Reducing caesarean deliveries

Specialists are providing obstetrical care by identifying opportunities to avoid unnecessary first caesarean deliveries, which have a big impact on subsequent deliveries, and are hoping to ultimately reduce the number of caesarean deliveries.

“Given the risks associated with the initial caesarean and its implications in subsequent pregnancies, the most effective approach to reducing overall morbidities related to caesarean delivery is to avoid the first caesarean,” explained George Saade, MD, University of Texas Medical Branch, Texas, and one of the article authors.

“The implications of a caesarean rate of 30 percent or more – since approximately one in three pregnancies are delivered by caesarean [in the USA] – have significant effects on the medical system as well as on the health of women and children. It is essential to embrace this concern and provide guidance on strategies to lower the primary caesarean rate.”

A caesarean delivery increases the risk of maternal complications, including intraoperatively, and has clear implications for future pregnancies, in that it increases the chances of a repeat caesarean delivery. Adhesions of uterus, bowel and bladder can result in trauma at surgery, while abnormal placentation and uterine rupture can be catastrophic for both mother and baby.

Workshop participants synthesised available information regarding factors leading to a woman’s first caesarean delivery, including obstetric, maternal, and foetal indications for caesarean delivery; labour management and induction practices; and non-medical factors. Participants also reviewed the implications of the first caesarean on future reproductive health, and considered recommendations for practice, opportunities for patient and community education, and potential areas for research.

Guidelines as to when caesarean delivery is appropriate for ‘failed induction’, ‘arrest of labour progress’ or ‘non-reassuring foetal status’ were among the many key points addressed in the workshop from which the paper was written, to assist in reducing caesarean rates. The need to keep operative vaginal delivery as an acceptable birth method when indicated; and that counselling regarding the effect of caesarean delivery on future reproductive health were also highlighted.

At the end of the workshop, the participants concluded that although numerous factors contribute to the primary caesarean rate, the clinician’s ability to modify some of these and mitigate others is the first step toward lowering the primary caesarean rate. Education regarding the normal labour course and the implications of first caesarean may allow women and their providers to avoid practices that increase the potential for unneeded first caesarean deliveries.

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