Obstetrics and gynecology recommendation 11
Do not do a cesarean delivery for the sole indication of failure of progress in labour in the latent phase of labour for a woman at term with a singleton fetus and cephalic presentation.
Choosing Wisely Canada: Recall and describe a clinical encounter in which you were called on to choose wisely
Tiffany Chow: I recently cared for a 30-year-old multiparous woman who was being induced owing to gestational diabetes. She had successfully delivered vaginally previously. However, this induction was quite lengthy, took multiple days, and involved both a Foley bulb and prostaglandin administration. After several visits to the hospital and little sleep, she was understandably exhausted. After discovering that she was dilated only 3 cm, she asked whether we should consider cesarean delivery.
CWC: In your exchange with the patient, how did you raise the need to choose wisely?
TC: Weighing the pros and cons: While cesarean sections are safe, it is major surgery with risks. I always share that, in addition to the commonly known risks of infection and bleeding, there is also the risk of complications from anesthesia, blood clots, and injuries to surrounding organs. I also share that if a woman hopes to deliver vaginally in the future, there would be increased risk of uterine rupture.
Education: The most common reason for cesarean section delivery is labour that is failing to progress, commonly known as labour dystocia. These rates have increased in recent years 1 and a likely reason is that we are overcalling dystocia. Dystocia should never be diagnosed in the latent, or slow, phase of labour, which in the past had been viewed as being between 0 cm and 4 cm of cervical dilation 2. However, recent guidelines suggest the transition to active labour, or the rapid phase of labour, may be after 6 cm of cervical dilation.
In my discussion with the patient, I reassured her that she was not yet in the active phase of labour and that if we could get her there, she would likely deliver vaginally.
CWC: What are the key elements of the communication that made it a success?
TC: Finding the hidden fears: There are often concerns that a woman may not be comfortable sharing her fears immediately. When I sense this anxiety, I try to normalize it and let the woman know that if she has concerns, they are likely very common. The nurses, who spend so much time getting to know and understand the patient, can be immensely helpful in addressing these concerns.
In this case, my patient had a fear of infection after having her water broken. I explained that I was monitoring for signs of infection, such as her temperature and her baby’s heart rate. She was also concerned that she would not have enough energy to push because of how exhausted she was. I offered an early epidural so that she could have analgesia and rest so she would be ready to push when the time came.
Navigating emotion and fatigue: I check on my patients frequently. When exhausted and not thinking clearly, they are often unable to voice their fears or make informed decisions about their medical care. In many nonemergency cases, giving the woman time to rest and then reassessing the situation are key. Most women do not come to hospital intending to have a cesarean section; thus, this is a serious discussion that should be done with a clear head.
In this case, my patient was able to make clear and informed decisions regarding her method of delivery. She successfully delivered a healthy baby vaginally and both remain well.
- Health Indicators Interactive Tool [caesarean section, 1997 to 2019]. Ottawa, ON: Canadian Institute for Health Information; 2021. Available from: https://yourhealthsystem.cihi.ca/epub/. Accessed 2022 Nov 4.
- ACOG committee opinion no. 766. Approaches to limit intervention during labour and birth. Obstet Gynecol 2019;133(2):e164-73.
This article first appeared in Canadian Family Physician. This interview was prepared by Dr. Aaron Jattan, Department of Family Medicine, University of Manitoba, for Choosing Wisely Canada.