Doctors Say Modern Definition Of ‘Normal’ Labor May Be Driving C-section Rate

By Jessica Robinson

The high rate of C-sections is a heated topic lately -- in Florida last month, one woman unsuccessfully took her hospital to federal court to avoid having one. It’s a life-saving surgery in complicated births, but today nearly a third of pregnancies end up as a C-section. Public health officials across the U.S. DO say the number of C-sections being performed has gotten way out of hand. And doctors are wondering if their definition of what a normal labor is might be one of the problems.

Now, you might be thinking: This is about elective C-sections. There has been a flurry of stories in recent years about that phenomenon.

Dr. Aaron Caughey: “We thought that that might have been a big contributor. …

Dr. Aaron Caughey is the chair of obstetrics and gynecology at Oregon Health and Science University.

Dr. Aaron Caughey: “But it doesn't appear elective C-section is the huge driver. I would say no bigger than a 1-2 percent problem.”

Caughey sits on a national panel that explored potential causes for the high rate. It would be nice if it were one simple thing. But it's more complicated than that. Older women getting pregnant, an increase in fertility treatments, legal liability – all these and more contribute to the problem. But Dr. Caughey says one thing is certain:

Dr. Aaron Caughey: “We've seen the cesarean rate rise over the last 15 to 20 years for no good medical reason.”

And Dr. Caughey says there is one particular factor that makes a huge difference. It's how you define a normal labor.

Educational film reels like this one from 1950 describe the typical experience for a mother-to-be. And it turns out our modern standard for labor goes back just as far. In the '50s a physician named Emanuel Friedman tracked the labors of hundreds of women and came up with what is known as the Friedman Curve – and Dr. Caughey says, it stuck.

Dr. Caughey: “The Friedman Curve is still the curve that is in every textbook on the planet today.”

The problem is, Friedman's studies were not rigorous by today's standards. For one thing, he excluded some data that seemed outside the norm. As a result, the Friedman Curve shows labor starting earlier and progressing faster. Dr. Caughey says when you restrict the definition of normal, you get to abnormal much quicker, and that's contributed to doctors jumping in sooner.

Aaron Caughey: “And all data since then points to a longer length of time and a much wider range of normal. In other words, there are women that take a lot longer in labor, and that's ok.”
Dr. Caughey helped write a new set of C-section guidelines released earlier this year by the American Congress of Obstetricians and Gynecologists. The basic message is: be patient.

… which might be easier said than done.

It's almost 7 o'clock on a Thursday night at Valley Hospital in Spokane. And Dr. Nathan Meltzer is still at work. He has one mother in labor. She’s been there for more than 12 hours.

Dr. Nathan Meltzer: “It would be very easy to encourage her to say ‘We gave it a good try,’ but it's 7 o'clock and I could do a C-section right now and be home with my family in time for dinner. It's tempting, but it's not the right thing. The right thing is to wait and see how this turns out. Whether it ends up in a C-section tonight or a C-section tomorrow or a vaginal birth any time between now and when it happens – it's willing to wait and give it time.”

The fetal heart rate monitor is a comforting sound to Kelly, the mother-to-be. She looks surprisingly relaxed propped up on some pillows in her hospital room – she has had an epidural. It’s her second pregnancy. The first time Kelly had to have a C-section. But this time, she wanted to give birth vaginally. Some doctors wouldn’t even try a vaginal birth after a previous caesarian but Kelly was determined not to have another section.

Kelly: “It was scary. You feel like you can't breath. When they pulled my daughter out all I could do was reach for her hand and then I puked and went into recovery. So I didn't get to spend any time with her or anything.”

And mother-infant bonding isn't the only issue. A C-section is major surgery. It includes all the possible surgery risks like infection and blood clots. And it has a much longer recovery period for the new mother.

Kelly: “I kept waking up. ‘Can I see my daughter?’ ‘No not yet.’”

All good reasons for hospitals around the country to reduce the C-section rate. At 13 percent, Valley Hospital has one of the lowest section for rates for low-risk pregnancies in Washington. But it's a small hospital. Rates have reached 30 percent at larger hospitals.

Though, some are now reversing the trend.

Dr. Tanya Sorensen: “Since the beginning of 2014, we've found that our C-section rates have dropped fairly significantly.

Dr. Tanya Sorensen specializes in maternal-fetal medicine at Swedish Hospital in Seattle. The rate for C-sections on low-risk pregnancies there has gone from 31 to 26 percent in just six months.

Swedish is one of 17 hospitals involved in a pilot program aimed at reducing unnecessary C-sections. One big push is to track data and get doctors to rethink that Friedman labor curve they learned about in school. And also to re-educate mothers and their partners that with labor it’s ok to be patient.

Sorensen cautions though, the end goal of reducing C-sections shouldn't be a number, it should be patient health.

Dr. Tanya Sorensen: “One thing we are absolutely not wanting to do is reduce the C-section rate at the risk of mother or baby safety.”

And speaking of mothers and babies, Kelly, our patient from earlier in the story, found the waiting paid off for for her. About 20 minutes before midnight, after pushing for a little over an hour, Colton was born. No C-section required.


ACOG Guidelines:
http://www.acog.org/Resources_And_Publications/Obstetric_Care_Consensus_Series/Safe_Prevention_of_the_Primary_Cesarean_Delivery

1950 educational video on childbirth:
https://archive.org/details/0027_Labor_and_Childbirth_03_00_49_00

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