A new way to reduce C-section risk?

James Nicholson from Penn's Department of Family Medicine and Community HealthDr. James Nicholson says his recent research indicates that a new maternal care method could help reduce the risk of cesarean section.
Photo credit: Candace diCarlo

As opposed to traditional birth, cesarean section presents a number of additional risks—more blood loss, higher infection and potential complications for future pregnancies. And so, according to conventional thinking, inducing labor is best avoided, because it may lead to higher incidence of C-section.

But what if inducing labor—not when the health of the mother or child is in question, but based on a timetable derived by measuring a mother’s risk factors—could actually help lower the risk of C-section?

That was the question James Nicholson, assistant professor in Penn’s Department of Family Medicine and Community Health, set out to answer in a study that involved 1,869 women at a rural New England hospital.

Nicholson’s study found that women exposed to an alternative method of obstetric care, in which their risk factors were calculated and preventive induction was utilized if necessary, had a 5.3 percent cesarean rate, compared to an 11.8 percent rate for women who received more traditional obstetric care. “The study provides evidence that this method of care might work,” Nicholson says. “But it requires a mindset that induction will work.”

The alternative maternal care method used in the study is dubbed Active Management of Risk in Pregnancy at Term, or AMOR-IPAT. Doctors using this method employ a “scoring” system in which they look at risk factors such as a woman’s short stature, obesity, chronic hypertension, advanced maternal age, anemia and low blood count, all of which are conditions that can lead to a higher C-section risk. Once those factors are calculated, a woman’s ideal delivery window can be determined. Inductions never take place before 38 weeks.

“These things have never been looked at before in a continuous fashion,” Nicholson says. “Once you determine what the optimal gestation age is, if a mom hasn’t delivered on her own, you bring her in for a preventive induction. We use a lot more inductions, but not in the classic method where there’s already a problem that has developed.”

Though inducing labor when a complication with the mother or baby is not present is not widely accepted, Nicholson says his use has not led to higher ratess of adverse outcomes. “We find that the risk of neonatal intensive care went down, blood loss was lower, length of time in the hospital was less.”

He adds: “There are theoretical risks associated with induction, but all those deal with when [a woman] is induced for either the baby or mom’s sake. We’re taking our time with it and trying to get labor going when mom and baby are in good condition.”

Released in July and published in the summer edition of the Annals of Family Medicine, the study results were similar to a 400-patient study from an urban setting published two years ago that reported a 4 percent cesarean delivery rate in women exposed to AMOR-IPAT. The next step for Nicholson is to try to secure funding for an 800-patient study that will enroll women before delivery, and in the early third trimester randomize them into either active or control groups. The study would run for four years.

“This study paints the picture of association—it just says it’s possible,” Nicholson says. “It’s up to the[future study] to prove whether it does or doesn’t work. ... The inclination is to say whenever you induce, you have trouble. What this hinges on is the quantum leap that asks, what if you do a preventive induction?”

Originally published on September 20, 2007