768 Use of standardized documentation tool for indication of primary cesarean section in nulliparous women

Abstract

Cesarean births in the United States have increased from 1996 to 2011, with nearly one third of deliveries via cesarean. Efforts to promote safe vaginal births through best-practice strategies aim to reduce the number of cesarean deliveries in the most variably managed low-risk patients: nulliparous, term, singleton gestation, vertex presentation (NTSV). The California Maternal Quality Care Collaborative (CMQCC) introduced a pre-cesarean checklist for labor dystocia to promote vaginal birth. This quality improvement project aims to look at the effectiveness of a standardized documentation tool on adherence to guidelines of indications for primary cesarean delivery at a tertiary care center. The institutional review board at Santa Clara Valley Medical Center waived review of this quality improvement project. A standardized documentation tool was implemented for use on February 1, 2018. Electronic delivery reports were queried 6 months prior and after implementation, then narrowed to NTSV deliveries. Primary outcome was to determine if the documented indication for cesarean met criteria based on guidelines. Secondary outcomes included verification of documented metrics (time of membrane rupture, oxytocin administration, length of second stage) and if there was an indication for cesarean delivery. Individual charts were reviewed by two physicians. Statistical analysis was performed using chi-square and t-test as appropriate. Utilization rate was 14.8 vs. 64.2% (pre- vs. post-, p=<0.001). There was no significant difference between patient demographics or stated indication for cesarean. Primary outcome was confirmed in 78.4 vs. 87.4% (p=0.16) of cases. Supporting metrics were verified in 94.3 vs. 92.6% (p=0.87) of cases. Overall, a qualified indication for cesarean was found in 87.5 vs. 92.6% (p=0.360) of cases. The NTSV cesarean rate was 20 vs. 25% pre- and post-implementation, respectively. The use of a standardized documentation tool did not result in a statistically significant difference in adherence to primary cesarean guidelines at a single tertiary care center.