Background

Balancing risks and benefits
Outcome | Risk | |
---|---|---|
Vaginal delivery | Cesarean delivery | |
Maternal | ||
Overall severe morbidity and mortality | 8.6% 0.9% | 9.2% 2.7% |
Maternal mortality b Defined as any 1 of following: death, hemorrhage requiring hysterectomy or transfusion; uterine rupture; anesthetic complications; shock; cardiac arrest; acute renal failure; assisted ventilation venous thromboembolic event; major infection; in-hospital wound disruption, wound hematoma, or both. Data from Liu et al7 | 3.6:100,000 | 13.3:100,000 |
Amniotic fluid embolism | 3.3-7.7:100,000 | 15.8:100,000 |
Third- or fourth-degree perineal laceration 117 | 1.0-3.0% | NA (scheduled delivery) |
Placental abnormalities, | Increased with prior cesarean vs vaginal delivery, and risk continues to increase with each subsequent cesarean delivery | |
Urinary incontinence 6 | No difference between cesarean and vaginal delivery at 2 y | |
Postpartum depression 117 | No difference between cesarean and vaginal delivery | |
Neonatal | ||
Laceration 2 | NA | 1.0-2.0% |
Respiratory morbidity 2 | <1.0% | 1.0-4.0% (without labor) |
Shoulder dystocia | 1.0-2.0% | 0% |
Indications for primary cesarean


Clinical management Q&A
What is the appropriate definition of abnormally progressing first-stage labor?
Definition of abnormal first-stage labor
Cervical dilation, cm | Median elapsed time, h | ||
---|---|---|---|
Parity 0 (95th percentile) | Parity 1 (95th percentile) | Parity ≥2 (95th percentile) | |
3-4 | 1.8 (8.1) | – | – |
4-5 | 1.3 (6.4) | 1.4 (7.3) | 1.4 (7.0) |
5-6 | 0.8 (3.2) | 0.8 (3.4) | 0.8 (3.4) |
6-7 | 0.6 (2.2) | 0.5 (1.9) | 0.5 (1.8) |
7-8 | 0.5 (1.6) | 0.4 (1.3) | 0.4 (1.2) |
8-9 | 0.5 (1.4) | 0.3 (1.0) | 0.3 (0.9) |
9-10 | 0.5 (1.8) | 0.3 (0.9) | 0.3 (0.8) |

How should abnormally progressing first-stage labor be managed?
Management of abnormal first-stage labor
Recommendations | Grade of recommendations |
---|---|
First stage of labor | |
A prolonged latent phase (eg, >20 h in nulliparous women and >14 h in multiparous women) should not be indication for cesarean delivery. | 1B Strong recommendation, moderate-quality evidence |
Slow but progressive labor in first stage of labor should not be indication for cesarean delivery. | 1B Strong recommendation, moderate-quality evidence |
Cervical dilation of 6 cm should be considered threshold for active phase of most women in labor. Thus, before 6 cm of dilation is achieved, standards of active-phase progress should not be applied. | 1B Strong recommendation, moderate-quality evidence |
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 h of adequate uterine activity, or at least 6 h of oxytocin administration with inadequate uterine activity and no cervical change. | 1B Strong recommendation, moderate-quality evidence |
Second stage of labor | |
A specific absolute maximum length of time spent in second stage of labor beyond which all women should undergo operative delivery has not been identified. | 1C Strong recommendation, low-quality evidence |
Before diagnosing arrest of labor in second stage, if maternal and fetal conditions permit, allow for following: • At least 2 h of pushing in multiparous women (1B) • At least 3 h of pushing in nulliparous women (1B) Longer durations may be appropriate on individualized basis (eg, with use of epidural analgesia or with fetal malposition) as long as progress is being documented. (1B) | 1B Strong recommendation, moderate-quality evidence |
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. | 1B Strong recommendation, moderate-quality evidence |
Manual rotation of fetal occiput in setting of fetal malposition in second stage of labor is reasonable intervention to consider before moving to operative vaginal delivery or cesarean delivery. To safely prevent cesarean deliveries in setting of malposition, it is important to assess fetal position in second stage of labor, particularly in setting of abnormal fetal descent. | 1B Strong recommendation, moderate-quality evidence |
Fetal heart rate monitoring | |
Amnioinfusion for repetitive variable fetal heart rate decelerations may safely reduce rate of cesarean delivery. | 1A Strong recommendation, high-quality evidence |
Scalp stimulation can be used as means of assessing fetal acid-base status when abnormal or indeterminate (formerly, nonreassuring) fetal heart patterns (eg, minimal variability) are present and is safe alternative to cesarean delivery in this setting. | 1C Strong recommendation, low-quality evidence |
Induction of labor | |
Before 41 0/7 wks of gestation, induction of labor generally should be performed based on maternal and fetal medical indications. Inductions at ≥41 0/7 wks of gestation should be performed to reduce risk of cesarean delivery and risk of perinatal morbidity and mortality. | 1A Strong recommendation, high-quality evidence |
Cervical ripening methods should be used when labor is induced in women with unfavorable cervix. | 1B Strong recommendation, moderate-quality evidence |
If maternal and fetal status allow, cesarean deliveries for failed induction of labor in latent phase can be avoided by allowing longer durations of latent phase (up to ≥24 h) and requiring that oxytocin be administered for at least 12-18 h after membrane rupture before deeming induction failure. | 1B Strong recommendation, moderate-quality evidence |
Fetal malpresentation | |
Fetal presentation should be assessed and documented beginning at 36 0/7 wks of gestation to allow for external cephalic version to be offered. | 1C Strong recommendation, low-quality evidence |
Suspected fetal macrosomia | |
Cesarean delivery to avoid potential birth trauma should be limited to estimated fetal weights of at least 5000 g in women without diabetes and at least 4500 g in women with diabetes. Prevalence of birth weight of ≥5000 g is rare, and patients should be counseled that estimates of fetal weight, particularly late in gestation, are imprecise. | 2C Weak recommendation, low-quality evidence |
Excessive maternal weight gain | |
Women should be counseled about IOM maternal weight guidelines in attempt to avoid excessive weight gain. | 1B Strong recommendation, moderate-quality evidence |
Twin gestations | |
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/noncephalic presenting twins should be counseled to attempt vaginal delivery. | 1B Strong recommendation, moderate-quality evidence |
Other | |
Individuals, organizations, and governing bodies should work to ensure that research is conducted to provide better knowledge base to guide decisions regarding cesarean delivery and to encourage policy changes that safely lower rate of primary cesarean delivery. | 1C Strong recommendation, low-quality evidence |
What is the appropriate definition of abnormal second-stage labor?
- Rouse D.J.
- Weiner S.J.
- Bloom S.L.
- et al.
- Rouse D.J.
- Weiner S.J.
- Bloom S.L.
- et al.
- Rouse D.J.
- Weiner S.J.
- Bloom S.L.
- et al.
How should abnormally progressing second-stage labor be managed?
- Spong C.Y.
- Berghella V.
- Wenstrom K.D.
- Mercer B.M.
- Saade G.R.
What other management approaches may reduce cesarean deliveries in the second stage of labor?
Operative vaginal delivery
Manual rotation of the fetal occiput
Which fetal heart tracings deserve intervention, and what are these interventions?
What is the effect of induction of labor on cesarean delivery?
- Spong C.Y.
- Berghella V.
- Wenstrom K.D.
- Mercer B.M.
- Saade G.R.
What are the other indications for primary cesarean delivery? What alternative management strategies can be used for the safe prevention of cesarean delivery in these cases?
Fetal malpresentation
Suspected fetal macrosomia
Excessive maternal weight gain
Twin gestation
Herpes simplex virus
Continuous labor and delivery support
What organizational actions are necessary for the primary cesarean delivery rate to safely decline?
Appendix
Basow DS, ed. UpToDate, Waltham, MA, 2013. Available at: http://www.uptodate.com/home/grading-guide. Accessed Oct. 9, 2013.
Obstetric Care Consensus documents will use Society for Maternal–Fetal Medicine grading approach: http://www.ajog.org/article/S0002-9378%2813%2900744-8/fulltext. | |||
Recommendations are classified as either strong (Grade 1) or weak (Grade 2), and quality of evidence is classified as high (Grade A), moderate (Grade B), and low (Grade C). 118 Thus, recommendations can be 1 of following 6 possibilities: 1A, 1B, 1C, 2A, 2B, 2C | |||
Grade of recommendation | Clarity of risk and benefit | Quality of supporting evidence | Implications |
---|---|---|---|
1A. Strong recommendation, high-quality evidence | Benefits clearly outweigh risk and burdens, or vice versa. | Consistent evidence from well-performed randomized controlled trials or overwhelming evidence of some other form. Further research is unlikely to change confidence in estimate of benefit and risk. | Strong recommendations, can apply to most patients in most circumstances without reservation. Clinicians should follow strong recommendation unless clear and compelling rationale for alternative approach is present. |
1B. Strong recommendation, moderate-quality evidence | Benefits clearly outweigh risk and burdens, or vice versa. | Evidence from randomized controlled trials with important limitations (inconsistent results, methodological flaws, indirect or imprecise), or very strong evidence of some other research design. Further research (if performed) is likely to have impact on confidence in estimate of benefit and risk and may change estimate. | Strong recommendation, and applies to most patients. Clinicians should follow strong recommendation unless clear and compelling rationale for alternative approach is present. |
1C. Strong recommendation, low-quality evidence | Benefits appear to outweigh risk and burdens, or vice versa. | Evidence from observational studies, unsystematic clinical experience, or from randomized controlled trials with serious flaws. Any estimate of effect is uncertain. | Strong recommendation, and applies to most patients. Some of evidence base supporting recommendation is, however, of low quality. |
2A. Weak recommendation, high-quality evidence | Benefits closely balanced with risks and burdens. | Consistent evidence from well-performed randomized controlled trials or overwhelming evidence of some other form. Further research is unlikely to change confidence in estimate of benefit and risk. | Weak recommendation, best action may differ depending on circumstances or patients or societal values. |
2B. Weak recommendation, moderate-quality evidence | Benefits closely balanced with risks and burdens; some uncertainty in estimates of benefits, risks, and burdens. | Evidence from randomized controlled trials with important limitations (inconsistent results, methodological flaws, indirect or imprecise), or very strong evidence of some other research design. Further research (if performed) is likely to have effect on confidence in estimate of benefit and risk and may change estimate. | Weak recommendation, alternative approaches likely to be better for some patients under some circumstances. |
2C. Weak recommendation, low-quality evidence | Uncertainty in estimates of benefits, risks, and burdens; benefits may be closely balanced with risks and burdens. | Evidence from observational studies, unsystematic clinical experience, or from randomized controlled trials with serious flaws. Any estimate of effect is uncertain. | Very weak recommendation, other alternatives may be equally reasonable. |
Best practice | Recommendation in which either: (i) there is enormous amount of indirect evidence that clearly justifies strong recommendation (direct evidence would be challenging, and inefficient use of time and resources, to bring together and carefully summarize), or (ii) recommendation to contrary would be unethical. |
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Article info
Footnotes
The information reflects emerging clinical and scientific advances as of the date issued, is subject to change, and should not be construed as dictating an exclusive course of treatment or procedure. Variations in practice may be warranted based on the needs of the individual patient, resources, and limitations unique to the institution or type of practice.
The authors report no conflict of interest.
This article is being published concurrently in the March 2014 issue of Obstetrics & Gynecology (Obstet Gynecol 2014;123:693-711).