For many decades, we sought to minimize the number of cesarean deliveries, attempting to deliver vaginally as many patients as possible. In medical staff rooms and labor and delivery suites around the country, obstetricians boasted to colleagues that the cesarean rate in their practice was 10%. This approach was founded on the idea that cesarean delivery was more dangerous than vaginal birth for both mother and newborn, and its benefits relatively limited.
A total cesarean section delivery rate in the range of 30% is appropriate and clinically justified, cumulative experience now suggests.
In 1990, the US Public Health Service proposed that a total cesarean delivery rate of 15% could be achieved within 10 years.1 Since then, however, numerous advances in the clinical science of obstetrics have expanded the indications for cesarean section. Our current cesarean rate is 26.1%.2
New findings support higher rate
Cumulative clinical experience now suggests that a total cesarean section rate in the range of 30% is appropriate and clinically justified.
- Recent advances demonstrate that cesarean is superior to vaginal delivery for most women with a breech-presenting fetus.
- For most women with arrest of labor in the second stage or a prolonged second stage, substantial observational evidence indicates that cesarean is more often preferable to midforceps delivery.
- Additional findings suggest that for many women, repeat cesarean may be preferable to the risks of planned vaginal birth.
Research is underway that may add further indications. For example, a clinical trial is assessing the benefits of planned cesarean versus vaginal delivery for twin gestation.
A most interesting clinical trial would be one that examines the relative benefits and risks of planned vaginal delivery versus cesarean delivery for women with a low-risk, vertex, singleton gestation at term.
Changing views for a changing population
Shifts in patient characteristics and in patient and physician preferences have also pushed the cesarean rate higher:
- The proportion of births among nulliparous women and older patients is higher than ever; both groups have a higher cesarean rate.
- Patient-choice elective cesarean delivery is increasingly recognized as ethical and reasonable for women who fully understand the benefits and risks.
Finally, liability risks associated with abnormal labor, such as the setting of a nonreassuring fetal heart rate tracing, contribute to a re-evaluation of the target rate.
Given today’s understanding of obstetrical science and patient and physician preferences, the historical goal of 15% appears inappropriate. A rate in the range of 30% is more likely to balance the relative benefits and risks to mother and fetus.
If a credentialed clinician and an informed patient both believe a cesarean section is best, then it is clearly indicated.