61: Hospital-level cesarean and operative delivery rate and risk for adverse outcomes

Abstract

Hospital-level cesarean rates are used as a quality indicator and operative vaginal delivery (OVD) with vacuum or forceps may represent an alternative to cesarean in some clinical scenarios. However, it is not known whether OVD is more common among vaginal deliveries at hospitals with low cesarean rates. It is also not known whether hospitals with higher OVD rates have higher risk for neonatal injury, 3rd/4th degree vaginal lacerations, and shoulder dystocia. The objective of this study was to address these knowledge gaps. The Nationwide Inpatient Sample from 1998-2011 was used for this serial cross sectional analysis. Singleton, liveborn delivery hospitalizations were identified. Hospitals were divided into five quintiles based cesarean deliveries rates; OVD among all vaginal deliveries was calculated. The analysis was then repeated excluding cesarean deliveries and ordering hospitals into quintiles based on OVD rates; risk for 3rd/4th degree lacerations and shoulder dystocia among all vaginal deliveries was then calculated. Finally, birth injury based on OVD quintiles was analyzed for the entire hospital newborn population. Of 10,318,573 deliveries, 6,695,987 were vaginal. Among vaginal deliveries, OVD was more common in the lowest vs. highest cesarean quintiles (10.6% vs 8.7%, p< 0.01) (Figure 1). Hospital mean OVD rates were 3.5%, 6.4%, 8.6%, 11.4%, and 17.6% of all vaginal deliveries by OVD quintile. Shoulder dystocia (Figure 2A) and 3rd and 4th degree vaginal lacerations (Figure 2B) for the entire vaginal delivery population increased significantly from lowest to highest OVD quintile (p< 0.01). Evaluating the entire hospital newborn populations, risk for birth injury was 30.5% (95% CI 28.7%-32.4%) greater in the highest vs. lowest OVD quintile hospitals. In this analysis, lower cesarean rates were associated with higher OVD rates. Higher OVD rates were in turn associated with hospital-level risk for shoulder dystocia, 3rd/4th degree laceration, and neonatal injury. In the setting of efforts to reduce cesarean it is also important to track these outcomes.View Large Image Figure ViewerDownload Hi-res image Download (PPT)