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Contemporary Trends in Cesarean Delivery Rates and IndicationsFunding None.
Objective This study aimed to describe cesarean delivery rates and indications at a single center in order to assess the impact of the guidelines published by the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine on trends in labor management.
Study Design This is a retrospective cohort study of patients ≥23 weeks' gestation delivering at a single tertiary care referral center from 2013 to 2018. Demographic characteristics, mode of delivery, and main indication for cesarean delivery were ascertained by individual chart review. Cesarean delivery indications (mutually exclusive) were the following: repeat cesarean delivery, nonreassuring fetal status, malpresentation, maternal indications (e.g., placenta previa or genital herpes simplex virus), failed labor (any stage labor arrest), or other (i.e., fetal anomaly and elective). Polynomial (cubic) regression models were used to model rates of cesarean delivery and indications over time. Subgroup analyses further examined trends in nulliparous women.
Results Of the 24,637 patients delivered during the study period, 24,050 were included in the analysis; 7,835 (32.6%) had a cesarean delivery. The rates of overall cesarean delivery were significantly different over time (p < 0.001), declining to a minimum of 30.9% in 2014 and peaking at 34.6% in 2018. With regard to the overall cesarean delivery indications, there were no significant differences over time. When limited to nulliparous patients, the rates of cesarean delivery were also noted to be significantly different over time (p = 0.02) nadiring at 30% in 2015 from 35.4% in 2013 and then rising up to 33.9% in 2018. As for nulliparous patients, there was no significant difference in primary cesarean delivery indications over time except for nonreassuring fetal status (p = 0.049).
Conclusion Despite changes in labor management definitions and guidelines encouraging vaginal birth, the rates of overall cesarean delivery did not decrease over time. The indications for delivery, particularly failed labor, repeat cesarean delivery, and malpresentation have not significantly changed over time.
The rates of overall cesarean deliveries did not decrease despite the 2014 published recommendations for the reduction in cesarean deliveries.
There were no significant differences in the indications of cesarean deliveries among nulliparous or multiparous women.
Despite the adoption of strategies to reduce the overall and primary cesarean delivery rates, these trends remain unchanged.
Indications for delivery, particularly failed labor, repeat cesarean delivery, and malpresentation have also not significantly changed over time.
Additional strategies to encourage and increase vaginal delivery rates must be adopted.
Keywordscontemporary trends - primary and repeat cesarean deliveries - external cephalic version - fetal malpresentation - nonreassuring fetal heart tones - labor arrest - trail of labor after cesarean
Data were presented as a virtual poster presentation at the Society for Maternal-Fetal Medicine Annual meeting from January 25–30, 2021, and were published in the supplemental edition of the American Journal of Obstetrics and Gynecology 2021;224(2):S322.
Received: 17 February 2023
Accepted: 19 May 2023
Accepted Manuscript online:
22 May 2023
Article published online:
26 June 2023
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- 1 Menacker F, Hamilton BE. Recent trends in cesarean delivery in the United States. NCHS Data Brief 2010; (35) 1-8
- 2 Caughey AB, Cahill AG, Guise JM, Rouse DJ. American College of Obstetricians and Gynecologists (College), Society for Maternal-Fetal Medicine. Safe prevention of the primary cesarean delivery. Am J Obstet Gynecol 2014; 210 (03) 179-193
- 3 Martin JA, Hamilton BE, Osterman MJK, Driscoll AK. Births: final data for 2018. Natl Vital Stat Rep 2019; 68 (13) 1-47
- 4 Sandall J, Tribe RM, Avery L. et al. Short-term and long-term effects of caesarean section on the health of women and children. Lancet 2018; 392 (10155): 1349-1357
- 5 Silver RM, Landon MB, Rouse DJ. et al; National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. Maternal morbidity associated with multiple repeat cesarean deliveries. Obstet Gynecol 2006; 107 (06) 1226-1232
- 6 Marshall NE, Fu R, Guise JM. Impact of multiple cesarean deliveries on maternal morbidity: a systematic review. Am J Obstet Gynecol 2011; 205 (03) 262.e1-262.e8
- 7 Klar M, Michels KB. Cesarean section and placental disorders in subsequent pregnancies–a meta-analysis. J Perinat Med 2014; 42 (05) 571-583
- 8 Clark EA, Silver RM. Long-term maternal morbidity associated with repeat cesarean delivery. Am J Obstet Gynecol 2011; 205 (6, suppl): S2-S10
- 9 Tulandi T, Agdi M, Zarei A, Miner L, Sikirica V. Adhesion development and morbidity after repeat cesarean delivery. Am J Obstet Gynecol 2009; 201 (01) 56.e1-56.e6
- 10 Bowman ZS, Smith KR, Silver RM. Cesarean delivery and risk for subsequent ectopic pregnancy. Am J Perinatol 2015; 32 (09) 815-820
- 11 Williams CM, Asaolu I, Chavan NR. et al. Previous cesarean delivery associated with subsequent preterm birth in the United States. Eur J Obstet Gynecol Reprod Biol 2018; 229: 88-93
- 12 Zhang J, Landy HJ, Ware Branch D. et al; Consortium on Safe Labor. Contemporary patterns of spontaneous labor with normal neonatal outcomes. Obstet Gynecol 2010; 116 (06) 1281-1287
- 13 ACOG Practice Bulletin No. ACOG Practice Bulletin No. 106: intrapartum fetal heart rate monitoring: nomenclature, interpretation, and general management principles. Obstet Gynecol 2009; 114 (01) 192-202
- 14 ACOG Committee Opinion No. ACOG Committee Opinion No. 745: mode of term singleton breech delivery. Obstet Gynecol 2018; 132 (02) e60-e63
- 15 ACOG Practice Bulletin No. ACOG Practice Bulletin No. 205: vaginal birth after cesarean delivery. Obstet Gynecol 2019; 133 (02) e110-e127
- 16 Lu MY, Blanchard CT, Ausbeck EB. et al. Evaluation of a risk-stratified, heparin-based, obstetric thromboprophylaxis protocol. Obstet Gynecol 2021; 138 (04) 530-538
- 17 Gravett C, Eckert LO, Gravett MG. et al; Brighton Collaboration Non-reassuring fetal status Working Group. Non-reassuring fetal status: case definition & guidelines for data collection, analysis, and presentation of immunization safety data. Vaccine 2016; 34 (49) 6084-6092
- 18 Lo JO, Mission JF, Caughey AB. Hypertensive disease of pregnancy and maternal mortality. Curr Opin Obstet Gynecol 2013; 25 (02) 124-132
- 19 Molina G, Weiser TG, Lipsitz SR. et al. Relationship between cesarean delivery rate and maternal and neonatal mortality. JAMA 2015; 314 (21) 2263-2270
- 20 Sargent J, Caughey AB. Vaginal birth after cesarean trends: which way is the pendulum swinging?. Obstet Gynecol Clin North Am 2017; 44 (04) 655-666
- 21 Grobman WA, Rice MM, Reddy UM. et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal–Fetal Medicine Units Network. Labor induction versus expectant management in low-risk nulliparous women. N Engl J Med 2018; 379 (06) 513-523
- 22 Arulkumaran S, Koh CH, Ingemarsson I, Ratnam SS. Augmentation of labour: mode of delivery related to cervimetric progress. Aust N Z J Obstet Gynaecol 1987; 27 (04) 304-308
- 23 Rouse DJ, Owen J, Hauth JC. Active-phase labor arrest: oxytocin augmentation for at least 4 hours. Obstet Gynecol 1999; 93 (03) 323-328
- 24 Cross SN, Greenberg JT, Pettker CM, Raab CA, Illuzzi JL. Indications contributing to the decreasing cesarean delivery rate at an academic tertiary center. Am J Obstet Gynecol MFM 2019; 1 (02) 165-172
- 25 Becker DA, Blanchard CT, Szychowski JM, Rogers SL, Brumfield CG, Subramaniam A. Resident operative vaginal delivery volume after educational curriculum implementation. Am J Perinatol 2020; 37 (13) 1296-1300
- 26 External Cephalic Version. External cephalic version: ACOG practice bulletin summary, number 221. Obstet Gynecol 2020; 135 (05) 1239-1241
- 27 Olson Koutrouvelis G. Role of external cephalic version in reducing the cesarean delivery rate. Obstet Gynecol 2019; 133 (05) 855-856
- 28 Kim GJ. Reviving external cephalic version: a review of its efficacy, safety, and technical aspects. Obstet Gynecol Sci 2019; 62 (06) 371-381
- 29 Say R, Thomson R, Robson S, Exley C. A qualitative interview study exploring pregnant women's and health professionals' attitudes to external cephalic version. BMC Pregnancy Childbirth 2013; 13: 4
- 30 Glazer KB, Danilack VA, Field AE, Werner EF, Savitz DA. Term labor induction and cesarean delivery risk among obese women with and without comorbidities. Am J Perinatol 2022; 39 (02) 154-164