Tuesday, February 9, 2016

Yet More Evidence That You Shouldn't Go To The Hospital Too Early

Image from Zwelling 2010 study
Here are two more studies showing that early admission in labor to the hospital is a risk factor for obstetric interventions and for a cesarean.

This is something we've written about before, but given these two latest studies, it's a point worth repeating.

Study #1

In the first study, early admission (at less than 4 cm dilation) increased the utilization of epidurals, artificial augmentation of contractions, and cesareans.

21.8% of first-time moms with early admission had a cesarean, compared with 14.5% of first-time moms with later admission.

In women who had had children before, the cesarean rate was 3.7% in those admitted early, compared with 1.9% in those admitted later.

Most interestingly, the hospital lowered their overall cesarean rate between 2012 and 2014 by admitting fewer women in early labor (10.5% to 7.9%). Take note, fellow hospitals!

Study #2

In the second study, "early" admission was defined as less than 6 cm of dilation. Note the difference in cutoffs between the two studies; this is important.

This change reflects the new recommendation that 6 cm be considered the criteria for "active labor" rather than the old cutoff of 4 cm. Indeed, a recent consensus statement from the American Congress of Obstetricians and Gynecologists and the Society for Fetal-Maternal Medicine suggests that the definition of "active" labor be changed to 6 cm. Lamaze International has highlighted this with their related discussions on "Six is the New Four." Here is one hospital that is considering the new recommendation, which is great.

This study found that women admitted at less than 6 cm had more than THREE times the risk for cesarean (13.2% vs. 3.5%).

When broken down between women who had never given birth before and those with previous births, the increased risk for cesarean with early admission only reached statistical significance in multiparous women (11.0% vs. 2.5%, or more than FOUR times the risk).

In first-time mothers, the cesarean rate was 16.8% in those admitted before 6 cm dilation, vs. 7.1% in those admitted at 6 cm or later. Clearly there was a major trend towards significance (a relative risk of 2.35), but the confidence interval crossed 1.0, which means the findings could have been due to chance. So conclusions are limited there but strongly suggest that with a larger group, statistical significance might well have been reached.

The authors concluded:
Decreasing cervical dilation at admission, particularly <6 cm, is a modifiable risk factor for cesarean, especially in multiparous women. 
In other words, here is a simple way for hospitals to help decrease their cesarean rates.


The take-home message for mothers is that if you plan to birth in the hospital, don't rush to the hospital too early in labor. 

Consider hiring a doula for labor support both at home and in the hospital. This can help decrease your chances for a cesarean and give you the confidence to not go in too early. This may be especially important for first-time mothers who have never labored before and aren't sure what to expect.

Obviously, if there is something that doesn't feel right or your intuition says needs attention, you should not hesitate to go in and ask for evaluation. And of course, sometimes there are medical considerations that might also call for early evaluation; your care provider will help you determine the situations to be cautious about.

But most of the time, there is no need to be in the hospital right away if labor has started. The sooner you go in, the more likely you are to have interventions like oxytocin augmentation and cesareans. Stay home with good labor support until labor is well-established and moving along. If you go in too early, don't be afraid to go home for a while before you return to stay, as long as both you and baby seem to be doing well.

The take-home message for hospitals is that they can lower their primary cesarean rates just by encouraging women to stay home longer in early labor, and by adopting 6 cm as the new standard for "active" labor and hospital admission for most women.

Given the known health risks of a too-high cesarean rate, this has important implications for public health.


Obstet Gynecol. 2016 Feb 4. [Epub ahead of print] Cervical Dilation on Admission in Term Spontaneous Labor and Maternal and Newborn Outcomes. Kauffman E1, Souter VL, Katon JG, Sitcov K. PMID: 26855106
OBJECTIVE: To examine associations between cervical dilation on admission and maternal and newborn outcomes in term spontaneous labor. METHODS: This is a retrospective cohort study of 11,368 singleton, term (37-43 6/7 weeks of gestation) spontaneously laboring women delivering in 14 hospitals in Washington State between 2012 and 2014 using chart abstracted data from the Obstetrics Clinical Outcomes Assessment Program. Women with prior cesarean delivery or ruptured membranes on admission were excluded. Pregnancy history, cervical dilation on admission, and outcomes were analyzed. Associations between early (less than 4 cm cervical dilation) and late (4 cm or greater cervical dilation) admission and outcomes were examined using general linear models with a log-link stratifying by parity. Results were reported as adjusted relative risks (RRs) with 95% confidence intervals (CIs). RESULTS: Early admission compared with late admission was associated with increased epidural use of 84.8% compared with 71.8% in nulliparous women and 66.3% compared with 53.1% in multiparous women (nulliparous RR 1.18, 95% CI 1.13-1.24; multiparous RR 1.25, 95% CI 1.18-1.32); oxytocin augmentation in 58.5% compared with 36.6% in nulliparous women and 45.9% compared with 20.7% in multiparous women (nulliparous RR 1.56, 95% CI 1.50-1.63; multiparous RR 2.14, 95% CI 1.87-2.44); and cesarean delivery of 21.8% compared with 14.5% in nulliparous women and 3.7% compared with 1.9% in multiparous women (nulliparous RR 1.50, 95% CI 1.32-1.70; multiparous women RR 1.95, 95% CI 1.47-2.57). Early admission was associated with increased neonatal intensive care unit admission for newborns of nulliparous women only (RR 1.38, 95% CI 1.01-1.89). Between 2012 and 2014, late admission increased 14.6% for nulliparous patients and 10.1% for multiparous patients, and the cesarean delivery rate decreased from 10.5% to 7.9% (P<.001) for all. CONCLUSION: Early admission (less than 4 cm cervical dilation) is a risk factor for increased medical intervention and cesarean delivery.
Am J Perinatol. 2016 Jan;33(2):188-94. doi: 10.1055/s-0035-1563711. Epub 2015 Sep 7. Optimal Admission Cervical Dilation in Spontaneously Laboring Women. Wood AM1, Frey HA2, Tuuli MG1, Caughey AB3, Odibo AO4, Macones GA1, Cahill AG1. PMID: 26344012
OBJECTIVE: To estimate the impact of admission cervical dilation on the risk of cesarean in spontaneously laboring women at term. STUDY DESIGN: Secondary analysis of a prospective cohort study of women admitted in term labor with a singleton gestation. Women with rupture of membranes before admission, induction of labor, or prelabor cesarean were excluded. The association between cesarean and cervical dilation at admission was estimated, and results were stratified by parity. Relative risks (RRs) and 95% confidence intervals (CIs) were calculated, using cervical dilation ≥ 6 cm as the reference group. Cesarean for arrest was secondarily explored. RESULTS: A total of 2,033 spontaneously laboring women met inclusion criteria. Women admitted at <6 cm dilation had an increased risk of cesarean compared with those admitted at ≥6 cm (13.2 vs. 3.5%; RR 3.73; 95% CI 1.94-7.17). The increased risk was noted in nulliparous (16.8 vs. 7.1%; RR 2.35; 95% CI 0.90-6.13) and multiparous (11.0 vs. 2.5%; RR 4.36; 95% CI 1.80-10.52) women, but was statistically significant only in multiparous women. CONCLUSIONS: Decreasing cervical dilation at admission, particularly <6 cm, is a modifiable risk factor for cesarean, especially in multiparous women. This should be considered in the decision-making process about timing of admission in term labor.


aliphil said...

I think 6 cm is standard here (UK). I went in when I didn't feel able to cope at home any longer - the worst pains were in the fronts of my thighs, which no one had mentioned as a possibility and I had no clue how to deal with - and was told by an extremely unsympathetic midwife that I shouldn't have come because I was only 2 cm. The same midwife forced me into having an epidural a couple of hours later, because "you're pushing and you're not ready to push yet". If she'd bothered to check before the epidural was in, she'd have found I was fully dilated at that point.

Janeen said...

YES YES YES!!! I have no doubt that early admission was what caused the slippery slope to a cesarean with my oldest (sadly, lack of at home support was a huge part of the reason I went in to the hospital) and having much better labor support with a doula and a midwife as a montrice kept me at home until labor was very active. Even though I was a five at admission according to the doc, the midwife had me at a higher dilation before I went to the hospital and while they tried to push the repeat cesarean on me, it was only two and a half hours after being admitted that my second daughter was born vaginally. No IV drugs and no epidural either (both things I was avoiding because I responded so badly to them the last time around). Good labor support at home is absolutely essential!