Doctors Urge Patience, And Longer Labor, To Reduce C-Sections

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Women with low-risk pregnancies should be allowed to spend more time in labor, to reduce the risk of having an unnecessary C-section, the nation's obstetricians say.

The new guidelines on reducing cesarean deliveries are aimed at first-time mothers, according to the American College of Obstetricians and the Society for Maternal-Fetal Medicine, which released the guidelines Wednesday online and in Obstetrics and Gynecology.

About one-third of all births in the U.S. are done by C-section, and most of those are in first-time mothers. There's been a 60 percent increase in these deliveries since the 1990s, but childbirth hasn't become markedly safer for babies or mothers.

That discrepancy has led many to conclude that the operation is being overused. A C-section is major surgery. The procedure can increase complications for the mother and raise the risk during future pregnancies.

Women giving birth for the first time should be allowed to push for at least three hours, the guidelines say. And if epidural anesthesia is used, they can push even longer. Techniques such as forceps are also recommended to help with vaginal delivery.

Early labor should also be given more time, the doctors say, with the start of active labor redefined to cervical dilation of 6 centimeters, rather than 4.

It seems that a key point of the new guidelines is that doctors and patients shouldn't rely too slavishly on fetal heart rate monitors when trying to figure out if the baby's in distress. Is that right?

The incidence of a child being injured in the womb is pretty low, probably about 1 percent in a normal pregnancy. In 100,000 women you're going to have 1,000 problems. If you miss one that's really bad, that's an injured baby, that's an upset family. It really impacts the doctors and the nurses, and, of course, it's costly to the hospital. We don't want to miss things. But if we're trading off hundreds of C-sections to prevent one injury, the question is what that trade-off should be. At some point that number is too high. The harm on the moms is too high, and on future pregnancies, too.

Is that different from what you learned in medical school?

My practice really changed when I came to San Francisco in 1999. I was initially horrified by how long the physicians and the midwives allowed women to labor. I came from an environment where we had benchmarks, and we followed them. Then we started looking at the second phase of labor, just when you're pushing. We found, lo and behold, that women who pushed longer than three hours, longer than four hours, even five hours, the babies didn't have worse outcomes than the babies delivered in the second hour. And they did better than babies delivered in the first hour.

How can it be that we're just now finding out what's a normal length of labor?

You know, before 1955 there was essentially no quantitative data on the length of labor. Then Emanuel Friedman said we should study this. He studied 500 women, and, of those, he said here are the 200 women who have idealized labors. We then managed 4 million a women a year for the next 50 years based on 200 women. It's not that the wrong approach was taken; it's that we started science and then didn't continue to do the science.

How is science done? A lot of it is driven by economic demand. There's no money in being patient in labor. I don't think they're going to come up with a special stopwatch. Because of that, nobody has really pushed to look at this again.