be reliable indicators of normal neonatal umbilical cord ing (65). In contrast, there are no current data to support
arterial pH (7.20 or greater) (53, 54). interventions specifically for decelerations with “atypical
Most intrapartum fetal heart rate tracings are features” (such as shoulders, slow return to baseline, or
Category II (50, 55). Category II tracings are indetermi- variability only within the deceleration) because they
nate and comprise a diverse spectrum of fetal heart rate have not been associated with fetal acidemia (66, 49).
patterns that require evaluation, continued surveillance, There is not consistent evidence that ST-segment
initiation of appropriate corrective measures when indi- analysis and fetal pulse oximetry either improve out-
cated, and re-evaluation (48). Based on the high rate of comes or reduce cesarean delivery rates (67, 68). Despite
first cesarean deliveries performed for the indication the evidence that fetal scalp sampling reduces the risk of
of “nonreassuring fetal heart rate” (also known as an cesarean delivery (69, 70) and the poor ability of elec-
“abnormal or indeterminate fetal heart rate”) and the tronic fetal heart rate monitoring patterns to predict pH,
rarity of Category III patterns, it can be deduced that Cate- intrapartum fetal scalp sampling has fallen out of favor in
gory II tracings likely account for most cesarean deliveries the United States. This predominantly is due to its inva-
performed for nonreassuring fetal status (16). Thus, one sive nature, the narrow clinical presentations for which it
important consideration for health care providers who are might be helpful, and the need for regulatory measures
making the diagnosis of nonreassuring fetal status with to maintain bedside testing availability. Currently, this
the intent to proceed with cesarean delivery is to ensure testing is not performed in most U.S. centers and a fetal
that clinically indicated measures have been undertaken blood sampling “kit” that is approved by the U.S. Food
to resolve the concerning elements of the Category II trac- and Drug Administration is not currently manufactured.
ing or provide reassurance of fetal well-being. The unnecessary performance of cesarean deliver-
Scalp stimulation to elicit a fetal heart rate accelera- ies for abnormal or indeterminate fetal heart rate trac-
tion is an easily employed tool when the cervix is dilated ings can be attributed to limited knowledge about the
and can offer clinician reassurance that the fetus is not ability of the patterns to predict neonatal outcomes and
acidotic. Spontaneous or elicited heart rate accelerations the lack of rigorous science to guide clinical response to
are associated with a normal umbilical cord arterial pH the patterns (55, 71). Supplemental oxygen (72), intra-
(7.20 or greater) (54, 56). Recurrent variable decelera- venous fluid bolus (73), and tocolytic agents (74) are
tions, thought to be a physiologic response to repetitive routine components of intrauterine resuscitation (75)
compression of the umbilical cord, are not themselves that have extremely limited data for effectiveness or
pathologic. However, if frequent and persistent, they safety. Performance of these interventions without a
can lead to fetal acidemia over time. Conservative mea- subsequent change in fetal heart rate pattern is not nec-
sures, such as position change, may improve this pattern. essarily an indication for cesarean delivery. Medication
Amnioinfusion with normal saline also has been demon- exposure, regional analgesia, rapid labor progress, cervical

examination, infection, maternal hypotension, and mater- larly the use of cervical ripening agents for the unfavor-
nal fever all can affect the fetal heart rate pattern (48). able cervix and the lack of a standard definition of what
Attention to such factors will optimize clinical deci- constitutes prolonged duration of the latent phase (a
sion making regarding the management of abnormal or failed induction). Numerous studies have found that the
indeterminate fetal heart rate patterns and the need for use of cervical ripening methods––such as misoprostol,
cesarean delivery. Specifically, amnioinfusion for repetitive dinoprostone, prostaglandin E2 gel, Foley bulbs, and lam-
variable fetal heart rate decelerations may safely reduce the inaria tents––lead to lower rates of cesarean delivery than
rate of cesarean delivery (Table 3). Scalp stimulation can induction of labor without cervical ripening (69, 88). The
be used as a means of assessing fetal acid–base status when benefit is so widely accepted that recent studies do not
abnormal or indeterminate (formerly, nonreassuring) fetal include a placebo or nonintervention group, but rather
heart patterns (eg, minimal variability) are present and is a compare one cervical ripening method with another (89).
safe alternative to cesarean delivery in this setting (Table 3). There also are data to support the use of more than one
of these methods sequentially or in combination, such as
◗ What is the effect of induction of labor on cesarean misoprostol and a Foley bulb, to facilitate cervical ripen-
delivery? ing (90). Thus, cervical ripening methods should be used
The use of induction of labor has increased in the United when labor is induced in women with an unfavorable
States concurrently with the increase in the cesarean cervix (Table 3).
delivery rate, from 9.5% of births in 1990 to 23.1% of In the setting of induction of labor, nonintervention
births in 2008 (76, 77). Because women who undergo in the latent phase when the fetal heart tracing is reassur-
induction of labor have higher rates of cesarean delivery ing and maternal and fetal statuses are stable seems to
than those who experience spontaneous labor, it has been reduce the risk of cesarean delivery. Recent data indicate
widely assumed that induction of labor itself increases that the latent phase of labor is longer in induced labor
the risk of cesarean delivery. However, this assumption compared with spontaneous labor (91). Furthermore,
is predicated on a faulty comparison of women who are at least three studies support that a substantial propor-
induced versus women in spontaneous labor (78). Studies tion of women undergoing induction who remain in
that compare induction of labor to its actual alternative, the latent phase of labor for 12–18 hours with oxytocin
expectant management awaiting spontaneous labor, have administration and ruptured membranes will give birth
found either no difference or a decreased risk of cesarean vaginally if induction is continued (92–94). In one study,
delivery among women who are induced (79–82). This 17% of women were still in the latent phase of labor after
appears to be true even for women with an unfavorable 12 hours, and 5% remained in the latent phase beyond 18
cervix (83). hours (93). In another study, of those women who were
Available randomized trial data comparing induc- in the latent phase for longer than 12 hours and achieved
tion of labor versus expectant management reinforce active phase of labor, the majority (60%) gave birth vagi-
the more recent observational data. For example, a nally (94). Membrane rupture and oxytocin administra-
meta-analysis of prospective randomized controlled trials tion, except in rare circumstances, should be considered
conducted at less than 42 0/7 weeks of gestation, found prerequisites to any definition of failed labor induction,
that women who underwent induction of labor had a and experts have proposed waiting at least 24 hours in
lower rate of cesarean delivery compared with those the setting of oxytocin and ruptured membranes before
who received expectant management (84). In addition, a declaring an induction failed (33).
meta-analysis of three older, small studies of induction of Therefore, if the maternal and fetal status allow,
labor before 41 0/7 weeks of gestation also demonstrated cesarean deliveries for failed induction of labor in the
a statistically significant reduction in the rate of cesarean latent phase can be avoided by allowing longer durations
delivery (85). Additionally, increases in stillbirth, neona- of the latent phase (up to 24 hours or longer) and requir-
tal, and infant death have been associated with gestations ing that oxytocin be administered for at least 12–18 hours
at 41 0/7 weeks and beyond (86, 87). In a 2012 Cochrane after membrane rupture before deeming the induction a
meta-analysis, induction of labor at 41 0/7 weeks of failure (Table 3).
gestation and beyond was associated with a reduction in
perinatal mortality when compared with expectant man- ◗ What are the other indications for primary cesarean
agement (85). Therefore, before 41 0/7 weeks of gestation, delivery? What alternative management strategies
induction of labor generally should be performed based can be used for the safe prevention of cesarean deliv-
on maternal and fetal medical indications. Inductions ery in these cases?
at 41 0/7 weeks of gestation and beyond should be per- Although labor arrest and abnormal or indeterminate
formed to reduce the risk of cesarean delivery and the risk fetal heart rate tracing are the most common indications
of perinatal morbidity and mortality (Table 3). for primary cesarean delivery, less common indications—
Once a decision has been made to proceed with a such as fetal malpresentation, suspected macrosomia,
labor induction, variations in the management of labor multiple gestation, and maternal infection (eg, herpes
induction likely affect rates of cesarean delivery, particu- simplex virus)—account for tens of thousands of cesar-

ean deliveries in the United States annually. Safe preven- mends that it is “important to discuss appropriate weight
tion of primary cesarean deliveries will require different gain, diet, and exercise at the initial visit and periodically
approaches for each of these indications. throughout the pregnancy” (104). Although pregnancy
weight-management interventions continue to be devel-
Fetal Malpresentation
oped and have yet to translate into reduced rates of cesar-
Breech presentation at 37 weeks of gestation and beyond ean delivery or morbidity, the available observational
is estimated to complicate 3.8% of pregnancies, and more data support that women should be counseled about the
than 85% of pregnant women with a persistent breech IOM maternal weight guidelines in an attempt to avoid
presentation are delivered by cesarean (95). In one recent excessive weight gain (Table 3).
study, the rate of attempted external cephalic version
was 46% and decreased during the study period (96). Twin Gestation
Thus, external cephalic version for fetal malpresentation is The rate of cesarean deliveries among women with twin
likely underutilized, especially when considering that most gestations increased from 53% in 1995 to 75% in 2008
patients with a successful external cephalic version will (105). Even among vertex-presenting twins, there was an
give birth vaginally (96). Obstetricians should offer and increase from 45% to 68% (105). Perinatal outcomes for
perform external cephalic version whenever possible (97). twin gestations in which the first twin is in cephalic pre-
Furthermore, when an external cephalic version is planned, sentation are not improved by cesarean delivery. Thus,
there is evidence that success may be enhanced by regional women with either cephalic/cephalic-presenting twins or
analgesia (98). Fetal presentation should be assessed and cephalic/noncephalic-presenting twins should be coun-
documented beginning at 36 0/7 weeks of gestation to seled to attempt vaginal delivery (Table 3) (106). In order
allow for external cephalic version to be offered (Table 3). to ensure safe vaginal delivery of twins, it is important to
Before a vaginal breech delivery is planned, women should train residents to perform twin deliveries and to maintain
be informed that the risk of perinatal or neonatal mortality experience with twin vaginal deliveries among practicing
or short-term serious neonatal morbidity may be higher obstetric care providers.
than if a cesarean delivery is planned, and the patient’s Herpes Simplex Virus
informed consent should be documented.
In women with a history of herpes simplex virus, the
Suspected Fetal Macrosomia administration of acyclovir for viral suppression is an
Suspected fetal macrosomia is not an indication for important strategy to prevent genital herpetic outbreaks
delivery and rarely is an indication for cesarean delivery. requiring cesarean delivery and asymptomatic viral shed-
To avoid potential birth trauma, the College recom- ding (107, 108). Given the favorable benefit-risk profile
mends that cesarean delivery be limited to estimated fetal for the administration of maternal acyclovir, efforts
weights of at least 5,000 g in women without diabetes and should be made to ensure that women with a history of
at least 4,500 g in women with diabetes (Table 3) (99). genital herpes, even in the absence of an outbreak in the
This recommendation is based on estimations of the current pregnancy, are offered oral suppressive therapy
number needed to treat from a study that modeled the within 3–4 weeks of anticipated delivery (109) and at the
potential risks and benefits from a scheduled, nonmedi- latest, at or beyond 36 weeks of gestation (110). Cesarean
cally indicated cesarean delivery for suspected fetal mac- delivery is not recommended for women with a history
rosomia, including shoulder dystocias and permanent of herpes simplex virus infection but no active genital
brachial plexus injuries (100). The prevalence of birth disease during labor (110).
weight of 5,000 g or more is rare, and patients should be Continuous Labor and Delivery Support
counseled that estimates of fetal weight, particularly late
Published data indicate that one of the most effective
in gestation, are imprecise (Table 3). Even when these
tools to improve labor and delivery outcomes is the con-
thresholds are not reached, screening ultrasonography
tinuous presence of support personnel, such as a doula.
performed late in pregnancy has been associated with the
A Cochrane meta-analysis of 12 trials and more than
unintended consequence of increased cesarean delivery
15,000 women demonstrated that the presence of con-
with no evidence of neonatal benefit (101). Thus, ultraso-
tinuous one-on-one support during labor and delivery
nography for estimated fetal weight in the third trimester
was associated with improved patient satisfaction and a
should be used sparingly and with clear indications.
statistically significant reduction in the rate of cesarean
Excessive Maternal Weight Gain delivery (111). Given that there are no associated measur-
A large proportion of women in the United States gain able harms, this resource is probably underutilized.
more weight during pregnancy than is recommended by
the Institute of Medicine (IOM). Observational evidence ◗ What organizational actions are necessary for the
suggests that women who gain more weight than recom- primary cesarean delivery rate to safely decline?
mended by the IOM guidelines have an increased risk of A number of approaches are needed to reduce the pri-
cesarean delivery and other adverse outcomes (15, 102, mary cesarean delivery rate, which in turn would lower
103). In a recent Committee Opinion, the College recom- the repeat cesarean delivery rate. Although national and

regional organizations can take the lead in setting the Obstet Gynecol 2008;199:36.e1-36.e5; discussion 91–2.
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Society for Maternal-Fetal Medicine Grading System: Grading of Recommendations
Assessment, Development, and Evaluation (GRADE) Recommendations
Obstetric Care Consensus documents will use Society for Maternal-Fetal Medicine’s grading approach: http://www.ajog.org/article/
S0002-9378%2813%2900744-8/fulltext. Recommendations are classified as either strong (Grade 1) or weak (Grade 2), and quality of
evidence is classified as high (Grade A), moderate (Grade B), and low (Grade C)*. Thus, the recommendations can be 1 of the following
6 possibilities: 1A, 1B, 1C, 2A, 2B, 2C.
Grade of Clarity of Risk Quality of

Recommendation and Benefit Supporting Evidence Implications
1A. Strong recommendation, Benefits clearly outweigh risk Consistent evidence from Strong recommendations, can
high quality evidence and burdens, or vice versa. well performed randomized apply to most patients in most
controlled trials or over- circumstances without reservation.
whelming evidence of some Clinicians should follow a strong
other form. Further research recommendation unless a clear
is unlikely to change and compelling rationale for an
confidence in the estimate alternative approach is present.
of benefit and risk.
1B. Strong recommendation, Benefits clearly outweigh risk Evidence from randomized Strong recommendation, and
moderate quality evidence and burdens, or vice versa. controlled trials with important applies to most patients.
limitations (inconsistent Clinicians should follow a strong
results, methodologic flaws, recommendation unless a clear
indirect or imprecise), or very and compelling rationale for an
strong evidence of some other alternative approach is present.
research design. Further
research (if performed) is
likely to have an impact on
confidence in the estimate of
benefit and risk and may
change the estimate.
1C. Strong recommendation, Benefits appear to outweigh Evidence from observational Strong recommendation, and
low quality evidence risk and burdens, or vice versa. studies, unsystematic clinical applies to most patients. Some of
experience, or from randomized the evidence base supporting the
controlled trials with serious recommendation is, however, of
flaws. Any estimate of effect low quality.
is uncertain.
2A. Weak recommendation, Benefits closely balanced Consistent evidence from well- Weak recommendation, best
high quality evidence with risks and burdens. performed randomized action may differ depending on
controlled trials or over- circumstances or patients or
whelming evidence of some societal values.
other form. Further research is
unlikely to change confidence
in the estimate of benefit
and risk.
2B. Weak recommendation, Benefits closely balanced Evidence from randomized Weak recommendation, alternative
moderate quality evidence with risks and burdens; some controlled trials with important approaches likely to be better for
uncertainty in the estimates limitations (inconsistent results, some patients under some
of benefits, risks, and burdens. methodologic flaws, indirect or circumstances.
imprecise), or very strong
evidence of some other
research design. Further
research (if performed) is likely
to have an effect on confidence
in the estimate of benefit and
risk and may change the estimate.
2C. Weak recommendation, Uncertainty in the estimates Evidence from observational Very weak recommendation, other
low quality evidence of benefits, risks, and burdens; studies, unsystematic clinical alternatives may be equally
benefits may be closely experience, or from randomized reasonable
balanced with risks and burdens. controlled trials with serious flaws.
Any estimate of effect is uncertain.
Best practice Recommendation in which either (i) there is enormous amount of indirect evidence that clearly justifies
strong recommendation (direct evidence would be challenging, and inefficient use of time and resources,
to bring together and carefully summarize), or (ii) recommendation to contrary would be unethical.
Modified from Grading guide. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA, 2013. Available at: http://www.uptodate.com/home/grading-guide. Retrieved
October 9, 2013.
*Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Alonso-Coello P, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recom-
mendations. GRADE Working Group. BMJ 2008;336:924–6.
Published concurrently in the March 2014 issue of the American Journal of Obstetrics and Gynecology.
Copyright March 2014 by the American College of Obstetricians and Gynecologists, 409 12th Street, SW,
PO Box 96920, Washington, DC 20090-6920. All rights reserved.
Safe prevention of the primary cesarean delivery. Obstetric Care Consensus No. 1. American College
of Obstetricians and Gynecologists. Obstet Gynecol 2014;123:693–711.

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The American College of

Obstetricians and Gynecologists

VBAC rate* CD rate † Primary CD rate†

2 Obstetric Care Consensus No. 1

Maternal Vaginal Delivery Cesarean Delivery

Obstetric Care Consensus No. 1 3

cesarean delivery included, in order of frequency, labor Clinical Management Questions

4 Obstetric Care Consensus No. 1

Obstetric Care Consensus No. 1 5

Median Elapsed Time (h)

Parity 0 Parity 1 Parity 2 or Greater

6 Obstetric Care Consensus No. 1

Recommendations Grade of Recommendations

Fetal heart rate monitoring

Obstetric Care Consensus No. 1 7

Recommendations Grade of Recommendations

8 Obstetric Care Consensus No. 1

Obstetric Care Consensus No. 1 9

10 Obstetric Care Consensus No. 1

Obstetric Care Consensus No. 1 11

12 Obstetric Care Consensus No. 1

Obstetric Care Consensus No. 1 13

14 Obstetric Care Consensus No. 1

Obstetric Care Consensus No. 1 15

16 Obstetric Care Consensus No. 1

Obstetric Care Consensus No. 1 17

18 Obstetric Care Consensus No. 1

Grade of Clarity of Risk Quality of

Obstetric Care Consensus No. 1 19

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