Imagine the act of baking chocolate chip cookies from scratch. In a bowl, mix flour, brown sugar, vanilla, eggs and chocolate chips with a bit of elbow grease and love. Thumb the plops of dough onto a pan and wait.     Wait.     Pad around the kitchen. Peek in your oven window and watch the dough begin to rise. Finally, when the cookies are  finished, wait some more for them to cool because you've burned your tongue before.  Expecting that first batch can be excruciating--painful even.

Baking cookies is a lot like making babies. There's a lot of sweaty, hard work involved, and it's usually messy. And then there's a lot of waiting--painful waiting. But patience really pays off for cookie lovers and for soon-to-be mothers. According to a recent study by researchers at the University of California, San Francisco, 130,000 cesarean deliveries could be prevented each year in the United States by simply being patient during stalled labors. The study found that pregnant women whose labor stalled while in the active phase of childbirth can reduce health risks to themselves and their infants by waiting out the delivery process for an extra two hours.

These findings appear in the November, 2008 issue of “Obstetrics and Gynecology,” the official journal of the American College of Obstetricians and Gynecologists (ACOG). While the ACOG already recommends waiting at least two hours with adequate contractions in the setting of no progress in active labor, it is routine practice in many clinical settings to proceed with a cesarean for “lack of progress” before those ACOG criteria have been met, according to Aaron Caughey, MD, PhD, an associate professor in the UCSF Department of Obstetrics, Gynecology and Reproductive Sciences, Division of Maternal-Fetal Medicine, and senior author on the paper.  Arrest in the active phase of labor has been previously shown to raise the risk of cesarean delivery between four- and six-fold.

“One third of all first-time cesareans are performed due to active-phase arrest during labor, which contributes to approximately 400,000 surgical births per year,” said Caughey, who is affiliated with the UCSF National Center of Excellence in Women’s Health. “In our study, we found that just by being patient, one third of those women could have avoided the more dangerous and costly surgical approach.”

The study concluded that just two more hours could prevent a caesarean pregnancy without additional risk to the mother or the baby--efforts to continue with a normal delivery can reduce the maternal risks associated with cesarean delivery, without a significant difference in the health risk to the infant.

The study examined the health outcomes of 1,014 pregnancies that involved active-phase arrest – two or more hours without cervical dilation during active labor. The study found that although two-thirds of women proceeded with a cesarean, one-third of the women achieved a normal delivery without harm to themselves or their child. While cesarean section was necessary two-thirds out of the time, one out of three times it wasn't. Based on the study's findings, many obstetricians and mother’s can be encouraged to wait, see if the pregnancy progresses and when possible, "bake the bun 'til it's done." With patience, many mothers can avoid the added pain of surgery as well as its after effects.

While some mothers might opt for a cesarean section, believing it less dangerous, compared to vaginal delivery, cesarean sections are the more dangerous and expensive surgical approach. Following a vaginal delivery, a mother will typically go home in a day or two and return to normal activities in one to two weeks. By contrast, mothers who deliver by cesarean section go home three to five days after surgery but it might require four or more weeks to recover. Also, c-section mothers are likely to have vaginal bleeding and be on pain medication while their incision heals. Despite the increased risk of c-sections, according to the UCSF study, the cesarean delivery rate reached an all-time high in 2006 of 31.1 percent of all deliveries.

“Cesarean delivery is associated with significantly increased risk of maternal hemorrhage, requiring a blood transfusion, and postpartum infection,” Caughey said. “After a cesarean, women also have a higher risk in future pregnancies of experiencing abnormal placental location, surgical complications, and uterine rupture.”

The ten-year study identified all women who experienced what is known as active-phase arrest during their delivery at UCSF from 1991 to 2001. The study only included women with live, singleton deliveries who were delivered full-term. The researchers examined maternal outcomes such as maternal infection, endomyometritis, postpartum hemorrhage and the need for blood transfusions. It also examined the infant’s Apgar score, rates of infection and frequency of admission to the neonatal intensive care unit, among other health indicators. The study found an increased risk of maternal health complications in the group that underwent cesarean deliveries, including postpartum hemorrhage, severe postpartum hemorrhage and infections such as chorioamnionitis and endomyometritis, but found no significant difference in the health outcomes of the infants.

Co-authors on the paper were Dana E.M. Henry, MD; Yvonne W. Cheng, MD, MPH; Brian L. Shaffer, MD; Anjali J. Kaimal, MD; and Katherine Bianco, MD, all from the UCSF Department of Obstetrics, Gynecology and Reproductive Sciences, Division of Maternal-Fetal Medicine.