Contemporary cesarean delivery practice in the United States

doi:10.1016/j.ajog.2010.06.058

American Journal of Obstetrics and Gynecology

Volume 203, Issue 4, October 2010, Pages 326.e1-326.e10

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https://doi.org/10.1016/j.ajog.2010.06.058 Get rights and content

Objective

To describe contemporary cesarean delivery practice in the United States.

Study Design

Consortium on Safe Labor collected detailed labor and delivery information from 228,668 electronic medical records from 19 hospitals across the United States, 2002-2008.

Results

The overall cesarean delivery rate was 30.5%. The 31.2% of nulliparous women were delivered by cesarean section. Prelabor repeat cesarean delivery due to a previous uterine scar contributed 30.9% of all cesarean sections. The 28.8% of women with a uterine scar had a trial of labor and the success rate was 57.1%. The 43.8% women attempting vaginal delivery had induction. Half of cesarean for dystocia in induced labor were performed before 6 cm of cervical dilation.

Conclusion

To decrease cesarean delivery rate in the United States, reducing primary cesarean delivery is the key. Increasing vaginal birth after previous cesarean rate is urgently needed. Cesarean section for dystocia should be avoided before the active phase is established, particularly in nulliparous women and in induced labor.

Section snippets

Materials and Methods

The Consortium on Safe Labor included 12 clinical centers (with 19 hospitals) across 9 American College of Obstetricians and Gynecologists (ACOG) US districts. There were 8 university affiliated teaching hospitals, 9 teaching community hospitals, and 2 nonteaching community hospitals. They were chosen because of the availability of electronic medical records at each institution and because their geographic distribution covers all ACOG US districts. A total of 228,668 deliveries with 233,844

Results

The overall rate of cesarean delivery in our cohort was 30.5%, varying from 20% to 44% among the participating hospitals. Table 1 presents the overall and specific categories of cesarean delivery (primary vs repeat, and prelabor vs intrapartum) by maternal characteristics. With advancing maternal age, the overall cesarean rate doubled from 21.0% at age <20 years to 42% in women 35 years or older, mainly due to repeat, prelabor cesarean deliveries. Obesity was associated with substantially

Comment

Our study is a large, contemporary assessment of cesarean delivery practice for the US obstetric population. We found that:

•
One in 3 nulliparous women was delivered by cesarean section.
•
Prelabor repeat cesarean delivery due to a previous uterine scar was the most common reason for cesarean section, contributing almost a third of all cesarean deliveries. In contrast, the rate of trial of labor is disappointingly low, and the associated success rate for vaginal birth has declined.
•
Approximately 44%

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Cited by (505)

Oxytocin is not associated with postpartum hemorrhage in labor augmentation in a retrospective cohort study in the United States
2024, American Journal of Obstetrics and Gynecology
Previous studies reported conflicting results on the relationship between oxytocin use for labor augmentation and the risk of postpartum hemorrhage, probably because it is rather challenging to disentangle oxytocin use from labor dystocia.
This study aimed to investigate the independent association between oxytocin use for augmentation and the risk of postpartum hemorrhage by using advanced statistical modeling to control for labor patterns and other covariates.
We used data from 20,899 term, cephalic, singleton pregnancies of patients with spontaneous onset of labor and no previous cesarean delivery from Intermountain Healthcare in Utah in the Consortium on Safe Labor. Presence of postpartum hemorrhage was identified on the basis of a clinical diagnosis. Propensity scores were calculated using a generalized linear mixed model for oxytocin use for augmentation, and covariate balancing generalized propensity score was applied to obtain propensity scores for the duration and total dosage of oxytocin augmentation. A weighted generalized additive mixed model was used to depict dose–response curves between the duration and total dosage of oxytocin augmentation and the outcomes. The average treatment effects of oxytocin use for augmentation on postpartum hemorrhage and estimated blood loss (mL) were assessed by inverse probability weighting of propensity scores.
The odds of both postpartum hemorrhage and estimated blood loss increased modestly when the duration and/or total dosage of oxytocin used for augmentation increased. However, in comparison with women for whom oxytocin was not used, oxytocin augmentation was not clinically or statistically significantly associated with estimated blood loss (6.5 mL; 95% confidence interval, 2.5–10.3) or postpartum hemorrhage (adjusted odds ratio, 1.02; 95% confidence interval, 0.82–1.24) when rigorously controlling for labor pattern and potential confounders. The results remained consistent regardless of inclusion of women with an intrapartum cesarean delivery.
The odds of postpartum hemorrhage and estimated blood loss increased modestly with increasing duration and total dosage of oxytocin augmentation. However, in comparison with women for whom oxytocin was not used and after controlling for potential confounders, there was no clinically significant association between oxytocin use for augmentation and estimated blood loss or the risk of postpartum hemorrhage.
Misoprostol with balloon vs oxytocin with balloon in high-risk pregnancy induction: a randomized controlled trial
2023, American Journal of Obstetrics and Gynecology MFM
Pregnancies at high risk for maternal, fetal, or placental complications often necessitate induction of labor in the late preterm or early term period for delivery. Limited data exist on the safest method of induction to use in this specific patient population.
This study aimed to compare the combination of oxytocin plus a Cook balloon vs misoprostol plus a Cook balloon for induction of labor in high-risk pregnancies.
We conducted an open-label, randomized controlled trial at a single institution from July 2020 to May 2022. The study was approved by the institutional review board and registered with ClinicalTrials.gov (NCT04492072). Individuals with a high-risk pregnancy, at least ≥22 weeks’ gestation, with a singleton in cephalic presentation, Bishop score ≤6, and intact membranes were offered enrollment. A high-risk pregnancy was defined as a pregnancy with any of the following complications: hypertensive disease of pregnancy, fetal growth restriction, oligohydramnios, suspected placental abruption requiring delivery, uncontrolled pregestational diabetes, or abnormal biophysical profile or nonstress test requiring delivery. The primary outcome was the rate of cesarean delivery. Secondary maternal outcomes included induction to delivery interval, number of vaginal deliveries within 24 hours, rates of uterine tachysystole, intraamniotic infection, operative vaginal delivery, and postpartum hemorrhage. Secondary fetal outcomes included fetal heart rate abnormalities, stillbirth, Apgar scores <7 at 5 minutes, admission to the neonatal intensive care unit, arterial umbilical blood pH <7.1, sepsis, and neonatal death. A subgroup analysis was planned for the primary outcome to assess the different indications for cesarean delivery. An intent-to-treat analysis was performed.
During the 22 months of the trial, a total of 150 patients were randomized, and 73 (49%) of those were induced with oxytocin and a Cook balloon and 77 (51%) were induced with misoprostol and a Cook balloon. There was no significant difference in the overall rate of cesarean delivery between the study groups, (21.9% vs 31.1%; relative risk, 0.70; 95% confidence interval, 0.41–1.21), nor among those for which the cesarean delivery was performed for a specific indication. There were no differences in the secondary maternal and fetal or neonatal adverse outcomes.
In high-risk pregnancies, the rate of cesarean delivery and adverse maternal and fetal outcomes were similar for induction of labor with oxytocin and a Cook balloon and for induction with misoprostol and a Cook balloon.
Adverse maternal outcomes associated with major fetal malformations after singleton live birth
2023, American Journal of Obstetrics and Gynecology MFM
Major fetal malformations complicate 2% to 5% of live births. It is unclear what effect fetal malformations have on severe maternal morbidity.
This study aimed to compare maternal outcomes between individuals with a fetus with major or minor fetal malformations and those with a fetus without major or minor fetal malformations.
This was a secondary analysis of the Consortium on Safe Labor database. Our study was limited to the current analysis of pregnant individuals with a singleton live birth. Major fetal malformations based on the Centers for Disease Control and Prevention's criteria were defined. Fetal malformations that did not meet the criteria for major fetal malformations were categorized as minor fetal malformations. Our primary maternal outcome was severe maternal morbidity as defined by the Centers for Disease Control and Prevention. Missing values were imputed by multiple imputation using the k-nearest neighbor imputation method. Poisson regression with robust error variance was used to obtain adjusted relative risks with 95% confidence intervals, controlling for confounders.
Of 216,881 deliveries, there were 201,860 cases (93.1%) with no congenital malformation, 12,106 cases (5.6%) with minor fetal malformations, and 2845 cases (1.3%) with major fetal malformations. Compared with individuals with no fetal malformation, those with major fetal malformations were more likely to have severe maternal morbidity (0.7% vs 1.2%; adjusted relative risk, 1.51; 95% confidence interval, 1.07–2.12), postpartum hemorrhage (3.6% vs 6.9%; adjusted relative risk, 1.76; 95% confidence interval, 1.50–2.06), preeclampsia (5.1% vs 8.3%; adjusted relative risk, 1.48; 95% confidence interval, 1.31–1.67), and cesarean delivery (26.7% vs 42.3%; adjusted relative risk, 1.51; 95% confidence interval, 1.45–1.58). Compared with individuals with no fetal malformation, those with minor fetal malformations were more likely to have severe maternal morbidity (0.7% vs 1.4%; adjusted relative risk, 1.73; 95% confidence interval, 1.48–2.02), maternal death (0.01% vs 0.03%; adjusted relative risk, 4.50; 95% confidence interval, 1.18–17.19), postpartum hemorrhage (3.6% vs 6.1%; adjusted relative risk, 1.54; 95% confidence interval, 1.41–1.68), preeclampsia (5.1% vs 8.6%; adjusted relative risk, 1.50; 95% confidence interval, 1.41–1.60), superimposed preeclampsia (1.2% vs 2.4%; adjusted relative risk, 1.25; 95% confidence interval, 1.14–1.38), cesarean delivery (26.7% vs 39.6%; adjusted relative risk, 1.38; 95% confidence interval, 1.35–1.41), chorioamnionitis (3.0% vs 4.7%; adjusted relative risk, 1.41; 95% confidence interval, 1.29–1.53), and postpartum endometritis (0.6% vs 1.0%; adjusted relative risk, 1.58; 95% confidence interval, 1.31–1.90).
Major and minor congenital fetal malformations are independent risk factors for severe maternal morbidity and other pregnancy complications.
Improving Nurse Management of the Second Stage of Labor
2023, Nursing for Women's Health
To develop, implement, and evaluate an educational program to improve nurses’ management of the second stage of labor.
Evidence-based practice project guided by the Iowa Model–Revised.
Acute care teaching hospital in central California averaging 2,100 births/year with 12 labor, delivery, and recovery rooms and a Level III nursery.
Eighteen registered nurses participated in the educational intervention.
An instructional course addressed contemporary labor management guidelines and delayed and open/closed glottis pushing. Assessment/documentation of maternal–fetal status, progress/fetal descent, and nurse/provider communication were discussed. Participants engaged in an interactive experience regarding maternal positions.
Data collected from the electronic health record included the number of position changes, nurse/provider communication interactions, and minutes from 10 cm to birth and minutes in delayed pushing.
Second-stage labor outcomes for nulliparous patients at term with a singleton in vertex presentation improved with more position changes and percentage of spontaneous vaginal births. Patients of nurses who participated in the educational intervention (n = 18) had a vaginal birth rate of 87.5% and a surgical birth rate of 6.2%. Patients of nurses who did not participate in the educational intervention (n = 31) had a vaginal birth rate of 81.8% and a surgical birth rate of 9.1%.
Based on the positive response to the intervention and improved clinical outcomes, regularly scheduled interactive nursing education focused on strategies to improve the second stage of labor may be beneficial.
Assessment of uterine contractions in labor and delivery
2023, American Journal of Obstetrics and Gynecology
Normal labor and delivery are dependent on the presence of regular and effective contractions of the uterine myometrium. The mechanisms responsible for the initiation and maintenance of adequate and synchronized uterine activity that are necessary for labor and delivery result from a complex interplay of hormonal, mechanical, and electrical factors that have not yet been fully elucidated.
Monitoring uterine activity during term labor and in suspected preterm labor is an important component of obstetrical care because cases of inadequate and excessive uterine activity can be associated with substantial maternal and neonatal morbidity and mortality. Inadequate labor progress is a common challenge encountered in intrapartum care, with labor dystocia being the most common indication for cesarean deliveries performed during labor. Hereafter, an accurate assessment of uterine activity during labor can assist in the management of protracted labor by diagnosing inadequate uterine activity and facilitating the titration of uterotonic medications before a trial of labor is prematurely terminated. Conversely, the ability to diagnose unwanted or excessive uterine activity is also critical in cases of threatened preterm labor, tachysystole, or patients undergoing a trial of labor after cesarean delivery. Knowledge of uterine activity in these cases may guide the use of tocolytic medications or raise suspicion of uterine rupture. Current diagnostic capabilities are less than optimal, hindering the medical management of term and preterm labor.
Currently, different methods exist for evaluating uterine activity during labor, including manual palpation, external tocodynamometry, intrauterine pressure monitoring, and electrical uterine myometrial activity tracing. Legacy uterine monitoring techniques have advantages and limitations. External tocodynamometry is the most widespread tool in clinical use owing to its noninvasive nature and its ability to time contractions against the fetal heart rate monitor. However, it does not provide information regarding the strength of uterine contractions and is limited by signal loss with maternal movements. Conversely, the intrauterine pressure catheter quantifies the strength of uterine contractions; however, its use is limited by its invasiveness, risk for complications, and limited additive value in all but few clinical scenarios. New monitoring methods are being used, such as electrical uterine monitoring, which is noninvasive and does not require ruptured membranes. Electrical uterine monitoring has yet to be incorporated into common clinical practice because of lack of access to this technology, its high cost, and the need for appropriate training of clinical staff. Further work needs to be done to increase the accessibility and implementation of this technique by experts, and further research is needed to implement new practical and useful methods. This review describes current clinical tools for uterine activity assessment during labor and discusses their advantages and shortcomings.
The review also summarizes current knowledge regarding novel technologies for monitoring uterine contractions that are not yet in widespread use, but are promising and could help improve our understanding of the physiology of labor, delivery, and preterm labor, and ultimately enhance patient care.
The evolution of the labor curve and its implications for clinical practice: the relationship between cervical dilation, station, and time during labor
2023, American Journal of Obstetrics and Gynecology
The assessment of labor progress is germane to every woman in labor. Two labor disorders—arrest of dilation and arrest of descent—are the primary indications for surgery in close to 50% of all intrapartum cesarean deliveries and are often contributing indications for cesarean deliveries for fetal heart rate abnormalities.
Beginning in 1954, the assessment of labor progress was transformed by Friedman. He published a series of seminal works describing the relationship between cervical dilation, station of the presenting part, and time. He proposed nomenclature for the classification of labor disorders. Generations of obstetricians used this terminology and normal labor curves to determine expected rates of dilation and fetal descent and to decide when intervention was required.
The analysis of labor progress presents many mathematical challenges. Clinical measurements of dilation and station are imprecise and prone to variation, especially for inexperienced observers. Many interrelated factors influence how the cervix dilates and how the fetus descends. There is substantial variability in when data collection begins and in the frequency of examinations. Statistical methods to account for these issues have advanced considerably in recent decades. In parallel, there is growing recognition among clinicians of the limitations of using time alone to assess progress in cervical dilation in labor. There is wide variation in the patterns of dilation over time and most labors do not follow an average dilation curve.
Reliable assessment of labor progression is important because uncertainty leads to both over-use and under-use of cesarean delivery and neither of these extremes are desirable. This review traces the evolution of labor curves, describes how limitations are being addressed to reduce uncertainty and to improve the assessment of labor progression using modern statistical techniques and multi-dimensional data, and discusses the implications for obstetrical practice.

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: The Consortium on Safe Labor was supported by the Intramural Research Program of the Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, through Contract no. HHSN267200603425C.

: Reprints not available from the authors.

: Cite this article as: Zhang J, Troendle J, Reddy UM, et al, for the Consortium on Safe Labor. Contemporary cesarean delivery practice in the United States. Am J Obstet Gynecol 2010;203:326.e1-10.

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ResearchObstetricsContemporary cesarean delivery practice in the United States

Objective

Study Design

Results

Conclusion

Section snippets

Materials and Methods

Results

Comment

Lancet

Lancet

Obstet Gynecol

Am J Obstet Gynecol

Clin Perinatol

Am J Obstet Gynecol

Obstet Gynecol

Obstet Gynecol

Cesarean section of request: a comparison of obstetricians' attitudes in eight European countries

BJOG

Association between rising professional liability insurance premiums and primary cesarean delivery rates

Obstet Gynecol

Multiple imputation for nonresponse in surveys

Births: final data for 2004

Research
Obstetrics
Contemporary cesarean delivery practice in the United States