With more than one third of pregnancies in the United States being delivered by cesarean and the growing knowledge of morbidities associated with repeat cesarean deliveries, the Eunice Kennedy Shriver National Institute of Child Health and Human Development, the Society for Maternal-Fetal Medicine, and the American College of Obstetricians and Gynecologists convened a workshop to address the concept of preventing the first cesarean delivery. The available information on maternal and fetal factors, labor management and induction, and nonmedical factors leading to the first cesarean delivery was reviewed as well as the implications of the first cesarean delivery on future reproductive health. Key points were identified to assist with reduction in cesarean delivery rates including that labor induction should be performed primarily for medical indication; if done for nonmedical indications, the gestational age should be at least 39 weeks or more and the cervix should be favorable, especially in the nulliparous patient. Review of the current literature demonstrates the importance of adhering to appropriate definitions for failed induction and arrest of labor progress. The diagnosis of “failed induction” should only be made after an adequate attempt. Adequate time for normal latent and active phases of the first stage, and for the second stage, should be allowed as long as the maternal and fetal conditions permit. The adequate time for each of these stages appears to be longer than traditionally estimated. Operative vaginal delivery is an acceptable birth method when indicated and can safely prevent cesarean delivery. Given the progressively declining use, it is critical that training and experience in operative vaginal delivery are facilitated and encouraged. When discussing the first cesarean delivery with a patient, counseling should include its effect on future reproductive health.
Pregnancy and Perinatology Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland; the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Jefferson Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania; the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Brown Alpert School of Medicine, Women and Infants Hospital, Providence, Rhode Island; the Department of Obstetrics & Gynecology, MetroHealth Medical Center Case Western Reserve University, Cleveland, Ohio; the Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, University of Texas Medical Branch, Galveston, Texas; and the Publications and Executive Committees of the Society for Maternal-Fetal Medicine, Washington, DC.
Corresponding author: Catherine Y. Spong, MD, Chief, Pregnancy and Perinatology Branch, NICHD, NIH, 6100 Executive Boulevard, Room 4B03 MSC 7510, Bethesda, MD 20892; e-mail: email@example.com.
This article is an executive summary of a Society for Maternal-Fetal Medicine, Eunice Kennedy Shriver National Institute of Child Health and Human Development, and American College of Obstetricians and Gynecologists workshop that was held February 7–8, 2012, in Dallas, Texas.
Dr. Spong, Associate Editor of Obstetrics & Gynecology, was not involved in the review or decision to publish this article.
Financial Disclosure The authors did not report any potential conflicts of interest.