Document Type

Conference Proceeding

Publication Date


Publication Title

American Journal of Obstetrics and Gynecology



The American College of Obstetrics and Gynecology (ACOG) introduced updated guidelines for labor management (2014) and fetal heart rate interpretation in an attempt to reduce cesarean delivery (CD) rates – especially the primary CD. We sought to describe CD rates and indications at a single center in order to assess the impact of these guidelines on trends in clinical practice.

Study Design

Retrospective cohort study of women ≥ 23 weeks gestation delivering at a single tertiary care referral center from 2013 - 2018. Demographic characteristics, mode of delivery, and main CD indication were ascertained by individual chart review. Main CD indications were defined as repeat CD, non-reassuring fetal status (NRFS), malpresentation, maternal indications (i.e. placenta previa or genital HSV), failed labor (any stage labor arrest), or other (i.e. fetal anomaly, elective). Polynomial (cubic) regression models were used to model rates of CD and main indications over time. Subgroup analyses further examined trends for nulliparous women.


Of 24,637 women delivered during the study period, 24,050 women were included in the analysis; 7,835 (32.6%) had a CD. No clinically significant changes in the overall CD rate appeared during the study period (min 30.9% in 2014, max 34.6% in 2018). While CD for NRFS significantly changed over time - decreasing to a nadir in 2015 then rising (p=0.003), there were no differences in any other CD indications over time (Figure 1). When limited to nulliparous women, the rates of CD were similarly stable during the study period (min 30.7% in 2014, max 35.6% in 2013) and there were no differences in any primary CD indications over time (Figure 2).


Despite the changes in labor management definitions and guidelines encouraging vaginal birth, rates of CD and indications for CD particularly failed labor, repeat CD, and malpresentation have not significantly changed over time. Studies should evaluate whether factors like patient preference and practice/provider variation contribute to the steady rate of CD.





First Page



Presented at the Society for Maternal Fetal Medicine (SMFM) Annual Meeting, Virtual, January 29, 2021.