Cesarean birth for the failed progress in labor

Abstract

"Failure to progress" is the leading indication for primary cesarean section and has a major impact on the escalating cesarean birth rate in the United States. We investigated the labor and delivery records of nulliparous women at term with vertex presentations admitted to the clinic and private services of our hospital to determine the importance of different management strategies associated with operative deliveries. Birth weights and immediate neonatal outcome were identical between the clinic and private services. The cesarean birth rate on the clinic service was 5.2%, compared with 17.1% on the private service; 80% of the abdominal deliveries on the private service were for "failure to progress." Epidural use rates were similar on both services and were associated with a 70% incidence of oxytocin augmentation. Once oxytocin augmentation became part of labor management, a 14-fold increase in cesarean sections was observed for the private service, but oxytocin had no impact on the cesarean birth rate in the clinic service. The placement of an intrauterine pressure catheter and an approach to the use of oxytocin that might be characterized as "selective active management" were necessary to achieve efficient uterine action in a timely fashion, permitting a high likelihood of vaginal birth on the clinic service.