Hospitals hope relaxed labor guidelines can reduce nation's rate of cesarean births



When the number of cesarean deliveries in the Allegheny Health Network spiked last year, obstetrical department leaders issued new guidelines on when to perform them and began monitoring doctors‘‍ individual cesarean delivery rates.

“It really took just a month or two, and the rates plummeted down to where they‘‍d been historically,” which is percentages in “the upper 20s, low 30s,” said Allan Klapper, the network’‍s chairman of obstetrics and gynecology.

Increased vigilance and new thinking both may play into the medical profession’‍s efforts to lower the nation‘‍s cesarean rate. About one-third of babies are delivered by cesarean, and the American College of Obstetricians and Gynecologists says the surgery — riskier in some ways than a vaginal birth — is overused.

In February, the college issued its own guidelines aimed at reducing cesareans. Noting that slow labor is a common reason for a cesarean, the guidelines attempt to change expectations about the amount of time involved.

“Evidence now shows that labor actually progresses slower than we thought in the past, so many women might just need a little more time to labor and deliver vaginally instead of moving to a cesarean delivery,” college member Aaron B. Caughey said when the guidelines were issued.

The guidelines also call for more frequent use of techniques for turning babies who are in the breech position, of using forceps to facilitate vaginal births and of developing better, more standardized methods of fetal heart monitoring. Concerns about the baby’‍s heart rate are another frequent reason for cesarean deliveries.

The college especially wants to promote vaginal birth among first-time mothers because data show that women who have one cesarean likely will deliver in the same manner a second time.

However, when women who have had a cesarean become pregnant again, doctors and midwives should help them understand their options and calculate the likelihood of a successful vaginal birth, said Hyagriv N. Simhan, vice chairman for obstetrical services at University of Pittsburgh School of Medicine and medical director of obstetrical services at Magee-Womens Hospital of UPMC.

“In so doing, a higher proportion of women may choose a vaginal birth after cesarean,” Dr. Simhan said. Magee‘‍s overall cesarean rate was 29 percent last year, he said.

Recently released results from a study on early births provide more caution about cesareans.

The study examined 7.3 million uncomplicated births that occurred from 1995 to 2009 in Pennsylvania, California and Missouri and found that nearly one baby in 25 was delivered earlier than medically necessary through cesarean or induced labor.

“That‘‍s a lot of babies,” said one of the authors, Scott Lorch, a neonatologist at The Children’s Hospital of Philadelphia. Patient and physician preference both seem to play a role, Dr. Lorch said.

The study said early cesareans increased the baby’‍s chance of respiratory problems, while both types of early-term births increased the infant‘‍s hospital stay.

Doctors say they do face pressure from mothers who want to schedule a birth for convenience, and Jan Mallak, an Export resident and founder of Heart and Hands Doula Service, decried what she called the “too posh to push” culture.

Doulas are hired, often on a private-fee basis, by women seeking an unmedicated, vaginal delivery. Doulas attend their clients at hospitals, birthing centers and in the expectant mom‘‍s home. They offer emotional and physical help to mothers before, during and after delivery.

The college’‍s new guidelines cite “continuous labor and delivery support” as a way to lower the cesarean rate — words that could give doulas‘‍ work a boost.

Stephanie O'Mara of Carrick delivered sons Bobby, 4, and Matthew, 3, by cesarean but wanted to increase the chances of a vaginal birth for 10-month-old Joshua.

To help her realize her goal, she hired a doula from Heart and Hands -- and called it the best $600 she ever spent. "She was worth her weight in gold," she said, also praising the Magee midwives who delivered Joshua.

Ashley Moyer of Perry, Lawrence County, said her experience with Blessed Arrivals doula service last year was so positive that she would “shout it from the rooftops.”

She had vaginal deliveries of sons Zachary, 7, and Colby, 3. For Charlotte, who will turn 1 in September, she also wanted her vaginal delivery to be unmedicated. She said she hired a doula because she thought she would need more support than her husband, Ryan, could provide. 

Even though the nation’‍s overall cesarean rate has hovered around 33 percent in recent years, some say interest in doulas already is on the rise. Ms. Mallak said her monthly “meet the doulas” at a Panera in Oakland are “jammed every time.”

Interest in midwives, who perform vaginal deliveries in hospitals and other settings, also is said to be increasing among women interested in natural births.

“We are struggling to keep up with the demand,” said Ann McCarthy, clinical director of the Midwife Center for Birth and Women‘‍s Health in the Strip District. The center’‍s midwives last year delivered 423 babies, including Charlotte Moyer, with an overall cesarean rate of 8.5 percent.

Some of the college’‍s new guidelines — such as allowing more time for labor — reflect doulas‘‍ beliefs.

 “As long as the mother and the baby are both stable, there isn’‍t really a reason to not let it unfold,” said Amy Farr, owner of Armstrong County-based Blessed Arrivals.


Joe Smydo: jsmydo@post-gazette.com or 412-263-1548.

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