For at least one medical center, the adoption of March 2014 consensus guidelines on cesarean delivery was associated with a significant reduction in the primary C-section rate among nulliparous patients attempting vaginal delivery.
“This investigation confirms that adoption of consensus guidelines was associated with a reduction in the primary cesarean delivery rate among nulliparous patients at our institution. The observed decrease is both statistically and clinically significant,” Dr. Jonas G. Wilson-Leedy of the department of obstetrics and gynecology at the Penn State Milton S. Hershey Medical Center and colleagues wrote (Obstet Gynecol. 2016;128:145-52. doi: 10.1097/AOG.0000000000001488).
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The researchers conducted a before-after retrospective analysis of medical records at their hospital, assessing the rates of the induced or augmented cesarean delivery rate, the overall cesarean delivery rate, and the performance of cesarean for arrest disorder at less than 6 cm dilatation in women delivering before (Sept. 13, 2013 to Feb. 28, 2014) and after (May 1, 2014 to Sept. 28, 2014) guideline implementation.
The guidelines – issued in March 2014 by the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine – encouraged changes in labor management, including defining 6 cm dilatation as the threshold for active labor and urging longer durations of expectant management before cesarean delivery for labor arrest.
The researchers analyzed records of 275 and 292 women before guideline adoption and after guideline adoption, respectively.
After guideline adoption, the cesarean delivery rate was significantly reduced in the subpopulation of patients induced or augmented, dropping from 71 of 200 patients (35.5%) to 49 of 200 patients (24.5%), for an odds ratio of 0.59. The drop in the cesarean delivery rate remained significant even when spontaneously laboring patients were included in the analysis, the researchers reported.
Using a multivariable logistic regression model, the overall cesarean delivery rate was also found to be significantly reduced in the post–guideline adoption period, from 26.9% to 18.8%.
The rate of cesarean delivery for arrest of dilation at less than 6 cm declined from 7.1% to 1.1% after guideline adoption (P = .006). Rates of postpartum hemorrhage fell from 38.2% to 29.5% (OR, 0.68) in the postguidline period. A similar drop was seen in a composite measure of maternal morbidity, which declined from 45.1% to 36.3% (OR, 0.69) after adoption of the guidelines.
“Our data suggest that a significant decrease in cesarean deliveries for labor arrest at less than 6 cm dilatation contributed to the reduction in cesarean delivery rate,” the researchers wrote. “Consistent with recommendations discouraging diagnosis of arrest of dilation in latent labor, a sixfold reduction in this indication was identified postguideline.”
Although the researchers did not identify significant increases in either maternal or neonatal morbidities, the study was not sufficiently powered to assess those outcomes.
The researchers reported having no potential conflicts of interest.