From the Guidelines
The physician's recommendation for a cesarean delivery is not medically justified in this scenario, and the patient should continue labor under the care of the on-call obstetrician. The patient is making progress in labor, with 1 cm dilation over 3 hours, and has normal vital signs, and the fetal heart rate tracing is category 1, which is reassuring 1. The primary indication for the cesarean appears to be the physician's personal schedule rather than a true medical necessity. According to the American Journal of Obstetrics and Gynecology, if CPD can be ruled out, vaginal delivery is preferable, provided it does not prove difficult 1.
Some key points to consider in this scenario include:
- The patient's labor progression, although slow, is still progressing, and the fetal heart rate tracing is normal
- The physician's personal schedule should not influence the medical decision-making process
- The on-call obstetrician can continue to monitor the patient's labor and perform a cesarean delivery if medically indicated
- Performing an unnecessary cesarean delivery exposes the patient to increased risks, including surgical complications, longer recovery, and potential complications in future pregnancies 1
The standard of care would be to continue supporting this normal labor process with appropriate monitoring, as stated in the study published in the American Journal of Obstetrics and Gynecology 1. The physician should prioritize the patient's best interests by facilitating a handoff to the on-call physician rather than recommending an intervention based on personal scheduling constraints.
From the Research
Protracted Labor Course and Cesarean Delivery
- The patient in question has had a protracted labor course, with cervical dilation increasing only 1 cm over the last 3 hours, and is now at 8 cm dilation 2.
- The fetal heart rate tracing is category 1, which is a normal tracing, and vital signs are normal.
- The physician is considering performing a cesarean delivery due to the protracted labor course and their inability to attend the delivery in a few hours.
Non-Reassuring Fetal Heart Rate Tracing and Cesarean Delivery
- Non-reassuring fetal heart rate tracing is a common indication for cesarean delivery, but it does not uniformly predict poor fetal outcome 2.
- A study found that 44.5% of patients who underwent cesarean delivery for non-reassuring fetal heart rate tracing may have been able to labor longer 3.
- Another study found that the use of a proposed algorithm for managing non-reassuring fetal heart rate tracings could potentially reduce the rate of cesarean deliveries for this indication 3.
Decision to Delivery Time Interval and Neonatal Outcome
- A study found that a decision to delivery time interval of less than or equal to 30 minutes did not significantly improve neonatal outcomes, but was associated with a higher rate of NICU admissions 4.
- Another study found that the risk of cesarean delivery for fetal distress was higher in patients with certain medical and obstetric conditions, such as severe preeclampsia and fetal growth restriction 5.
Cesarean Delivery for Non-Reassuring Fetal Heart Rate Tracing
- Cesarean delivery for non-reassuring fetal heart rate tracing is a common procedure, and understanding the prevalence and risk factors is important for clinicians 6.
- The American College of Obstetricians and Gynecologists guidelines recommend intrauterine resuscitation for non-reassuring fetal heart rate tracings, and clinicians should take steps to minimize legal liability 6.