Recommendations on The Clinical Interventions For The Prevention of The Primary Cesarean Section
- Recommendations
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1. Measures During ANC and Before Labor |
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1.1. Planning of Birth |
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1.1.1. Discuss the benefits and risks of both caesarean and vaginal birth with women, taking into account their circumstances, concerns, priorities and plans for future pregnancies. (See Appendix I) [6, GPS, LQE] Rational: Women are part of the decision making process. They should be well informed of the benefits and risks of each route of delivery. |
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1.1.2. Fetal presentation should be assessed and documented beginning at 36 0/7 weeks of gestation to guide the plan of management. (GPS, VLQE) |
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1.2. Breech Presentation & Other Fetal Malpresentation |
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1.2.1. Offer women who have an uncomplicated singleton breech pregnancy after 36+0 weeks, external cephalic version by an experienced obstetrician, unless: ➡️ the woman is in established labor ➡️ there is fetal compromise ➡️ the woman has ruptured membranes or vaginal bleeding ➡️ the woman has any other medical conditions (for example, severe hypertension) that would make external cephalic version inadvisable. [7, 8, 9, Strong, LQE] Conditions: External Cephalic Version minimizes the need of Cesarean Section in breech presentations but needs experience. Only well trained obstetricians have to do it. |
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1.2.2. Before carrying out a caesarean birth for an uncomplicated singleton breech pregnancy, carry out an ultrasound scan to check that the baby is in the breech position. Do this as late as possible before the caesarean birth procedure. [6, GPS, LQE] |
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1.3. Suspected Fetal Macrosomia |
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1.3.1 Cesarean delivery to avoid potential birth trauma should be limited to estimated fetal weights of at least 4500 g in women without diabetes and at least 4000 g in women with diabetes. [GPS, LQE] |
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1.4. Twin Gestations |
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1.4.1. Perinatal outcomes for twin gestations in which first twin is in cephalic presentation are not improved by cesarean delivery. Thus, women with either cephalic/cephalic presenting twins or cephalic/non-cephalic presenting twins should be counseled to attempt vaginal delivery. [10, Strong, MQE] |
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1.5. Predicting Caesarean Birth for Cephalopelvic Disproportion |
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1.5.1. Do not use pelvimetry for decision making about mode of birth. [11, Strong, LQE] |
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1.5.2. Do not use the following for decision making about mode of birth, as they do not accurately predict cephalopelvic disproportion: ➡️ maternal shoe size ➡️ maternal height ➡️ estimations of fetal size (ultrasound or clinical examination). [12, 13, GPS, LQE] |
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1.6. Mother-To-Child Transmission of Hepatitis |
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1.6.1 Hepatitis B virus: Do not offer pregnant women with hepatitis B a planned caesarean birth for this reason alone, as mother-to-baby transmission of hepatitis B can be reduced if the baby receives immunoglobulin and vaccination. [6, 14, Strong, LQE] Rational: No randomized controlled trials were done to prove that ECS prevents mother-to-child transmission of HBV. According to the CDC, all infants should receive a dose of hepatitis B vaccine at birth regardless of the HBV infection status of the birth parent. This birth dose, together with the HBIG (given within 12 hours of birth), serves as postexposure immunoprophylaxis for infants born to a parent with HBV infection [15]. |
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1.6.2 Hepatitis C virus: Do not offer women who are infected with hepatitis C a planned caesarean birth for this reason alone. [6, Strong, VLQE] Rational: There's no evidence that a C-section reduces the risk of transmission, and it is not a standard practice to reduce transmission risk for women with HCV alone. |
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1.7. Body Mass Index |
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1.7.1. Do not use a BMI of over 50 kg/m2 alone as an indication for planned caesarean birth. [6, 16. GPS, VLQE] Rational: A study found that obese women with BMI > 50 kg/m2 have a 30-50% risk of wound complications, a 20% risk of NICU admission, and a 1% to 2% risk of maternal intensive care unit admission. |
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1.8. Cesarean On Maternal Request |
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1.8.1 If a pregnant woman with no medical indication for a caesarean birth requests a caesarean birth: ➡️ discuss and explore the reasons for the request ➡️ address concerns they have about the birth as pain and pain relief options ➡️ discuss the overall benefits and risks of CS birth compared with vaginal birth (See Appendix I) ➡️ Document the discussion and the decision taken [6, GPS, VLQE] |
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1.8.2. Don’t do cesarean section on request without a written consent from the woman indicating that this is a CS on request in absence of a medical or obstetric indication. [GPS] Rational: The GDG emphasizes the importance of documenting maternal request of C.S. in absence of medical indications and having a signed informed consent from her explaining all the risks associated with the procedure. |
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1.9. Head Engagement in A Primigravida |
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1.9.1 Non-engagement of the head in a primigravida should not be considered as an only factor requiring cesarean birth. [GPS] Rational: In a primigravida as well as a multipara, head engagement can occur as late as the second stage of labor. |
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2. Measures During Labor |
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2.1. Induction of Labor |
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2.1.1. Before 41 0/7 weeks of gestation, induction of labor generally should be performed based on maternal and fetal medical indications. Inductions at ≥ 41 0/7 weeks of gestation should be performed to reduce risk of cesarean delivery and risk of perinatal morbidity and mortality. [17,18, Strong, HQE] |
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2.1.2 Cervical ripening methods should be used when labor is induced in women with unfavorable cervix. [19,20,21, Strong, MQE] Rational: Many studies showed that the use of cervical ripening methods such as misoprostol, prostaglandin E gel, and other methods lead to lower rates of cesarean delivery than induction of labor without cervical ripening. |
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2.2. First Stage of Labor: Latent Phase |
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2.2.1 The use of the following definition of the latent phase of the first stages of labor is recommended for practice: The latent first stage is a period of time characterized by: ➡️ Painful uterine contractions and ➡️ variable changes of the cervix, including some degree of effacement and slower progression of dilatation up to 5 cm for first and subsequent labors. [22, Strong, LQE] |
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2.2.2 A prolonged latent phase (eg, >20 hours in nulliparous women and >14 hours in multiparous women) should not be an indication for cesarean delivery. [23, Strong, MQE] Rational: Most women with a prolonged latent phase ultimately will enter the active phase with expectant management. With few exceptions, the remainder either will cease contracting or, with amniotomy or oxytocin (or both), achieve the active phase [23]. |
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2.2.3. These durations are not recommended as an indication for intervention when maternal and fetal condition are reassuring. [23, Strong, MQE] |
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2.2.4. If slow progress is suspected, assess to identify: ➡️ Developing complications ➡️ Reassuring maternal and fetal condition ➡️ Emotional and physical needs [24,25, Strong, HQE] |
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2.3. First Stage of Labor: Active Phase |
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2.3.1. The use of the following definition of the active phase of the first stages of labor is recommended for practice: ➡️ The active first stage is a period of time characterized by regular painful uterine contractions, and a substantial degree of cervical effacement and more rapid cervical dilatation from 5 cm until full dilatation for first and subsequent labors. [22, Strong, LQE] |
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2.3.2 Use a partogram with a 4-hour action line to monitor progress of women in spontaneous labor with an uncomplicated singleton pregnancy at term, once in active phase, to reduce the likelihood of caesarean birth. [26, GPS, VLQE] Rational: Although quality of evidence for clinical benefit of the partogram is low, yet, the partogram provides a pictorial overview of progress, facilitates timely transfer of care, may assist in the detection of prolonged labor, and if an alert line is used in facilities a four hour action line is recommended for triaging women who may require additional care [26, GPS, VLQE]. |
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2.3.3. Regarding the Partogram: A minimum cervical dilatation rate of 1 cm/hour throughout active first stage is not recommended for identification of normal labor progression and a slower than 1-cm/hour cervical dilatation rate alone should not be a routine indication for obstetric intervention. Rational: There is insufficient evidence to support the use of the alert line as a classifier to detect women at risk of adverse birth outcomes and lead to unnecessary interventions due to the perception that labor progress is pathologically slow. However, women with suspected slow labor progress should be carefully evaluated to exclude developing complications (e.g. cephalopelvic disproportion) [22, GPS, VLQE] |
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2.3.4. A cervical dilatation of 0.5 cm per hour (2 cm in 4 hours) is considered normal in the active phase. [27, GPS, LQE] |
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2.3.5. Protracted labor (slower progress than is usual) is diagnosed when in: ➡️ Nulliparous women: a cervical dilatation of < 2 cm in 4 hours is found ➡️ Multiparous women: a cervical dilatation of < 2 cm in 4 hours or a slowing in the progress of labor If delay is suspected, check descent and rotation of the baby's head and changes in the strength, duration and frequency of uterine contractions (uterine atony). [27, GPS, LQE] |
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2.3.6. For women with intact membranes in whom delay in the established first stage of labor is confirmed: ➡️ consider amniotomy if membranes are intact, ➡️ oxytocin if inertia was diagnosed and ➡️ a repeat vaginal examination 2 hours later. ➡️ If oxytocin is used, ensure that the time between increments of the dose is no more frequent than every 30 minutes and increase oxytocin until there are 4–5 contractions in 10 minutes. ➡️ If cervical dilatation has increased by less than 2 cm after 4 hours of oxytocin, review is required to assess the need for caesarean section [27, GPS, LQE] |
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2.3.7. Labor may not naturally accelerate until a cervical dilatation threshold of 5 cm is reached. Therefore, the use of medical interventions to accelerate labor and birth (such as oxytocin augmentation or caesarean section) before this threshold is not recommended, provided fetal and maternal conditions are reassuring. [27, Strong, MQE] |
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2.3.8. Arrest in labor (complete cessation of progress) is diagnosed at cervical dilatation of 6 cm or more with ruptured membranes and no or limited cervical change for 4 hours of adequate contractions. [28,29, Strong, MQE] |
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2.3.9. Cesarean delivery for active-phase arrest in first stage of labor should be reserved for women ≥ 6 cm of dilation with ruptured membranes who fail to progress despite 4 hours of adequate uterine activity. [28,29, Strong, MQE] |
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2.4. Fetal Heart Rate Monitoring |
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2.4.1. Intermittent auscultation of the fetal heart rate with either a Doppler ultrasound device or Pinard fetal stethoscope is recommended for healthy pregnant women in labor. [30,31, Strong, LQE] |
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2.4.2. Standardization of protocol of the intermittent auscultation is important for health care planning and medico-legal purposes and, therefore, the WHO adopted the following protocol: · Interval: Auscultate every 15–30 minutes in active first stage of labor, and every 5 minutes in the second stage of labor. · Duration: Each auscultation should last for at least 1 minute; if the FHR is not always in the normal range (i.e. 110–160 bpm), auscultation should be prolonged to cover at least three uterine contractions. · Timing: Auscultate during a uterine contraction and continue for at least 30 seconds after the contraction
[30,31, Strong, LQE] |
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2.5. Second stage of labor |
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2.5.1. The use of the following definition and duration of the second stage of labor is recommended for practice: The second stage is the period of time between full cervical dilatation and birth of the baby, during which the woman has an involuntary urge to bear down, as a result of expulsive uterine contractions. [22, Strong, LQE] |
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2.5.2. The duration of the second stage varies from one woman to another: ➡️ In first labor, birth is usually completed within 2 hours ➡️ In subsequent labors, birth is usually completed within 1 hour. [GPS, VLQE] |
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2.5.3. Before diagnosing arrest of labor in second stage, if maternal and fetal conditions permit, allow for: ➡️ At least 1 h of pushing in multiparous women ➡️ At least 2 h of pushing in nulliparous women Longer durations may be appropriate on individualized basis (e.g., with use of epidural analgesia or with fetal malposition) as long as maternal and fetal conditions are reassuring and progress is being documented. [33, Strong, MQE] |
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2.5.4. Delay in active second stage is diagnosed when: ➡️ In nulliparous woman (any of): either insufficient flexion/rotation/descent within 1 hour or the second stage duration is > 2 hours. ➡️ In multiparous woman (any of): either insufficient flexion/rotation/descent within 30 minutes or the second stage duration is > 1 hour. Longer durations may be appropriate where maternal and fetal condition is optimal. [GPS, VLQE] |
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2.5.5. A specific absolute maximum length of second stage (passive plus active) has not been identified. Rather than rigid time limits, base decision-making on continuing assessment of: ➡️ Maternal physical and emotional condition ➡️ Fetal condition ➡️ Progress of labor ➡️ Maternal preferences [34, Strong, MQE] |
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2.5.6. Operative vaginal delivery in second stage of labor by experienced and well-trained physicians should be considered safe, acceptable alternative to cesarean delivery. Training in, and ongoing maintenance of, practical skills related to operative vaginal delivery should be encouraged. [35,36,37,38,39, STRONG, MQE] |