Which strategy is most associated with a decrease in cesarean section (CS) rates: ambulation, continuous support during labor, amniotomy early in labor, or epidural analgesia/anaesthesia for pain relief?

Continuous Support During Labor Significantly Reduces Cesarean Section Rates

Continuous support during labor is the most effective strategy for decreasing cesarean section rates among the options presented. This approach can reduce CS rates by up to 25% compared to routine care 1.

Evidence for Each Strategy's Effect on CS Rates

Continuous Support During Labor

• Most effective intervention for reducing CS rates
• Reduces cesarean section rates by 25% (RR 0.75,95% CI 0.64 to 0.88) 1
• Associated with shorter active labor (11.0 ± 5.7h vs 13.7 ± 3.9h with standard care) 2
• Can reduce CS rates by up to 51% according to some reviews 3
• Early studies in US hospitals showed CS rates of 8% with continuous support vs 13% in observed group and 18% in control group 4

Ambulation During Labor

• Limited evidence for significant reduction in CS rates
• May help with labor progress but not strongly associated with CS reduction
• Not specifically highlighted in guidelines as a primary strategy for CS reduction

Early Amniotomy

• Not associated with decreased CS rates
• May actually increase interventions without improving outcomes
• Active management packages including early amniotomy show only small reductions in CS rates and are highly interventional 5

Epidural Analgesia/Anesthesia

• Associated with increased rather than decreased CS rates
• Continuous EFM with epidural analgesia increases interventions including CS (NNH = 20) 6
• Women with birth plans were less likely to use epidural analgesia and had lower CS rates 6

Mechanisms of Continuous Support's Effectiveness

1. Physiological benefits:

   • Reduces maternal stress hormones (cortisol) during labor 2
   • Shorter duration of labor (MD -0.69 hours) 1

2. Reduced interventions:

   • Less use of intrapartum analgesia (RR 0.90) 1
   • Fewer instrumental vaginal births (RR 0.90) 1

3. Improved outcomes:

   • Higher rates of spontaneous vaginal birth (RR 1.08) 1
   • Lower rates of negative feelings about childbirth experience 1
   • Fewer babies with low five-minute Apgar scores (RR 0.62) 1

Implementation Considerations

Continuous support is most effective when:

• Provided by someone in a doula role (not hospital staff)
• Implemented in settings where epidural analgesia is not routinely available
• Used in settings where women are not permitted to have companions of their choosing
• Applied in middle-income countries (shows larger reduction in CS rates compared to high-income settings) 1

Clinical Pitfalls to Avoid

• Don't confuse continuous support with intermittent checks: True continuous support means having someone present throughout labor, not just periodic nursing checks.
• Don't rely on electronic fetal monitoring as a substitute: Continuous EFM increases CS rates (NNH = 20) without improving neonatal outcomes 6.
• Don't delay implementation: Continuous support appears most effective when started early in labor.
• Don't underestimate the impact: The reduction in CS rates with continuous support (25%) is clinically significant and exceeds many other interventions.

Continuous support during labor stands out as the most effective strategy among those presented for reducing cesarean section rates while simultaneously improving maternal satisfaction and neonatal outcomes.