David C. Lagrew

Decreasing the cesarean section rate in a private hospital: Success without mandated clinical changes

OBJECTIVE We analyzed the delivery statistics from our institution to describe a successful program of cesarean section delivery reduction and to help us understand what factors explained the reduction. STUDY DESIGN A retrospective analysis of various cesarean section rates and risk factors from a prospectively collected delivery database of all patients delivered between May 15, 1988, and June 30, 1994. During the study period we instituted a program of increasing awareness, confidential provider feedback, more aggressive laboring techniques, and other clinical guidelines. The delivery data were divided into 6-month intervals and analyzed by chi 2 tables. RESULTS The overall cesarean section rate fell from 31.1% to 15.4%. Similar reductions were noted in the primary (17.9% to 9.8%) and repeat cesarean section rates (13.2% to 5.7%). The primary cesarean section rate fall was accompanied by a drop in abdominal delivery for cephalopelvic disproportion and fetal distress. The repeat cesarean section rate is explained by a significant increase in trial and successful vaginal birth after cesarean delivery. No increase in maternal, fetal, or neonatal morbidity or mortality was observed. CONCLUSIONS We have demonstrated that the cesarean delivery rate can be safely lowered in a private hospital without mandated clinical changes. Our data suggest that careful and detailed feedback can lead to improved clinical practice.

National Partnership for Maternal Safety: Consensus Bundle on Obstetric Hemorrhage.

Hemorrhage is the most frequent cause of severe maternal morbidity and preventable maternal mortality and therefore is an ideal topic for the initial national maternity patient safety bundle. These safety bundles outline critical clinical practices that should be implemented in every maternity unit. They are developed by multidisciplinary work groups of the National Partnership for Maternal Safety under the guidance of the Council on Patient Safety in Womens Health Care. The safety bundle is organized into four domains: Readiness, Recognition and Prevention, Response, and Reporting and System Learning. Although the bundle components may be adapted to meet the resources available in individual facilities, standardization within an institution is strongly encouraged. References contain sample resources and “Potential Best Practices” to assist with implementation.

Ethnic differences in birth weight by gestational age: at least a partial explanation for the Hispanic epidemiologic paradox?

OBJECTIVE The purpose of this study was to evaluate ethnic differences in low birth weight and gestational age-dependent birth weight. STUDY DESIGN A retrospective cohort study of 47,669 newborn infants was conducted with the use of the perinatal database of the Memorial Health Care System. Logistic regression was used to estimate the odds ratio for low birth weight by ethnic group, which took into account gestational age at delivery. Multiple linear regression models were then developed to predict ethnic differences in birth weight by gestational age. RESULTS When compared with white women, the adjusted odds ratio for low birth weight in of Mexican origin women (1.16; 95% CI, 1.02-1.32) was substantially lower than that of African American women (2.21; 95% CI, 1.87-2.60). An analysis of birth weight by gestational age suggested that African American neonates were intrinsically smaller than Hispanic neonates (difference, 4.22%). CONCLUSION At least some of the differences in low birth weight that are noted among ethnic minorities may be attributable to ethnic differences in birth weight by gestational age.

Management of postdate pregnancy

Abstract Management of the problems associated with pregnancies that extend beyond 294 days of amenorrhea has become increasingly important in obstetrics. This article outlines some of the methods that minimize the risks to the mother, fetus, and neonate in postdate pregnancy. A brief description of the definitions, incidence, and impact of postdate pregnancy is given for a baseline on which to base management decisions. The current management techniques are then given for the following aspects: (1) diagnosis, (2) antepartum surveillance, (3) timing of delivery, and (4) intrapartum management. Finally a synopsis of research areas that may change management is given.

A State-wide Obstetric Hemorrhage Quality Improvement Initiative

PurposeThe mission of the California Maternal Quality Care Collaborative is to eliminate preventable maternal death and injury and to promote equitable maternity care in California. This article describes California Maternal Quality Care Collaboratives (CMQCCs) statewide multistakeholder quality improvement initiative to improve readiness, recognition, response, and reporting of maternal hemorrhage at birth and details the essential role of nurses in its success. Project Design and ApproachIn partnership with the State Department of Maternal, Child, and Adolescent Health, CMQCC identified maternal hemorrhage as a significant quality improvement opportunity. CMQCC organized a multidisciplinary, multistakeholder task force to develop a strategy for addressing obstetric (OB) hemorrhage. Project DescriptionThe OB Hemorrhage Task Force, co-chaired by nurse and physician team leaders, identified four priorities for action and developed a comprehensive hemorrhage guideline. CMQCC is using a multilevel strategy to disseminate the guideline, including an open access toolkit, a minimal support-mentoring model, a county partnership model, and a 30-hospital learning collaborative. Clinical ImplicationsIn participating hospitals, nurses have been the primary drivers in developing both general and massive hemorrhage policies and procedures, ensuring the availability of critical supplies, organizing team debriefing after a stage 2 (or greater) hemorrhage, hosting skills stations for measuring blood loss, and running obstetric (OB) hemorrhage drills. Each of these activities requires effort and leadership skill, even in hospitals where clinicians are convinced that these changes are needed. In some hospitals, the burden to convince physicians of the value of these new practices has rested primarily upon nurses. Thus, the statewide initiative in which nurse and physician leaders work together models the value of teamwork and provides a real-time demonstration of the potential for effective interdisciplinary collaboration to make a difference in the quality of care that can be achieved. Nurses provide significant leadership in multidisciplinary, multistakeholder quality projects in California. Ensuring that nurses have the opportunity to participate in formal leadership of these teams and are represented at all workgroup levels is critical to the overall initiative. Nurses brought key understanding of operational issues within and across departments, mobilized engagement across the state through the regional perinatal programs, and developed innovative approaches to solving clinical problems during implementation. Nursing leadership and integrated participation was especially critical in considering the needs of lower-resource settings, and was essential to the toolkits enthusiastic adoption at the unit/service level in facilities across the state.

Lowering the cesarean section rate in a private hospital: Comparison of individual physicians' rates, risk factors, and outcomes

OBJECTIVE Our purpose was to compare the practice patterns and outcomes of physicians delivering in our institution to identify risk factors and management techniques that could explain the differences in individual cesarean section rates. STUDY DESIGN We retrospectively reviewed detailed computerized delivery records (n = 16,230) collected from May 16, 1988, to July 30, 1995. We excluded physicians who had <100 deliveries at our institution during the study period. The physicians were divided into two groups depending on whether their individual cesarean section rates were greater than (control group) or less than 15% (target group). Various cesarean section rates, risk factors for abdominal delivery, labor management techniques, and neonatal outcome parameters were calculated for each group. The cesarean section rates of the two groups were analyzed by year to assess changes. RESULTS As expected by study design, the overall cesarean section rate was markedly different between the two groups (13.8% vs 23.8%). In addition, the primary, repeat, primigravid, and multiparous cesarean section rates were all lower for the target group. The rates of cesarean section for fetal distress (1.5% vs 3.3%) and cephalopelvic disproportion (5.3% vs 8.5%) were also significantly less in the target group. The rates of breech presentation, third-trimester bleeding, and active herpes cesarean sections were not lower. The control group had more postterm (8.6% vs 14.7%) and >4000 gm infants (12.0% vs 13.7%) but similar numbers of low birth weight, multiple gestation, and preterm infants. The target group used more epidural anesthesia, oxytocin induction, and trial vaginal births after cesarean delivery and more successful trial vaginal births after cesarean sections. Over the study period the cesarean section rate in the target group remained unchanged, whereas it steadily declined in the control group. CONCLUSIONS Individual physicians lower cesarean sections are primarily obtained by labor management and attempting vaginal birth after cesarean delivery. These practice patterns did not appear to lead to any increase in perinatal morbidity or mortality. Efforts to lower cesarean section rates of individual practitioners should focus on the areas of fetal distress, cephalopelvic disproportion, and repeat cesarean section.

Ethnic disparity in the success of vaginal birth after cesarean delivery

Objective. To estimate whether maternal race/ethnicity is independently associated with successful vaginal birth after cesarean delivery (VBAC). Study design. A retrospective cohort study from January 1, 1997 to July 30, 2002 of women with singleton pregnancies and a previous cesarean delivery. The odds ratio (OR) for successful VBAC as a function of ethnicity was corrected for age >35 years, parity, weight gain, diabetes mellitus, hospital site, prenatal care provider, gestational age, induction, labor augmentation, epidural analgesia, and birth weight >4000 g. Results. Among 54 146 births, 8030 (14.8%) occurred in women with previous cesarean deliveries. The trials of labor rates were similar among Caucasian (46.6%), Hispanic (45.4%), and African American (46.0%) women. However, there was a significant difference among ethnic groups for VBAC success rates (79.3% vs. 79.3% vs. 70.0%, respectively). When compared to Caucasian women, the adjusted OR for VBAC success was 0.37 (95% confidence interval (CI) 0.27–0.50) for African American women and 0.63 (95% CI 0.51–0.79) for Hispanic women. Conclusion. African American and Hispanic women are significantly less likely than Caucasian women to achieve successful VBAC.

Gestational age at cervical length measurement and preterm birth in twins

To estimate the risk of preterm delivery of twin pregnancies based upon sonographic cervical length measurement and gestational age at measurement.

Twin versus singleton pregnancies complicated by preterm premature rupture of membranes

Objective: To compare latency period, infectious morbidity, neonatal morbidity and neonatal mortality in twin versus singleton pregnancies complicated by preterm premature rupture of membranes (PPROM) remote from term. Methods: A retrospective, matched cohort study comparing 41 twin and 82 singleton pregnancies complicated by PPROM between 24-0/7 and 31-6/7 weeks’ gestation. The data were obtained by reviewing maternal and neonatal charts. Results: The median latency periods were 3.6 days (interquartile range 1.5–13.9 days) for twins and 6.2 days (interquartile range 2.9–11.8 days) for singletons (p = 0.86). Twins were less likely to be complicated by clinical chorioamnionitis when compared with singletons (4/41 [9.8%] vs. 19/82 [23.2%], relative risk [RR] 0.42, 95% confidence interval [CI] 0.18–0.96). Histological evidence of chorioamnionitis was also lower in twins compared with singletons (14/39 [35.9%] vs. 46/68 [67.7%], RR 0.56, 95% CI, 0.34–0.92). These differences persisted after adjusting for race, insurance status, latency period and route of delivery. Neonatal morbidity and mortality rates were similar between the two groups. Conclusions: There was not a statistically significant difference in the latency periods for twin and singleton pregnancies complicated by PPROM. Clinical chorioamnionitis and histological evidence of infection were significantly less common in twins compared with singletons.

The future of obstetrics/gynecology in 2020: a clearer vision. Why is change needed?

External and internal pressures are causing rapid changes to the delivery of health care that markedly will influence the practice of obstetrics and gynecology. These changes can be divided into broad categories: (1) Burden of the high cost of current health care on society; (2) demographic changes in women that include aging, obesity, diversity, and chronic medical conditions; and (3) workforce changes that include growing provider shortages, inexperience, and desires for improved lifestyles. The combination of these factors has brought health care to a strategic inflection point where current practice methods will lead to an inability to meet the demand for health care because of increasing volume while simultaneously controlling costs and improving quality. This necessitates providing womens health care in a redesigned fashion for it to flourish in the new world of medicine.