Lauren A. Miller

An Analysis of Operative Delivery Practices Over 30 Years [11D]

INTRODUCTION: The aim of this study was to determine delivery practice changes over the past 30 years for singleton pregnancies as a means to elucidate the underlying causes of the rising cesarean section (c/s) rate over the last several decades. METHODS: Delivery data was collected at a medium-sized teaching hospital in Colorado, averaging 4,690 singleton births/year, over 34 years. The numbers of forceps, vacuums, breeches and c/s were recorded for 79,723 singleton deliveries, from alternating years between 1978 and 2012 with complete records available. RESULTS: C/s done for breech presentation remained largely stable, averaging 3% of all deliveries (range 2.09–3.9%). The rate of operative vaginal delivery significantly decreased from a high of 14.7% in 1978 to 2% in 2010. Pooling the number of all operative deliveries (cesarean and forceps/vacuums combined) for non-breech presentation, the overall rate of deliveries requiring an operative approach remained stable at 27.7% in 1978 and 28% in 2012, (average 25.8%). CONCLUSION: Our data suggests that an even trade-off between operative vaginal deliveries and laboring c/s has occurred during the 2nd stage of labor over the past 30 years. The decrease in operative deliveries and not the decrease in breech vaginal deliveries, accounts for the increase in c/s rates. This decrease in operative deliveries is not surprising and has been demonstrated in other studies. This is presumably due to lack of training and comfort using operative vaginal techniques, as well as concerns for morbidity to both the newborn and the mother.

Connect the Dots - November 2016

According to the Centers for Disease Control and Prevention (CDC), in the single year from 2013 to 2014, there was a 9% increase in overdose deaths from natural and semisynthetic opioids such as oxycodone and hydrocodone.1 As surgeons we have a major responsibility to control our patients’ acute postoperative pain, prevent complications from pain medication, and prevent them from developing drug dependence. This fine balance requires a planned, multidisciplinary approach to the perioperative patient. The gynecologic oncology group at the Mayo Clinic reports the latest refinement to their enhanced recovery program in this issue (see page 1009), building on their prior work.2 In this quality improvement project, the team added injection of liposomal bupivacaine in the incision to their enhanced recovery program for gynecologic oncology patients and compared overall opioid use postoperatively with historic controls, showing that the total dose of opioid use was less and ileus was less frequent. Pain scores did not change, and overall pharmacy charges were no different. Rescue doses of pain medications were fewer in the liposomal bupivacaine group. When clinical quality research is developed and analyzed in a rigorous fashion, it provides others the opportunity to rapidly adopt, and adapt, successful programs to their own institutions. Kalogera et al’s team has demonstrated the classic plan–do–study–act paradigm in quality. By studying and reporting the outcomes of their enhanced recovery program previously2 and then making a defined incremental change to address the specific issue of postoperative opioid use, they have completed the next step. The program they have developed has shown a significant decline in surgical site infections and now shows a significant improvement in postoperative pain management through a reduction in opioid use and rescue dose need and fewer complications. Would this program work at your own institution?