Katharine D. Wenstrom, MD Director of Maternal-Fetal Medicine Women and Infants Hospital of RI Warren Alpert Medical School, Brown University

I have no conflicts to disclose

Objectives: Describe medical and social factors that contribute to the high cesarean rate in the US. Discuss current data on the normal progression of labor. Describe evidence-based management approaches to preventing the first cesarean. Describe how hospital polices, practitioner schedules, financial issues, medical legal concerns, and other factors all influence the management of labor.

Important Recent Literature Reviews/Guidelines : Preventing the first cesarean: Summary of a joint SMFM, NICHD, ACOG Workshop. Spong CY, Berghella V, Wenstrom K, Mercer BM, Saade GR. Obstet Gynecol 2012; 120:1181-93 Safe Prevention of the Primary Cesarean Delivery Obstetric Care Concensus by ACOG and SMFM Obstetrics and Gynecology 2014; 123(3): 693

Source: CDC/NCHS, National Vital Statistics System.

Data from Martin et al.77 ACOG. Safe prevention of primary cesarean delivery. Am J Obstet Gynecol 2014.

Cesarean Delivery, by Gestational Age: United States, Final 1996-2010 and Preliminary 2011 NOTES: Singletons only. Early preterm is less than 34 weeks of gestation; late preterm is 34-36 weeks; early term is 37-38 weeks; full term is 39-40 weeks. Access data table for above at: http://www.cdc.gov/nchs/data/databriefs/db124_tables.pdf#1.http://www.cdc.gov/nchs/data/databriefs/db124_tables.pdf#1 Source: CDC/NCHS, National Vital Statistics System.

CD, cesarean delivery; VBAC, vaginal birth after cesarean delivery. *Percent of women who have VBAC; yRate based on total number of deliveries. Data from National Vital Statistics and from Martin et al.77 ACOG. Safe prevention of primary cesarean delivery. Am J Obstet Gynecol 2014.

Repeat Cesarean Rate

Primary cesareans account for 50% of the increasing CS rate

Neonatal Risk of Adverse Outcomes by Mode of Delivery Vaginal Cesarean Laceration NA 1.0 2.0 % Resp Morbidity < 1.0 % 1.0 4.0 % Shoulder Dystocia 1.0 2.0 % 0% AJOG 2014; 123: 693-711

Maternal Risk of Adverse Outcomes by Mode of Delivery Vaginal Cesarean Morbidity and Mortality* 8.6% 9.2% Severe M and M** 0.9% 2.7% Maternal Mortality 3.6:100,000 13.3: 100,000 Amn Fluid Embolism 3.3-7.7:100,000 15.8: 100,000 3 rd or 4th Laceration 1.0 3.0% NA Placental Abnormalities Increased with cesarean; Risk goes up with each cesarean Urinary Incontinence No difference Postpartum Depression No difference AJOG 2014; 123: 693-711 * Cochrane Review 2011, 12 ** CMAJ 2007;176:455

Complications of Subsequent Cesarean Deliveries Compared With the First Cesarean Delivery Cesarean Placenta Cesarean Delivery Accreta OR (95% CI) Hysterectomy OR (95% CI) First* 0.2 % 0.7 % 2nd 0.3 % 1.3 (0.72.3) 0.4 % 0.7 (0.40.97) 3rd 0.6 % 2.4 (1.34.3) 0.9% 1.4 (0.92.1) 4th 2.1 % 9.0 (4.816.7) 2.4 % 3.8 (2.46.0) 5th 2.3 % 9.8 (3.825.5) 3.5 % 5.6 (2.711.6) 6 6.7 % 9.8 (11.378.7) 9.0 % 15.2 (6.933.5) Silver et al Obstet Gynecol 2006; 107: 1226

Target Cesarean Rate Healthy People 2020 Low risk, full term, singleton, vertex: 23.9%* *Healthy People 2010 : 15%

Core Issues Provider practices Induction of labor Diagnosis of labor arrest Fetal Intolerance of Labor Provider practice preferences, workload, financial incentives/disincentives Patient perceptions/education and societal attitudes (Medical-Legal Issues)

Systems Based Approaches Primary cesarean incidence HospitalsPayors OB Providers Patients

Consortium on Safe Labor L and D data from 228,668 deliveries at 23 weeks, at 19 US hospitals, 2002-2008: First delivery in database selected: 206,969 women Overall CS rate = 30.5% (Nullips = 31.2%) Zhang et al Am J Obstet Gynecol 2010; 203: 326

Non -Obstetric Factors Influencing Cesarean Rate Maternal age (age < 20 = 21%; age 35 = 42%) Obesity (BMI

Birth Rates, by Selected Age of Mother: USA, Final 1990-2012 and Preliminary 2013

Trends in Overweight and Obesity Among Adults, United States, 19622010 Overweight Obesity Extreme obesity

Percent of Women with Cesarean Deliveries by BMI: Nulliparas Deliveries Cesareans(%) TOTAL 57,230 21.8 BMI Category < 25.0 9,113 11.1 25.0 29.9 23,553 17.7 30.0 34.9 14,674 25.1 35.0 39.9 6,045 33.0 40.0 3,845 42.8 Kominiarek et al AJOG, 2010; 203:126 e1

Percent of Women with Cesarean Deliveries, by BMI: Multips, Prior CS Deliveries Cesareans(%) TOTAL 5,288 37.4 BMI Category < 25.0 523 24.9 25.0 29.9 1,891 32.6 30.0 34.9 1,503 38.8 35.0 39.9 831 43.7 40.0 540 52.8 Kominiarek et al AJOG, 2010; 203:126 e1

Obstetric Factors Influencing the Cesarean Rate Pre-Labor Cesarean: Previous cesarean (45.1%) Elective* (26.4%) Malpresentation (17.1%) Intrapartum: FTP or CPD (47.1%) Nonreassuring fetal status (27.3%) *Declined TOL, AMA, muliparity, post term, diabetes, chorio, chronic HTN, PROM, HPV, GBS, polyhydramnios, IUFD, desires TL, social/religious Zhang et al Am J Obstet Gynecol 2010; 203: 326

Potentially Modifiable Obstetric Indications for the First Cesarean Diagnostic Effect on Pre-Labor Maternal Indication Accuracy Preventing CS Preeclampsia High Small Prior shoulder dystocia Limited Small Prior myomectomy Limited Small Prior third-degree or 4th-degree High Small laceration, prior breakdown of repair, fistula Marginal and low-lying High Small placentation

Potentially Modifiable Maternal Indications for the First Cesarean Diagnostic Effect on Pre-Labor Maternal Indication Accuracy Preventing CS Obesity (BMI>30) High Small Infection ( HSV, HCV, HIV) High Small Cardiovascular Disease High Small (HTN crisis, cardiomyopathy, pulmonary HTN, CVA or aneurysm) Inadequate Pelvis Limited Small Maternal Request NA Small

Potentially Modifiable Fetal Indications for the First Cesarean Pre-Labor Diagnostic Effect on Fetal Indication Accuracy Preventing CS Malpresentation High Large Multiple gestation High Small Macrosomia Limited Small Malformations Moderate Small (eg NTD, hydrops)

Major Indications for Primary Cesarean Delivery Stage Indication % Prelabor Malpresentation 1015* Multiple gestation 3 Hypertensive disorders 3 Macrosomia 3 Maternal request 2 8

Malpresentation External Cephalic Version at 36 weeks: Success Rate 58% (35-86%) Breech Delivery of Second Twin: In experienced hands: Breech extraction and vaginal delivery of the nonvertex second twin does not increase morbidity Attempted external cephalic version is a reasonable alternative Boggess and Chisholm. Obstet Gynecol Surv, 1997; 52(12):728

Major Indications for Primary Cesarean Delivery Stage Indication % In labor First-stage arrest 1530* Second-stage arrest 1025 Failed induction 10 Nonreassuring FHR 10

FIGURE 3 Indications for primary cesarean delivery Data from Barber et al.16 ACOG. Safe prevention of primary cesarean delivery. Am J Obstet Gynecol 2014.

Potentially Modifiable Intrapartum Indications for the First Cesarean Diagnostic Effect on Labor Indication Accuracy Preventing CS Failed induction Limited Large Arrest of labor Limited Large Nonreassuring ante- Moderate Large or intrapartum fetal surveillance

Friedmans Curve

500 Primips at term with complete data: 70% age 20 30 (range 13-42) 67% had gynecoid pelvis 13.8% required pitocin (18% for induction) 98.2% delivered vaginally Obstet Gynecol 1955; 5: 567

Friedmans Curve Stage Mean (Hours) Latent Phase 8.6 Active Phase 4.9 First Stage 13.3 Second Stage 0.95 Obstet Gynecol 1955; 5: 567

Consortium on Safe Labor Multicenter retrospective study of 228,668 deliveries 62,415 parturients selected: Term, singleton, vertex, spontaneous labor, spontaneous vaginal delivery, normal outcome Zhang et al; Obstet Gynecol 2010; 116(6): 1281

Consortium on Safe Labor

Friedmans Curve

Consortium on Safe Labor Stage Mean 95 th percentile Latent Phase 6.0 hrs 15.7 hrs First Stage 8.4 hrs 20.4 hrs Zhang et al; Obstet Gynecol 2010; 116(6): 1281

Friedmans Curve Stage Mean SD* 1 SD* 2 SDs* Latent Phase 8.6 6.0 14.6 20.6 Active Phase 4.9 3.4 8.3 11.7 First Stage 13.3 7.6 20.9 28.5 Second Stage 0.95 0.8 1.75 2.5 *Hours Obstet Gynecol 1955; 5: 567

Friedmans Curve Protracted Latent Phase 27 women has latent phase > 20 hours; 2 delivered by CS (7%) Failure to Progress (Inertia) 46 patients had First Stage = 25.2 1.8 hours Second Stage = 1.6 0.22 hours; 6 delivered by CS (13%) Obstet Gynecol 1955; 5: 567

Friedmans Ideal Curve, Based on 200 Ideal Labors Stage Mean SD* 1 SD* 2 SDs* Latent Phase 7.1 4.0 11.1 15.2 Active Phase 3.4 3.0 6.4 9.4 First Stage 10.6 4.6 15.2 19.8 Second Stage 0.76 0.6 1.4 2.0 *Hours Obstet Gynecol 1955; 5: 567

Consortium on Safe Labor Stage Mean* 95th%* [Friedman 2SD**] Latent Phase 6.0 15.7 [15.2] First Stage 8.4 20.4 [19.8] * Hours after admission at 2-2.5 cm ** Ideal Labor Zhang et al; Obstet Gynecol 2010; 116(6): 1281

Definitions of Failed Induction and Arrest Disorders First-Stage Arrest 6 cm or greater dilation with membrane rupture and no cervical change for: 4 h or more of adequate contractions (eg, 200 Montevideo units) or 6 h or more if contractions inadequate Obstet Gynecol 2012; 120:1181 AJOG 2014;123(3): 693

Consortium on Safe Labor

Second Stage Duration in Nulliparas Rouse et al: 4,126 women enrolled in the Pulse Ox trial who reached the second stage: Hours in Second Stage < 1 hr 1 to < 2 2 to < 3 3 to < 4 4 to

Second Stage Duration Similar findings reported by: Moon et al. J Reprod Med, 1990; 35(3): 229 Retrospective review of1432 women with second stage > 2 hours No adverse neonatal outcomes Cheng et al. AJOG 2004; 191: 933 Retrospective review of 15,759 multips No adverse neonatal outcomes; maternal morbidity increased after 4 hours

Definitions of Failed Induction and Arrest Disorders Second-Stage Arrest No progress (descent or rotation) for: 2 h or more in multiparous women without an epidural 3 h or more in nulliparous women without an epidural [ 3 h or more in multiparous women with an epidural ]* [ 4 h or more in nulliparous women with an epidural ]* Obstet Gynecol 2012; 120:1181* AJOG 2014;123(3): 693

Effect of Delivery Route on Neonatal Injury Delivery Method Death ICH Other Spont Vag Del 1:5,000 1:1,900 1:216 CS no labor 1:1,250 1:2,040 1:105 CS during labor 1:1,250 1:952 1:71 Vacuum 1:3,333 1:860 1:122 Forceps 1:2,000 1:664 1:76 Towner et al N Engl J Med 1999;341: 1709

Operative Vaginal Delivery Maternal outcomes: Pelvic floor injury related to episiotomy, prolonged second stage, large fetus Pelvic floor dysfunction similar one year after operative vag delivery versus cesarean for 2 nd Stage Arrest UI rates similar after 2 deliveries or in older women regardless of CS vs vaginal Demisse K et al BMJ 2004; 329:24 Seidman DS et al Lancet 1992; 33: 1583 Crane AK. Female Pelvic Med Reconstr Surg 2013;19:13

Consortium on Safe Labor Rate of Labor Induction: 36.2% (All) 43.8% (Women Attempting SVD) Zhang et al; Obstet Gynecol 2010; 116(6): 1281

What is the Definition of a Failed Induction?

Rouse, et al. Failed Labor Induction: Toward an Objective Diagnosis 1,347 nullips at 36 weeks; cervix no more than 2 cm,

Length of Latent Phase with ROM ROM with Pitocin Vaginal Cesarean 0 to > 3 hours 63.2% 36.8% 3 to < 6 hours 59.6% 40.4% 6 to < 9 hours 50.7% 49.3% 9 to

Fetal Outcomes ROM / Pit Time n NICU NICU>48 Composite* 0 to < 3 hours 1,347 6.2% 3.3% 4.2% 3 to < 6 hours 918 6.0% 3.4 % 4.4% 6 to < 9 hours 408 7.4% 3.7% 5.2% 9 to < 12 hours 162 8.6% 4.3% 6.2% 12 hours 71 9.9% 2.8% 5.6% *5 min Apgar < 4; UA pH < 7.0; seizures; intubation in DR; death, NICU > 48 hours Obstet Gynecol 2011;117:267

Maternal Outcomes ROM /Pit Time n Infection 3rd /4th Lac Atony 0 to < 3 hours 1,347 13.2% 9.2% 4.7% 3 to < 6 hours 918 15.9% 10.1 % 5.7% 6 to < 9 hours 408 22.8% 11.6% 8.6% 9 to < 12 hours 162 27.8% 9.4% 9.9% 12 hours 71 31.0% 10.7% 11.3% Obstet Gynecol 2011;117:267

Induction of Labor Simon et al. Obstet Gynecol 2005; 105: 705 397 Nullips undergoing induction of labor Only latent phase > 18 hours increased rate of CS, chorio, hemorrhage No adverse neonatal outcomes Harper et al. Obstet Gynecol 2012; 119: 1113 5388 women laboring at term (1647 undergoing IOL) Time required for each cm of cervical change in latent phase was 2.0 5.5 hours longer in induced labor

Definitions of Failed Induction and Arrest Disorders Arrest of Labor Failure to generate regular (eg, every 3 min) contractions and cervical change: After at least 24 h of oxytocin administration, and At least 12 -18 hours after ROM Obstet Gynecol 2012; 120:118 AJOG 2014;123(3): 693

Management of FHR Tracings

Moderate FHR variability is reassuring FHR acceleration after fetal scalp stimulation is reassuring

Non-Medical Factors Influencing Cesarean Rate Institutional Factors: Time constraints for scheduling in L and D OR staff availability Inability to support prolonged inductions Physician Factors: Fatigue, workload, anticipated sleep deprivation Financial incentives and disincentives

Financial Incentives/ Disincentives for Cesarean Spetz et al: Birth certificate and hospital financial data from >500,000 births in California, 1995 Cesarean rates for patients with Kaiser (salaried MDs, profit sharing, standard shifts for MDs, utilization review / education / guidelines) versus Other HMOs, private insurance, Medicaid, other payment forms Medical Care 2001; 39(6): 536

Strategies to Reduce Cesarean Rates Aggressive Laboring Techniques Evidence Based Protocols Confidential Provider Feedback on CS Rate Perinatal Outcomes Feedback Second Opinion /Peer Review Review of Facilities. Staffing, Medical Care

Common Myths Among Patients Cesarean is better for my baby Operative vaginal delivery is bad Labor is bad for the baby Normal labor is a relatively short & predictable process Long labor is bad for you and your baby Induced labor is the same as spontaneous labor

Patient Perceptions/Education More realistic patient expectations of labor onset, understanding the differences between spontaneous vs. induced labor, and inability to predict timing or provider Improve patients understanding of labor benefits; labor can be/is safe and beneficial for both mother & baby Help patients understand that cesarean has risks for both mother & baby

Medical Legal Issues!

Quality Measures to Track and Provide Feedback for Each Ob Gyne Rate of non-medically indicated cesarean delivery Rate of non-medically indicated induction Rate of labor arrest or failed induction diagnosed without meeting accepted criteria Rate of cesarean deliveries for nonreassuring fetal heart rate (by NICHD category)

Summary A cesarean performed without an accepted indication should be labeled nonindicated Labor induction should be performed only for medical indications Diagnosis of failed induction should be made only after an adequate attempt Adequate time for normal latent, first, and second stages should be allowed

Summary If maternal and fetal status is reassuring, diagnosis of arrest of labor should be made only after adequate time has elapsed Medically indicated operative vaginal delivery is acceptable When discussing the first cesarean, its effects on subsequent pregnancy should be explained Financial incentives to limit the time spent managing labor should be eliminated

Documents

Katharine D. Wenstrom, MD Director of Maternal-Fetal Medicine Women and Infants Hospital of RI Warren Alpert Medical School, Brown University