Primary Cesarean Delivery Rate Research Articles

Preventing the Primary Cesarean Delivery—Adherence to Labor Arrest Guidelines [28P

INTRODUCTION: The ACOG/SMFM Safe Prevention of Primary Cesarean Delivery guidelines suggest minimum criteria at which cesarean should be performed for labor arrest with the goal of reducing primary cesarean delivery rates. This study evaluates current adherence to these criteria at an academic medical center with two different campuses in order to quantify variation in the modifiable proportion of the cesarean rate and to target quality improvement initiatives. METHODS: We analyzed cesareans deliveries performed for arrest of dilation, arrest of descent and failed induction among singleton, term, cephalic live births at a large academic center with two campuses from September 2018 to August 2019. Using the ACOG/SMFM guidelines, the labor course for each cesarean was examined to determine if minimum criteria were met. RESULTS: During the study period, there were 1716 cesarean deliveries with 286 performed for labor arrest disorders: 94 for arrest of dilation, 120 for arrest of descent, and 72 for failed induction of labor. At campus A, 27% met criteria for arrest of dilation, 46% for arrest of descent, and 45% for failed induction; at campus B, 95% met criteria for arrest of dilation, 61% for arrest of descent, and 60% for failed induction. Over the study period, the primary cesarean rates at campus A and B were 19.4% and 13.4%, respectively. CONCLUSION: The adherence to criteria for arrest disorders was suboptimal and varied significantly across campuses. Quality improvement initiatives targeted to improve adherence to criteria for labor arrest disorders have the potential to impact primary cesarean delivery rates.

Preventing the Primary Cesarean: Adherence to SMFM/ACOG Guidelines by Use of Intrauterine Pressure Catheter [29P

INTRODUCTION: In order to reduce the primary Cesarean delivery (CD) rate, SMFM and ACOG offer guidelines for diagnosing arrest of dilation (AOD) and failed induction of labor (FIOL). At our institution, adherence to these guidelines is low, at 28%, but there is limited understanding of contributing factors. The intrauterine pressure catheter (IUPC) is a recognized, helpful component of labor induction protocols, but few studies have examined whether its use is related to CD rates and adherence to labor guidelines. The objective of this study is to evaluate IUPC utilization and its relationship to SMFM/ACOG guideline adherence rates. METHODS: A retrospective cohort analysis was conducted at our institution of all singleton primary CDs performed for AOD or FIOL between March 1st 2014 and July 3rd 2018. Cases were defined as being adherent or non-adherent to published guidelines. A chi square test was used to compare the association of guideline adherence to IUPC use. RESULTS: Baseline characteristics were similar between adherent and non-adherent groups. For CDs that were non-adherent to ACOG guidelines, IUPCs were utilized in 208/767 cases (27.1%). For CDs that were adherent to ACOG guidelines, IUPCs were utilized in 123/295 cases (41.7%) (P less than 0.001). CONCLUSION: We observed a significantly greater rate of IUPC use in CDs that were adherent to SMFM/ACOG guidelines. Overall, adherent physicians performed fewer CDs. This finding suggests that IUPC utilization may be a helpful adjunct for improving labor management and lowering primary CD rates. Interventions around physician education are needed to increase appropriate IUPC use.

Indications for Primary Cesarean Deliveries and Their Association With Maternal Medical Comorbidities [17P

INTRODUCTION: Abnormal fetal heart tracing (FHT) remains one of the most common indications for primary cesarean delivery (PCD) in the United States. Literature suggests a possible association between maternal medical comorbidities and increased risk of cesarean delivery. This study aims to examine PCD for abnormal FHT stratified by various chronic and pregnancy-related medical comorbidities. METHODS: We used a retrospective cohort study design. Following IRB approval, electronic medical records were queried for all cesarean deliveries (n=666) performed at a single University hospital from January 1, to December 31, 2018. Data collected included maternal demographic, medical, and delivery information. Parametric and non-parametric tests were used for data analysis. RESULTS: Out of all cesarean deliveries, 357 surgeries were identified as PCDs. Most common maternal medical comorbidities included chronic hypertension (HTN) (11%, 39/357), pre-gestational diabetes mellitus (DM) (2.5%, 9/357), gestational HTN (9.5%, 34/357), preeclampsia without severe features (SF) (5%, 18/357), preeclampsia with SF (15%, 53/357), gestational DM (9.5%, 34/357). Subjects with chronic HTN (P=.003) and pre-gestational DM (P=.006) had a statistically significant higher rate of PCD for abnormal FHT. No difference was found for all other medical comorbidities. CONCLUSION: Our study suggests that patients with pre-existing medical comorbidities may have a statistically significant higher rate of PCD for abnormal FHT than other pregnancy-related medical comorbidities. Further prospective studies are needed to confirm this potential association and possibly aid in improving preventative measures for reducing PCD.

A Retrospective Review of Cesarean Deliveries for Suspected Fetal Macrosomia: Were They Indicated? [02K

INTRODUCTION: For low risk pregnancies, cesarean deliveries have a greater risk of morbidity and mortality than vaginal deliveries. Fetal macrosomia, especially at weights greater than 4500 g, also increases risks of both neonatal and maternal morbidity. Macrosomia, with estimated fetal weight (EFW) greater than 5000 g or greater than 4500 g in women with diabetes mellitus, is the currently accepted ACOG threshold at which cesarean delivery may be offered. This study evaluates current adherence to ACOG guidelines for cesarean deliveries for macrosomia at a large academic medical center. METHODS: We analyzed cesarean deliveries performed for suspected fetal macrosomia among individuals undergoing cesarean delivery between September 2018 and August 2019. Using the recorded EFW and actual birthweights, we determined whether criteria for indicated cesarean delivery for macrosomia was met. RESULTS: During the study period, 1,716 cesarean deliveries were performed with 24 performed for presumed macrosomia. The average EFW among those 24 undergoing primary cesarean delivery was 4399g. Of the 24 deliveries, 7 pregnancies were complicated by diabetes. Only 4 (17%) met the EFW thresholds, 2 of which had pregnancies complicated by diabetes. The average difference in EFW and actual birthweights was 371g (8%). 13 of the 24 ultrasounds performed for macrosomia had EFWs larger than the actual birth weight. CONCLUSION: The majority of primary cesarean deliveries performed for macrosomia did not follow currently accepted ACOG guidelines. Quality improvement initiatives aimed to improve adherence to these guidelines may provide an opportunity to facilitate efforts to decrease primary cesarean delivery rates.

External Cephalic Version in Twin Pregnancy [13N

INTRODUCTION: Decreasing the primary cesarean delivery rate and associated maternal and fetal complications is a priority for many obstetric providers. External cephalic version is a procedure recommended for women with singleton pregnancies where the fetus is malpresenting as vaginal breech delivery is inherently riskier than either vaginal or cesarean delivery. However, little is known about this procedure in the context of twin gestations. Women with twin gestations where the presenting fetus is not cephalic are instead recommended to undergo scheduled cesarean delivery. METHODS: A systematic review of the following electronic databases was performed, searching from their inception until September, 2019: MEDLINE, Ovid, Scopus, and clinicaltrials.gov. All reported cases of external cephalic version in twin pregnancy were included. Maternal demographics, procedure details, and outcomes data were collected. The primary outcome was successful version of the presenting twin to the cephalic presentation. Statistical analysis involved calculating means, standard deviations, frequencies and percentages as appropriate. RESULTS: Two case reports and one case series, totaling 22 patients, met inclusion criteria. No randomized controlled trials were identified. All were dichorionic pregnancies. Successful external cephalic version of twin A occurred in 60% (13/22) of women and 50% (11/22) had a successful vaginal delivery. The majority were performed using regional anesthesia and a uterine relaxant (19/22). No serious adverse events occurred in any of the reports. CONCLUSION: External cephalic version appears to be safe and effective for dichorionic twins where the presenting twin is malpresenting. Additional randomized controlled trials are needed to further evaluate this intervention for this patient population.

Agreement Between Providers When Determining Primary Cesarean Deliveries for Fetal Heart Tracings [03P

INTRODUCTION: The most common indications for primary cesarean delivery (PCD) in the US are labor dystocia and abnormal fetal heart tracing (FHT). Category II tracings make up the majority of intrapartum tracings and management may differ among providers (Obstetricians [OB], midwives [CNM], and family medicine physicians [FM]). This study aims to determine the characteristics of FHT which resulted in PCD at UI Health (UIH) by provider type. METHODS: IRB approved, retrospective cohort study of primary CD at UIH during 2018. Data was abstracted from electronic medical records and analyzed in SPSS. RESULTS: 357 PCD occurred during the study period. The most common indication for PCD was abnormal FHT (45.1%), malpresentation (18.2%), followed by labor dystocia (18.1%). When stratifying for provider type, FM had more CD for labor dystocia, while OB and CNM had more for FHT. However, when removing other objective indications, such as placenta previa and malpresentation, FHT was the most common regardless of which service managed antepartum and intrapartum care (45.1%, P=.12). The majority of tracings at the time of decision for CD were category II (84%). Minimal variability was present in (56%, P=.16). Late decelerations were most common at time of CD (46.6%, P=.17), followed by variable (41%, P=.55) and prolonged (15%, P=.14). CONCLUSION: Since standardization of categories of FHT by NICHD, there seems to be agreement among providers in terms of the management of category II tracings. More data is needed to confirm this trend, while continuing efforts to improve intrauterine resuscitation in order to decrease the PCD rate.

1114: Operative vaginal delivery and rates of primary cesarean in California hospitals

Rates of primary cesarean section and obstetric anal sphincter injury (OASIS) are quality metrics and patient safety indicators for hospitals in the United States. Over the last decade, rates of cesarean section have risen while operative vaginal deliveries have fallen out of favor. We examined hospital-level rates of cesarean section associated with third- and fourth-degree laceration. This is retrospective study of California hospital deliveries from 2007-2011. We excluded hospitals with < 50 deliveries per year. Hospital rates of primary cesarean section and severe (3rd/4th degree) laceration in nulliparous, term, singleton, vertex (NSTV) deliveries were calculated. Rates of each respective variable were used to generate a scatter plot. Pearson correlation was used to calculate covariance in order to examine the relationship between each delivery method. We identified 269 hospitals meeting inclusion criteria. The mean proportion of primary cesarean section was 0.164 ± 0.035, and the mean proportion of NSTV deliveries with severe perineal lacerations was 0.064 ± 0.027. The proportion of primary cesarean deliveries is overall negatively correlated with the proportion of severe perineal laceration among NSTV deliveries (correlation coefficient = -0.21, p< 0.001). There is an inverse relationship between hospital-level rates of primary cesarean delivery and severe OASIS injury in NSTV deliveries. Strategies to reduce numbers of patient safety indicators like OASIS injury may result in higher rates of primary cesarean.

1193: The combined influence of multiple maternal medical conditions on incidence of primary cesarean section

Common maternal medical co-morbidities such as hypertensive disorders, diabetes, tobacco use, and extremes of maternal age, BMI, and gestational weight gain, are known individually to have impact on the rate of cesarean delivery. Numerous prior studies have estimated the risk of individual risk factors on cesarean delivery, but many parturients have more than one condition that may compound cesarean risk. We aim to examine the risk for cesarean delivery in women with multiple maternal medical co-morbidities to determine the cumulative risk they pose on pregnancy. In this retrospective cohort study we analyzed data from the Ohio live birth records from 2006-2015 with the goal to estimate the influence of individual and combinations of maternal co-morbidities on rates of primary cesarean delivery. The exposures were individual and combined maternal morbidities (chronic hypertension, gestational hypertension, pre-gestational diabetes, tobacco use, advanced maternal age, obesity, and insufficient gestational weight gain) and outcomes were rates and adjusted relative risk (aRR) of Cesarean. There were 1,463,506 live births in Ohio during the study period, of which 1,044,570 (71.3%) had one or more risk factor. The rate and aRR range of Cesarean delivery were 19.9-36.2% (aRR 1.15-1.96) in pregnancies with a single risk factor and this increased to 29.8-45.8% (aRR1.54-2.70) in pregnancies complicated by multiple medical co-morbidities, see figures. A greater number of maternal medical co-morbidities during pregnancy is associated with increasing cumulative risk of primary cesarean delivery. These data provide specific estimates of risk with a variety of combinations of medical co-morbidities, which may be used for patient counseling, risk stratification and pregnancy management planning.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Indications contributing to the decreasing cesarean delivery rate at an academic tertiary center

Evaluating trends in indications may identify targets to safely reduce the primary cesarean delivery rate. The purpose of this study was to examine physician-documented indications for cesarean delivery to identify specific factors that contribute to a decreasing cesarean delivery rate. We analyzed rates of primary and repeat cesarean deliveries, which included indications for the procedure, among 22,265 live births at an academic tertiary center from 2009-2013. Time trends for each indication were modeled to estimate the absolute and cumulative annualized relative risk of cesarean delivery by indication over time and the relative contribution of each indication to the overall decrease in primary cesarean delivery rate. From 2009-2013, the cesarean delivery rate decreased from 36.5-31.4%; 74% of the decrease was attributable to a decrease in primary cesarean deliveries, which decreased from 21.7-17.6%. Among documented indications for primary cesarean delivery, labor arrest, abnormal or indeterminate fetal heart rate, and preeclampsia decreased significantly over time (P<.001), whereas malpresentation, multiple gestation, maternal-fetal, macrosomia, and other obstetric and elective/maternal requests did not change (P>.05). Labor arrest was responsible for the largest proportion of the decrease in the primary cesarean delivery rate (44%), followed by abnormal or indeterminate fetal heart rate (23%) and preeclampsia (13%). Primary cesarean births accounted for 74% of the decreasing cesarean delivery rate. Reductions in the diagnosis of labor arrest and abnormal fetal heart rate led to a decreased cesarean delivery rate at a major academic institution. Contemporaneous changes in definitions of labor arrest and approaches to fetal monitoring that were adopted at our institution may have considerable effect on the cesarean delivery rate.

Impact of Cesarean Delivery Rate Calculation Method on Hospital Ranking [6O

INTRODUCTION: How to best quantify a hospital's cesarean delivery (CD) rate remains controversial. We compared hospitals' ranked performance using two common methods of calculating the CD rate. METHODS: We included 64 hospitals in the Blue Cross Blue Shield (BCBS) Michigan Value Collaborative. We calculated the nulliparous, term, singleton, vertex (NTSV) CD rate based on birth certificate data and the low risk CD rate defined by the Society of Maternal Fetal Medicine using BCBS claims data. Hospitals were ranked according to each CD rate, changes in quartile rank were identified, and hospitals that did and did not shift quartile rank were compared. We compared changes in NTSV and SMFM CD rates for each hospital in the five-year period using Generalized Linear Models of their slope. RESULTS: The median NTSV CD rate was 27.9% (range: 17.7% to 39.5%); the median SMFM CD rate was 15.6% % (range: 9.5% to 26.5%). 30 (48%) hospitals shifted quartile rank when using NTSV vs SMFM methodology. Hospitals were more likely to shift quartile rank if their CD rate ranking placed them in a middle quartile or if they had a smaller share of BCBS patients. When comparing the change in hospital specific CD rates over the five year study period, there was concordance between the NTSV and SMFM methodology for only 69.2% (31 hospitals). CONCLUSION: As hospitals' primary CD rate comes under increasing scrutiny, payers, patients and quality improvement efforts should recognize the variability in rank that can be driven by measurement approach.

Self-Reported Opioid Allergy: Obstetrical Outcomes and Postpartum Pain Management [29P

INTRODUCTION: To determine how obstetrical outcomes and inpatient postpartum pain management are affected by self-reported opioid allergy (SROA). METHODS: Retrospective cohort study of singleton deliveries at >=37 weeks of gestation at a tertiary hospital from 2013-2016. Patients were excluded for NSAID allergies, drug abuse history, positive urine toxicology, general anesthesia for delivery, and incomplete records. The primary outcomes evaluated were mode of delivery and medications administered for inpatient postpartum analgesia. RESULTS: A total of 21,225 deliveries were included: 289 with SROA and 20,936 without SROA. In the SROA group, 29 reported reactions suggestive of true allergies (i.e. severe, life-threatening, hypersensitivity reactions). Among this subgroup, 51.7% (n=15) received opioids from the same chemical class (phenanthrenes) as their stated allergy. Women in the SROA group were older and more likely to be white and multiparous. The SROA group had a higher primary cesarean delivery rate (36.0% vs. 21.7%; P<0.0001) and overall cesarean delivery rate (58.1% vs. 35.3%; P<0.0001). Among cesarean deliveries, there was a small reduction in inpatient postpartum opioid analgesia in the SROA group compared to the non-SROA group (73.8% vs. 80.5%, respectively; P<0.04); no difference was noted among vaginal deliveries. Women in the SROA group who received opioids were more likely to receive multiple opioid medications (15.1% vs. 8.2%; P<0.005). CONCLUSION: True opioid allergy is rarely encountered in obstetrics. Women with SROA receive inpatient postpartum opioid analgesia at similar rates to those without SROA. Patients prone to adverse medication effects may be at increased risk for cesarean delivery.

State Based Perinatal Quality Collaborative Pilot-Statewide Reduction of Colorado Primary Cesarean Delivery Rate [04OP

INTRODUCTION: The Colorado Perinatal Care Quality Collaborative performed a pilot quality improvement project to increase adherence to guidelines from the Consensus for the Prevention of the Primary Cesarean Delivery in a statewide cohort of hospitals to safely reduce their nulliparous, term, singleton, vertex (NTSV) cesarean delivery (CD) rate. METHODS: This quality improvement initiative was performed at 6 community hospitals across Colorado. Pre (January 2017 to May 2018) and post intervention (June to Oct 2018) NTSV CD and composite maternal and neonatal morbidity rates were determined for each hospital and the overall cohort using Colorado State Vital Statistics data. Interventions included distributing institution and provider specific NTSV CD rates, education for providers and nurses, implementation of a pre-cesarean labor dystocia checklist, and convening two forums for collaboration between hospitals. NTSV CD and composite maternal and neonatal morbidity rates were compared before and after the interventions for each hospital and the cohort. RESULTS: The 6 participating hospitals perform 19% of live births in Colorado. Pre-intervention hospital NTSV CD rates ranged from 19.3% to 33.8%. The cohort pre-intervention NTSV CD rate was 24.6%, and decreased to 21.9% post-intervention (P=0.04, 95% CI 0.77-0.99). There was no significant increase in composite maternal or neonatal morbidity post-intervention (8.6% vs 7.1% and 7.1% vs 6.8% respectively). CONCLUSION: A quality improvement effort led by a state-based Perinatal Quality Collaborative was effective at safely reducing NTSV CD rates across multiple hospitals. Future efforts will aim at expanding the number of participating hospitals and sustainability.

Quality Improvement Project to Reduce Primary Cesarean Delivery Rates in Low Risk Women [7T

Quality Improvement Project to Reduce Primary Cesarean Delivery Rates in Low Risk Women [7T

Cesarean overuse and the culture of care

ObjectiveTo assess hospital unit culture and clinician attitudes associated with varying rates of primary cesarean delivery.Data Sources/Study SettingIntrapartum nurses, midwives, and physicians recruited from 79 hospitals in California participating in efforts to reduce cesarean overuse.Study DesignLabor unit culture and clinician attitudes measured using a survey were linked to the California Maternal Data Center for birth outcomes and hospital covariates.MethodsAssociation with primary cesarean delivery rates was assessed using multivariate Poisson regression adjusted for hospital covariates.Principal Findings1718 respondents from 70 hospitals responded to the Labor Culture Survey. The “Unit Microculture” subscale was strongly associated with primary cesarean rate; the higher a unit scored on 8‐items describing a culture supportive of vaginal birth (eg, nurses are encouraged to spend time in rooms with patients, and doulas are welcomed), the cesarean rate decreased by 41 percent (95% CI = −47 to −35 percent, P < 0.001). Discordant attitudes between nurses and physicians were associated with increased cesarean rates.ConclusionsHospital unit culture, clinician attitudes, and consistency between professions are strongly associated with primary cesarean rates. Improvement efforts to reduce cesarean overuse must address culture of care as a key part of the change process.

152: Impact of recommended changes in management of prolonged second-stage for prevention of the primary cesarean-delivery

In 2014, the American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal Fetal Medicine (SMFM) published an Obstetric Care Consensus for safe prevention of the primary cesarean delivery (CD). The objective of our study was to assess whether implementation of the new guidelines in our department,regarding second stage of labor, decreased our primary CD rate safely. A historical cohort study of all women, reaching the 2nd stage of labor, at term, in a single university-affiliated medical center (2010-2017). Following the new ACOG and SMFM guidelines, we changed our departmental definition of 2nd stage arrest of labor from 2 and 1 hour in nulliparous or multiparous women respectively, without epidural, to 3 and 2 hours in nulliparous or multiparous women respectively; with the addition of 1 hour to each group when using epidural analgesia. We compared maternal and neonatal outcomes over three year's periods: 1st period – pre-guidelines (2010-2013) vs. 2nd period – post-guidelines (2014-2017). The primary outcome was CD rate at 2nd stage of labor. 5931 women were included in the study. The CD rate of women in the 2nd stage of labor has increased significantly from 4% in the pre-guidelines period to 5.9% in the post-guidelines period (OR 1.48, 95%CI 1.16-1.89). After a sub-analysis of specific subgroups, the CD rate increase was solely observed in nulliparous women with epidural (6.1% vs. 10.2%, P <0.001). However, the CD rate for arrest of 2nd stage of labor was statistically reduced between the two periods (72.9% vs 59.8%, P <0.05). Maternal and neonatal outcomes did not differ between the 2 periods, apart for increased odds for vaginal operative delivery in the post-guidelines period (10.6% vs. 12.3%; P <0.05) (Table 1). After adjusting for confounders, including: age, parity, birthweight, labor induction, and epidural; we have found no association between the implementation of the new guidelines and a change in CD rate performed at the 2nd stage of labor (aOR 1.25, 95%CI 0.97-1.61). (Table 2) The implementation of the new ACOG and SMFM guidelines was not associated with a reduction in the CD rate performed at the 2nd stage of labor, or a difference in maternal or neonatal outcomes. However, it was associated with an increase in CD rate in nulliparous women with an epidural during the second stage.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Impact of Recommended Changes in Labor Management for Prevention of the Primary Cesarean Delivery

(Am J Obstet Gynecol. 2018;218(3):341.e1–341.e9) The significant increase in cesarean delivery (CD) rates is a cause of concern due to the potential negative consequences for maternal and infant health. Indications for CD are often overused and the CD rates vary among institutions, according to the population, management, and local practices. Therefore, in 2014, the American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine (SMFM) jointly published an Obstetric Care Consensus for safe prevention of the primary CD. This consensus established new guidelines for management and definitions for arrest of labor (AoL) and failed induction. The objective of this study was to assess whether adoption of the new consensus recommendations contributed to a safe decrease in the primary CD rate.

Adherence to Consensus Guidelines for the Management of Labor Arrest Disorders in a Single Academic Tertiary Care Medical Center.

To evaluate the degree of adherence to the new the American College of Obstetricians and Gynecologists/Society for Maternal-Fetal Medicine guidelines in labor arrest management. A retrospective study of term, live, singleton deliveries with intrapartum primary cesarean delivery solely for failed induction of labor or labor arrest. Adherence was defined according to the Safe Prevention of the Primary Cesarean Delivery 2014 criteria. We evaluated adherence and compared maternal and perinatal outcomes, delivery time frame, and billing provider. Multivariable Poisson regression models with robust error variance were used to calculate adjusted relative risk (aRR) and 95% confidence interval (CI). Two-hundred six deliveries met the inclusion criteria; 73% were deemed not adherent to the guidelines. The majority of cases were under the care of nonacademic private practice OB/GYN physicians. The adherence rate was higher in the active phase of labor (45%) than in second stage (17%) and latent phase (14%). There were no differences in perinatal outcomes between the two groups. The adherence to guidelines was higher among academic OB/GYN physicians (aRR, 2.24, 95% CI, 1.49-3.36) and during the weekday-night shift (aRR, 1.81, 95% CI, 1.10-2.98). Despite recent guidelines aimed to reduce the primary cesarean delivery rate, most cesarean deliveries performed for labor arrest disorders were not adherent to the guidelines.

The impact of extending the second stage of labor to prevent primary cesarean delivery on maternal and neonatal outcomes

A low rate of primary cesarean delivery is expected to reduce some of the major complications that are associated with a repeat cesarean delivery, such as uterine rupture, adhesive placental disorders, hysterectomy, and even maternal death. Since 2014, and in alignment with the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine, we changed our approach to labor dystocia, defined as abnormal progression of labor, by allowing a longer duration of the second stage of labor. To examine the effect of prolonging the second stage of labor on the rate of cesarean delivery, and maternal and neonatal outcomes. In a historical control group, we compared maternal and neonatal outcomes over 2 periods. Period I (9300 patients): from May 2011 until April 2014, when a prolonged second stage in nulliparous women was considered after 3 hours with regional anesthesia or 2 hours if no such anesthesia was provided. Second-stage arrest was defined in multiparous women after 2 hours with regional anesthesia or 1 hour without it. Period II (10,531 patients): from May 2014 until April 2017, allowed nulliparous and multiparous women continuing the second stage of labor an additional 1 hour before diagnosing second-stage arrest. Singleton deliveries at or beyond 37 weeks' gestation were initially considered for eligibility. We excluded women with high-risk pregnancies and known fetal anomalies. For comparing means, we used the t test. If variables were not normally distributed, we used the Mann-Whitney test instead. For comparing proportions, we used the χ2 test with continuity correction. The primary cesarean delivery was decreased in nulliparous women from 23.3% (819 of 3515) in period I to 15.7% (596 of 3796) in period II (relative risk [RR], 0.67; 95% CI, 0.61-0.74), a trend that was also significant in multiparous women (10.9%, 623 of 5785, in period I vs 8.1%, 544 of 6735, in period II; RR, 0.75; 95% CI, 0.67-0.84). The rate of operative vaginal deliveries in nulliparous women was higher in period II than in period I (19.2%, 732 of 3515, vs 17.7%, 622 of 3796, P < .0001). Rates of third- and fourth-degree laceration and of shoulder dystocia were also higher in period II. The rate of arterial cord pH < 7.0 and the rate of admission to the neonatal intensive care unit were higher in period II, but the early neurological outcome was not different when comparing the 2 periods. The new policy of labor management successfully decreased primary cesarean deliveries, with a small rise in instrumental deliveries. However, it also increased the other immediate maternal and neonatal complications. A higher rate of lower umbilical artery cord pH was the most significant finding; however, the early neurological outcome did not change. It is possible that the ongoing adjustment to the new labor protocol will avoid, in the future, maternal and neonatal complications. The long-term maternal and neonatal consequences of our new approach will be evaluated in future studies.

Clinical Impact of a Restrictive Labor Induction Approval Process

Background/Aims: The aim of this study was to evaluate the impact of a restrictive labor induction approval process on induction and primary cesarean delivery rates. Methods: A retrospective cohort study was conducted at a tertiary care academic center from 2006 through 2012. The cohort of deliveries before (pre-intervention) and after (post-intervention) the process included term, singleton pregnancies with no contraindication to vaginal delivery. The primary outcome was induction of labor rates, subgrouped on the basis of whether it was medically or nonmedically indicated. Secondary outcomes included the primary cesarean rate and other maternal and neonatal outcomes. Results: Of 13,753 deliveries, 6,746 met study inclusion criteria. There was a significant decrease in induction rates comparing the pre- and post-intervention periods (21.0 vs. 18.5%, p = 0.01). Nonmedically indicated induction rates also decreased significantly (2.9 vs. 0.6%, p < 0.001). No difference was observed in medically indicated induction (18.1 vs. 17.9%, p = 0.84), the primary cesarean rate (14.4 vs. 15.8%, p = 0.12), or any of the measured neonatal outcomes (p > 0.05). Conclusions: Implementation of a labor induction approval process was associated with a significant reduction in overall and non-indicated induction rates but did not affect the primary cesarean rate or neonatal outcomes.

Assessing the Feasibility of Measuring Variation in Facility Design Among American Childbirth Facilities.

To assess the feasibility of quantifying variation in childbirth facility design and explore the implications for childbirth service delivery across the United States. Design has been shown to impact quality of care in childbirth. However, most prior studies use qualitative data to examine associations between the design of patient rooms and patient experience. There has been limited exploration of measures of unit design and its impact on care provision. We recruited 12 childbirth facilities that were diverse with regard to facility type, location, delivery volume, cesarean delivery rate, and practice model. Each facility provided annotated floor plans and participated in a site visit or telephone interview to provide information on their design and clinical practices. These data were analyzed with self-reported primary cesarean delivery rates to assess associations between design and care delivery. We observed wide variation in childbirth unit design. Deliveries per labor room per year ranged from 75 to 479. The ratio of operating rooms to labor rooms ranged from 1:1 to 1:9. The average distance between labor rooms and workstations ranged from 23 to 114 ft, and the maximum distance between labor rooms ranged from 9 to 242 ft. More deliveries per room, fewer labor rooms per operating room, and longer distances between spaces were all associated with higher primary cesarean delivery rates. Clinically relevant differences in design can be feasibly measured across diverse childbirth facilities. The design of these facilities may not be optimally matched to service delivery needs.