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:
[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]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.[/pullquote]
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.
