Obstetric Hospitalists: Impact on the Vaginal Birth After Cesarean Delivery Rate [24Q

Abstract

INTRODUCTION: Florida continues to have one of the lowest VBAC rates in the U.S. In 2016, an obstetric hospitalist program was launched with the goals of improving safety, quality and cost. The purpose of this study was to evaluate the VBAC rate and assess adverse maternal and neonatal outcomes before and after program implementation. METHODS: This is a before-after retrospective cohort study at a non-academic tertiary care hospital located in Central Florida. In March 2016, AdventHealth for Women-Orlando instituted a full-time obstetric hospitalist program. For the primary outcome, pregnant women with a history of prior cesarean managed before the hospitalist program (2015) were compared to those managed after full program deployment (2017). Secondary outcomes included the cesarean delivery rate, maternal and neonatal outcomes. RESULTS: Between 2015 and 2017, the VBAC rate rose from 5.4% to 13.5% (OR 2.8 95% CI 1.8-4.1). Hospitalists had significantly higher rates than non-hospitalists (27.5% vs 7.3%; OR 4.8 95% CI 3.3-7.2). The cesarean delivery rate decreased from 43.7% to 38.4% (OR .80 95% CI .72-.89). For VBAC patients, uterine rupture was rare (0.8% in 2017); for failed trials of labor, the rupture rate was not significantly different (4.0% vs 4.8%; OR 1.2 95% CI .03-19.5). No unplanned hysterectomies occurred in either group. Neonatal ICU admissions for VBAC patients trended upward from 15.6% to 18.3% (OR 1.2 95% CI .42-3.5); in failed TOLACs, admissions declined (52.8% to 36.8%, OR .51 95% CI .26-1.04). CONCLUSION: The addition of obstetric hospitalists led to significant improvement in both VBAC and cesarean delivery rates, while maintaining patient safety goals.