New ACOG guidance on maternal-request cesareans and delivery before 39 weeks

Vaginal Delivery Recommended Over Maternal-Request Cesarean

March 21, 2013

Washington, DC — The nation’s largest ob-gyn organization recommends that pregnant women plan for vaginal birth unless there is a medical reason for a cesarean. In new guidelines issued today, The American College of Obstetricians and Gynecologists (The College) says maternal-request cesareans are especially not recommended for women planning to have several children, nor should they be performed before 39 completed weeks of pregnancy.

In the Committee Opinion, The College addresses the controversial issue of “maternal-request cesareans.” Cesarean deliveries done at the request of the mother without a medical indication represent an estimated 2.5% of all US births. Some women request cesareans because they fear childbirth pain, while others believe a cesarean will prevent urinary incontinence or preserve sexual functioning.

Cesareans involve risks and require longer hospital stays than uncomplicated vaginal births. Women face the risk of bladder and bowel injuries during cesarean surgery, as well as serious complications in future pregnancies. Placental problems, uterine rupture, and emergency hysterectomy are all risks that increase with each subsequent cesarean. Compared with vaginal births, planned cesareans have a lower risk of excessive bleeding during birth and the need for blood transfusions.

Benefits of vaginal births for women include shorter hospital stays, lower infection rates, and quicker recovery. Babies born vaginally have a lower risk of respiratory problems.

The rates of postpartum pelvic pain, sexual dysfunction, pelvic organ prolapse, and depression in women are similar between vaginal and cesarean births. The College says additional research is needed on both the short-term and long-term outcomes of maternal-request cesareans on women and babies.

Committee Opinion #559, “Cesarean Delivery on Maternal Request,” is published in the April issue of Obstetrics & Gynecology.

Nonmedically Indicated Early-Term Deliveries

ABSTRACT: For certain medical conditions, available data and expert opinion support optimal timing of delivery in the late-preterm or  early-term period for improved neonatal and infant outcomes. However, for nonmedically indicated early-term deliveries such an improvement has  not been demonstrated. Morbidity and mortality rates are greater among neonates and infants delivered during the early-term period compared with those delivered between 39 weeks and 40 weeks of gestation. Nevertheless, the rate of nonmedically indicated early-term deliveries continues to increase in the United States. Implementation of a policy to decrease the rate of nonmedically indicated deliveries before 39 weeks of gestation has been found to both decrease the number of these deliveries and improve neonatal outcomes; however, more research is necessary to further characterize pregnancies at risk for in utero morbidity or mortality. Also of concern is that at least one state Medicaid agency has stopped reimbursement for nonindicated deliveries before 39 weeks of gestation. Avoidance of nonindicated delivery before 39 weeks of gestation should not be accompanied by an increase in expectant management of patients with indications for delivery before 39  weeks of gestation. Management decisions, therefore, should balance the risks of pregnancy prolongation with the neonatal and infant risks
associated with early-term delivery.

Committee Opinion #561

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