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Will new guidelines to reduce C-sections change maternity care?

By Michele Munz
St. Louis Post-Dispatch
LIFE HEALTH-C-SECTIONS 1 SL
Stephanie S. Cordle - MCT
Nicole Madalon, a certified nurse-midwife, left, checks Andria Webb’s blood pressure at a birthing center in Fallon, Mo., on March 15. National obstetrician organizations together released new guidelines aimed at reducing the spiraling cesarean rate in the U.S. A big change was allowing women much more time in labor, based on new research.

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  • The role of mothers

    Lamaze International, which studies and promotes healthy birth practices, said the new guidelines were an important step in closing gaps between evidence and day-to-day care that women receive in labor. But systemic change is hard, and women should not wait, said Lamaze president Michele Ondeck.

    “This is why it’s critical for women to have the education, resources and support they need to push for evidence-based care now,” Ondeck said, “rather than waiting for providers to change their practice.”



Women planning to deliver at some birth centers are being encouraged to stay at home when their labor begins. They are advised to rest, eat, walk around and not to time every contraction.

Last month, national obstetrician organizations together released new guidelines aimed at reducing the spiraling cesarean rate in the U.S. A big change was allowing women much more time in labor, based on new research.

Other changes include providing continuous labor support, letting women attempt to deliver twins, not using the fetus’ weight as a reason for surgery and doing more to understand electronic fetal heart rate readings.

Women’s health advocates said the guidelines, developed jointly by the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine, could completely change how women approach birthing options.

“The consensus statement has the potential to be a game-changer in ongoing efforts to improve the quality of maternal health care and maternal and child health outcomes,” the National Partnership for Women and Families said in a statement.

But doctors acknowledge barriers. Changes are slow to take effect in massive hospital systems and in private practices where doctors have been doing things a certain way for decades.

The guidelines say that although national organizations can set the agenda to safely lower the cesarean rate: “Changing the local culture and attitudes of obstetric care providers regarding the issues involved in cesarean delivery reduction also will be challenging.”

Will hospitals need to have rooms available for longer? Will they urge women to stay home until they are in the later stage of labor? Will they bring back doula (labor coach) programs? Will they limit use of fetal heart rate monitoring?

“Those are great questions,” said Dr. Alison Cahill, chief of the maternal-fetal medicine division at Washington University School of Medicine, who helped develop the guidelines. “Could these change obstetrics in the U.S.? We don’t know yet.”

Showing the way

But one can look at midwife-led birth centers and their homelike facilities to see how care can be different.

A study released in January of more than 15,500 women who received care at birth centers in 33 states showed that fewer than 1 in 16 (6 percent) required a C-section, compared with nearly 1 in 4 (24 percent) similar low-risk women planning a hospital birth.

While the C-section rate in the U.S. has climbed to 1 in 3 births – a 60 percent increase since 1996 – the rate at birth centers has stayed the same for more than 20 years.

Cesareans are associated with increased maternal mortality and morbidity, and those risks significantly increase with subsequent C-sections. Death and intensive-care stays also become more likely for babies.

Because most women who have C-sections end up having repeat C-sections in subsequent pregnancies, the new guidelines focused on practices that could prevent the surgery in healthy first-time mothers.

One of the biggest reasons first-time mothers have cesareans is subjective: Doctors consider labor “stalled” or determine the electronic fetal heart rate readings are “nonreassuring.” But the latest evidence shows that labor lasts much longer than long thought, and little information exists on how to interpret questionable but common heart rate patterns.

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