Revised labor guidelines touted to reduce C-sections don’t work and harm babies

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They were announced with great fanfare.

In a document entitled Safe Prevention of the Primary Cesarean Delivery, The American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine recommended dropping the Friedman curves of labor progress and offered new standards for normally progressing labor:

Despite delaying the diagnosis of labor arrest for hours, the C-section rate didn’t fall, but the maternal and neonatal morbidity rates increased by 60% and 80% respectively.

Specifically:

…[C]esarean delivery for active phase arrest in the first stage of labor should be reserved for women at or beyond 6 cm of dilation with ruptured membranes who fail to progress despite 4 hours of adequate uterine activity, or at least 6 hours of oxytocin administration with inadequate uterine activity and no cervical change.

And:

…[B]efore diagnosing arrest of labor in the second stage and if the maternal and fetal conditions permit, at least 2 hours of pushing in multiparous women and at least 3 hours of pushing in nulliparous women should be allowed. Longer durations may be appropriate on an individualized basis …

They were greeted rapturously at the time they were introduced.

Judith Lothian wrote on Science and Sensibility:

These guidelines offer great promise in lowering the cesarean rate and making labor and birth safer for mothers and babies. They also suggest an emerging respect for and understanding of women’s ability to give birth and a more hands off approach to the management of labor. Women will be allowed to have longer labors. Obstetricians will need to be patient as nature guides the process of birth. Hospitals will have to plan for longer stays in labor and delivery. And women will need to have more confidence in their ability to give birth… The prize will be safer birth and healthier mothers and babies.

Now comes word that not only do the guidelines fail to reduce the C-section rate, they increase both maternal and neonatal morbidity.

The new paper is New Labor Management Guidelines and Changes in Cesarean Delivery Patterns by Rosenbloom et al.

The authors followed the labors of nearly 8000 women that occurred at their institution from 2010 to 2014. They found:

The CD [Cesarean delivery] rate in 2010 was 15.8% and in 2014 17.7% (p-trend 0.51). In patients undergoing CD for arrest of dilation, the median cervical dilation at the time of CD was at 5.5 cm in 2010 and 6.0 cm in 2014 (p-trend 0.94). In these patients, there was an increase in the time spent at last dilation: 3.8h in 2010 to 5.2h in 2014 (p-trend 0.02)…

There were 206 CDs for arrest of descent. The median pushing time in these patients increased in multiparous patients from 1.1h in 2010 to 3.4h in 2014 (p-trend 0.009); in nulliparous patients these times were 2.7h in 2010 and 3.8h in 2014 (p-trend 0.09). There was a significant trend towards increasing adverse neonatal and maternal outcomes (p<0.001 for each). The aOR for adverse maternal outcome for 2014 compared to 2010 was 1.66 (95%CI 1.27, 2.17) … The aOR of adverse neonatal outcome in 2014 compared to 2010 was 1.80 (95%CI 1.36, 2.36).

In other words, despite delaying the diagnosis of labor arrest for hours, the C-section rate didn’t fall, but the maternal and neonatal morbidity rates increased by 60% and 80% respectively.

This is precisely what Dr. Friedman came out of retirement at age 89 to warn about in Misguided guidelines for managing labor:

Using untested guidelines for the management of labor may adversely affect women and children. Even if those guidelines were to reduce the currently excessive cesarean delivery rate, the price of that benefit is likely to be a trade-off in harm to parturients and their offspring. The nature and degree of that harm needs to be documented before considering adoption of the guidelines.

Of course, the latest study is hardly the last word on the topic. As the authors themselves point out:

A similar study from Pennsylvania examined the adoption of the new labor guidelines in nulliparous patients; researchers found a decrease in cesarean rates from 26.9% to 18.8% and the frequency of CD for arrest of dilation dropped from 7.1% to 1.1% …

But:

…[T]heir primary outcome was the CD rate among induced or augmented patients, while ours was the total CD rate. Our study also incorporated a far greater number of patients and took place over 5 years.

The bottom line is that in this study, the “hands off approach” recommended by natural childbirth advocates not only didn’t reduce the C-section rate, it actually harmed mothers and babies. That’s nothing to cheer about.

  • Gæst

    Three hours of pushing!?! That sounds like a nightmare. I never made it to pushing, as my c-section was for fetal distress before that. But I do know that at eight centimeters dilated after eight hours of pitocin I would have cried and given up if I thought I had three hours of pushing ahead of me.

  • guest

    Expecting my first child, and receiving a lot of advice about how to avoid a C-section. People are very quick to suggest water birth, homebirth, and even unassisted home birth. When I say I am not comfortable with that due to the potential risk to the baby, they usually brush it off. I hear this a lot: “well, bad things hardly ever happen” or “mind over matter – if you go into birth thinking you can do it, then you won’t have any complications”

    Honestly, I don’t care much about whether or not I get a C-section. I figure that is up to my OB, and nature. My main priority is a healthy baby. If vaginal labor doesn’t work out, and the baby is at risk, “then do what you’ve gotta do to get her out safe” is basically my whole birth plan.

    Pain does not frighten me. Surgery does not frighten me. But losing my child, or seeing her harmed frightens me very badly.

    My biggest fear is actually premature labor. And yet, the same people who advocate natural childbirth to me say things like “wouldn’t it be great if the baby came a few weeks early, before the new year, for the tax break?” or “wouldn’t it be neat to have a Christmas baby?”

    I am always horrified by this. When I point out that this would mean the baby would come early enough to have to spend her first weeks in the NICU, they shrug it off like it’s no big deal. “But preemies are so little and cute!”

    It’s like there is no real focus on the baby or the baby’s wellbeing at all. Like all of the possible uncomfortable medical interventions are just fine for a newborn to endure, but it is unacceptable for a grown woman to experience even one, because it might mess up the “birth experience”.

    The cognitive dissonance is astounding.

    • Gæst

      I borrowed a baby name book from a neighbor and when she found out I was having twins she sent multiple emails to me about “not letting” doctors do a c-section. I’m very glad I didn’t listen to her.

    • The Bofa on the Sofa

      “But preemies are so little and cute!”

      #jawdrop

      Little? Yes. Cute? Not when they are tied up to all the tubes in the NICU.

      Healthy? Bah, who cares….

  • 3boyz

    A relative of mine just had her first baby in her late 40s. It was a planned c-section, she didn’t want to take any chances. People have asked but was there a problem? What was the section for? Her answer was that she researched the potential risks of a c-section and basically the biggest risk was to future pregnancies. Well, at her age, that’s almost certainly not happening, and even if it does, more than one more is definitely not happening. The risks of attempting a vaginal birth, though small, were larger than the risks of the planned section and it wasn’t worth it for her.

  • fiftyfifty1

    So Dr. Freidman invented his curve using data from real labors: If you stayed on the curve, the outcome tended to be good. If you fell off the curve, outcomes tended to be bad.
    So fast forward some decades, and the data from real labors has changed. Now fewer women stay on Friedman’s curve. More women fall off the curve. So natural birth proponents come to the conclusion that the curve must be wrong, not the women’s labors. They conclude that the biology of a normal birth has somehow shifted. That labors patterns that used to be abnormal and unhealthy are now normal and healthy.
    Wow, that seems so screwy! Doesn’t it seem more likely that the markers of a healthy normal labor haven’t changed, but what has changed is that more women are entering labor with suboptimal biology? I mean, come on, let’s face facts. My mother and grandmother had their first babies by age 21. I was in tip-top shape at 21. I was flexible, I had not a wrinkle, I decided I wanted to run a marathon so I went out that day and ran a marathon, even though I hadn’t trained for one. I was sore the next day, but I did it. 21 year olds are gods and goddesses! But when I had my first baby, I was well into my 30’s. I was fatter, I was less flexible, I was older. There was no way in hell I could have run a marathon. You can’t expect the same results.
    But we should expect the same results in labor even though women are older and heavier? No, we should predict that more women will have dysfunctional labors. And it turns out they do!!!!

    • Kq

      I had my kid at 33. They called me an “elderly” mother…

      • Heidi_storage

        What, really? I thought they didn’t stick the “advanced maternal age” label on you until you hit 35.

        • attitude devant

          no, it starts at 30

          • Heidi_storage

            Now, that’s a bit weird, because outcomes for women aged 30–34 are pretty darn close to outcomes for women aged 25–29. My docs didn’t treat me as if I were of advanced maternal age for any of my three (born at 31, 32, and 34).

          • MaineJen

            I was told 35 also.

          • Empress of the Iguana People

            Mine were also at 35. Probably depends on the docs or the region you live in.

    • guest

      Eh. I cringe at normalizing women having children in their teens and early twenties, or blaming labor complications on maternal age. It is so often used to shame women who waited to have children until their thirties and forties.

      Jean Twenge has written a lot on this subject, and the meta-analysis of the studies and research done on maternal age during pregnancy. Much of the “common knowledge” about increased risks in mothers over 30 is simply not supported by the data.

      There is an increased risk of miscarriage. That’s about it.

      And yet, nobody talks about the many very good studies that show an increased risk for many labor complications, babies with birth defects, and post-partum depression in women UNDER 30. Why? Because it doesn’t support the narrative that women should stay home, marry, and start having children as young as possible. It doesn’t leave much room for shaming women who choose to focus on careers or other pursuits during that decade of life.

      • Heidi_storage

        Well, it isn’t unreasonable to consider the role of biology and aging in having a baby; I think we can say that being older and heavier does present some risks, without implying that everyone ought to complete their childbearing by age 26, or that overweight mothers are baaaad.

      • AnnaPDE

        You are assuming the kind of economic uncertainty of current Western capitalist countries in this, though. FTM’s age was way lower in Eastern Europe during socialist times, and increased sharply after 1989. They had high proportions of women in all kinds of jobs, too. The fact that most people had a secure job right after graduation made a huge difference in women’s ability to have kids when they wanted to without having to fear for their career.

      • fiftyfifty1

        Natural childbirth advocates don’t want to admit that more women are having dysfunctional labors because it doesn’t fit with their worldview. But the science shows otherwise. You don’t want to admit that CS goes up with age, because it doesn’t fit with your worldview. But the science shows otherwise. The lowest rate of CS occurs among 16 year olds, and it marches up as the years go by.

        If women are shamed for delaying childbearing we should work on THAT, and on destigmatizing interventions in labor, not on denying the science.

      • Sarah

        Which labour complications and birth defects, and which studies?

  • Krista

    Wow, those are some really horrifying consequences from revising the criteria. Surely all those who claim to care about evidence based practices will now advocate for a return to the previous guidelines? Right? Unless they don’t actually care about the evidence…

    • When the measure of success is a procedure and not an outcome (like morbidity or mortality) – is when the way is so lost finding it again might take an inquest.

  • Empress of the Iguana People

    People go to midwives because they think they’ll get cozier, more individual care, right? How is it more individual to say “no one should have x intervention until y, z, and j are reached?” It’s a blanket generalization and like all blanket generalizations, there are going to be lots of cases where it doesn’t fit very well. My BIL needs a longer blanket for his 6’5″ frame than my 3’6″ son.

    • Glia

      This is something that bothers me about the whole natural birth/parenting thing in general. After you have had your “individualized” birth that must look a certain way, you will be so in touch with your child that you think ALL babies should be worn, that ALL babies should be with their at-home mothers at all times, that ALL babies should not only be exclusively breastfed, but should never be given solids until after 6 months, and at that point must do babyled weaning.

      • Roadstergal

        It’s the difference between ‘individualized’ to your needs vs to your wants. It doesn’t matter how pretty Chris Froome’s bike looks and how much I want it, it simply does not work for me. I need one that works for my biological reality.

  • attitude devant

    Ugh. Recently had to review a chart where the labor fell off the Friedman curve early and stayed off it, and yet the labor was allowed to continue. A centimeter every three hours, baby tolerating poorly…..sadly predictable results. Madness!

    • NoLongerCrunching

      What happened after it was investigated? Did it change practices?

      • attitude devant

        Never be surprised that practitioners are sucked in by the woo too. After all, the original article was included in our required reading for recertification in OB. If you’ve been around as long as I have, you’ve seen enough to be skeptical, but my younger colleagues are not quite so. Serious conversations have been had and management issues addressed, and….the rest is still unwritten. We’ll see.

    • Dr Kitty

      My mum did some of the research for partograms in Zimbabwe as a medical student, back in the 1970s.
      By working out early when things were going wrong it allowed traditional birth attendants to get labouring women to somewhere where oxytocin and a CS were possibilities. Transferring early rather than waiting until someone had already been in labour for 24 hours or pushing for 4 hours made a huge difference. Their morbidity and mortality among women and babies dropped almost immediately.

      This idea that partograms are vague guidelines rather than clear indications of warning signs when things are not going to plan is very pervasive.

      Mum has always been faintly horrified by the rather blasé attitude of NCB and NHS midwives to the charts, and chose an obstetrician who had trained in Africa and had similar feelings for her own pregnancies.

  • Roadstergal

    “currently excessive cesarean delivery rate”

    Why? Why is it excessive? Not enough babies dying?

    FFS.

    • Heidi_storage

      Anything above 15% is excessive, because lies spread around the world while truth is putting on its shoes.

    • TheArtistFormerlyKnownAsYoya

      I too am wondering why this statement seems generally accepted even by people like Dr. Friedman and Amy Tuteur?

    • guest

      I recently had a wonderful conversation with a CNM and a birth doula from a local hospital about cesarean rates. They said that in the United States, during their training, they had both been pushed to believe that there was no “acceptable” cesarean rate, that we should always strive to have lower numbers. Then they both had the opportunity to work outside of the United States, in developing countries. One went as part of an exchange program for medical professionals, the other as a volunteer for a humanitarian mission. They said that in a society without hospitals or modern medical care, in a completely different cultural context, they learned a lot about how vaginal birth could be done better. But they also learned that in 10% – 15% of cases, without a modern OR setup, no matter how prepared or committed the midwives and doctors and local healers were, either the mother or the baby (or both) died from labor complications.
      They both returned to the United States believing that the ideal cesarean rate should be 15% or greater.

      • Heidi

        If 10-15% involve death, surely one would have to think somewhere over 15% is ideal. Brain damage and pelvic floor damage are things c-sections can prevent after all. Besides the fact there’s no possible way to know with certainty if a case required a C-section without a negative outcome.

  • anh

    I had a planned csection on Monday. At noon so it was easy for everyone. Epidural failed and I had to be put under. Guess what? Recovery is ten million times better than my other daughter’s vaginal birth. By leaps and bounds.

    Why was I so keen to avoid this?

    I will say, I’m in a phenomenal hospital with ridiculously good care. And my daughter is in the NICU so I’m focusing on my own recovery. So I know I’m ludicrously privileged. But it’s honestly really not that awful.

    • Congratulations on the new arrival!

    • Lilly de Lure

      Congratulations – wishing all the best for the recovery of both you and your new arrival!

    • Empress of the Iguana People

      Congratulations! Hope she’s a NICU grad soon!

    • StephanieJR

      Congratulations! Hope everything keeps getting better.

    • AnnaPDE

      Congratulations! Sorry about that epidural (getting poked in the back and then not even having the payoff of watching people cut you open, how unfair!), but I’m glad you’re well and all the best for the newbie!

    • Dr Kitty

      Anh- I hope your little girl is doing well, I’m sure knowing she is in good hands is helping.

      Look after yourself, rest up and let us know how things go.

    • TheArtistFormerlyKnownAsYoya

      My planned c section was also a breeze.

  • MaineJen

    Them: “Women are allowed to labor even longer now, and you can push up to 3 hours fruitlessly! Isn’t that great?”

    Me: Uh…no

    • My insides clench just thinking about that, and I haven’t even had a baby!

    • KQ Not Signed In

      Pushing for 40 minutes without progressing before my CS was bad enough. Gah.

    • The Kids Aren’t AltRight

      The level of condescension is astounding. Guess what silly ladies! The people in charge are going to let you suffer for triple the time! Isn’t it exhilarating, you silly little thing!?

      • MaineJen

        And of course you’ll want to go all natural, right? There’s no reason to ease that pain. It’s good for you! Just listen to all that healthy vocalizing.

    • Merrie

      It seems like the narrative of a long difficult birth always has to be that you’ll make it through, success is just around the corner… But you never do know what is going to happen. The idea of prioritizing having the baby transit your vagina is just more bizarre to me the more I think about it. I mean, the goal of labor is to get the baby out. At a certain point, why keep suffering when it’s looking less and less likely that birth is going to take place vaginally? Pushing for 3 hours sounds like a nightmare, and particularly if it’s after a long difficult labor to begin with.

      • Sarah

        It is.

    • TheArtistFormerlyKnownAsYoya

      I was thinking…”allowed” or forced? This sounds like torture to me.

  • When avoiding a cesarean is the goal – the toll is the health and well being of mothers and their babies. How many more women suffer more severe damage to their pelvic floors? How many more women will care for disabled children? How many more women will leave the hospital with empty arms and broken hearts? How many more women will struggle with the trauma of their induction to motherhood? When will the right goals be set? The ones that really matter.

    • Lilly de Lure

      I’m sorry to say this but I’ve a horrible feeling that it will only happen when mothers who have been, or seen their children being unnecessarily maimed by medical teams following this crazy advice sue the living hell out of the teams that did so and hurt them. Suing ACOG for producing it in such an event might not be such a bad idea either.

      • MaineJen

        Isn’t that what’s happening with the NHS in Britain right now? Hence the dropping of the “push for normal birth” or whatever they were calling it.

  • Madtowngirl

    “Obstetricians will need to be patient as nature guides the process of birth.”

    Wow. As “nature guides” the process of birth. Lothian means “as some women and babies die,” right? Good grief, when are people going to realize that OBs don’t actually want to just get to their golf games?

    • Russell Jones

      Anthropomorphizing nature = religion, plain and simple. That’s fine and dandy. Natural birth advocates can believe whatever they want, just like anyone else. But granting religious beliefs the force and effect of law – or of medical protocol, as in this case – just doesn’t wash. So much for making reducing the number of c-sections an end in itself.

  • oscar

    The text in the cited paper on neonatal and maternal morbidity is missing from the post.

    • Amy Tuteur, MD

      Thanks! Fixed it.