1. Section Editor(s): Simpson, Kathleen Rice PhD, RNC, FAAN

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We should all be concerned about the cesarean birth rate in the United States. The percentage of births via cesarean increased nearly 60% from 1996 to 2009 to an all-time high of 32.9%. There was a slight decline in the rate from 2009 to 2010 (to 32.8%) and no change from 2010 to 2011 (Hamilton, Martin, & Ventura, 2012). It is unclear what the ideal cesarean birth rate is, but nearly one out of three women having a cesarean is high. There are likely many contributing factors to the cesarean birth rate in the United States, some of which are amendable to change.


Some experts believe that measurement and public reporting of institution and practitioner cesarean rates will promote change. In 2008, the National Quality Forum recommended measuring the rate of cesarean birth for low-risk nulliparous women at term with a singleton vertex fetus. In 2009, The Joint Commission (TJC) adopted this quality measure as part of their perinatal care measure set; starting in January 2014, all TJC-accredited hospitals with a birth volume of >=1,100 births annually will be required to submit these data.


In 2012, the National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, and American College of Obstetricians and Gynecologists convened a workshop of perinatal experts to discuss potential solutions to minimize risk of primary cesarean birth (Spong, Berghella, Wenstrom, Mercer, & Saade, 2012). A review of available evidence of possible contributing factors to primary cesarean birth was conducted. Summaries of potentially modifiable obstetric, maternal, and fetal indications were offered. Algorithms for spontaneous labor and induced labor were included, based on the most recent data about time frames that reflect normal labor progress in contemporary obstetric practice from the Consortium for Safe Labor project. Based on these data, recommendations were made to minimize risk of primary cesarean birth and monitor outcomes (Spong et al., 2012). Definitions of failed induction and arrest of labor disorders were incorporated into the recommendations. Encouragement of patience and a reconsideration of what constitutes normal labor progress for nulliparous women are major findings.


I encourage all perinatal nurses to review this important publication, become knowledgeable about the recommendations, and consider how practice on your unit might change to incorporate the key findings. Adoption of the clinical algorithms and definitions of normal labor progress could be the foundation for making a significant difference in reducing the cesarean birth rate for low-risk nulliparous women. This change could also lead to less maternal morbidity related to subsequent pregnancies and cesareans, and ultimately less unnecessary healthcare costs. Work with other members of the perinatal team to disseminate these findings. Educate women about cesarean birth. Childbirth Connection (2012) has an excellent patient education summary on their website that is at the appropriate literacy level for consumer education.


Helping to avoid preventable primary cesarean births is worthy of our efforts to spread the word that new evidence-based recommendations are available. The rising cesarean birth rate is major public health issue that can be remedied by a concerted team effort. That team should include nurses, physicians, midwives, and childbearing women.




Childbirth Connection. (2012). Cesarean section: What you need to know about C-section. New York, NY: Author.[Context Link]


Hamilton B. E., Martin J. A., Ventura S. J.(2012). Births: Preliminary data for 2011. National Vital Statistics Report, 61(5), 1-20. [Context Link]


Spong C. Y., Berghella V., Wenstrom K. D., Mercer B. M., Saade G. R.(2012). Preventing the first cesarean delivery: Summary of a joint Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, and American College of Obstetricians and Gynecologists workshop. Obstetrics and Gynecology, 120(5), 1181-1193. doi:http://10.1097/AOG.0b013e3182704880 [Context Link]