Lisa C. Kellar

The association between increased use of labor induction and reduced rate of cesarean delivery.

AIM An association was recently reported between a low cesarean section delivery rate and a method of obstetrical care that involved the frequent use of risk-guided prostaglandin-assisted preventive labor induction. We sought to confirm this finding in a subsequent group of pregnant women. METHODS A retrospective cohort study design was used to compare the outcomes of 100 consecutively delivered women, who were exposed to the alternative method of care, with the outcomes of 300 randomly chosen women who received standard management. The primary outcome was group cesarean delivery rate. Secondary outcomes were rates of neonatal intensive care unit admission, low 1-minute Apgar score, low 5-minute Apgar score, and major perineal trauma. RESULTS Women exposed to the alternative method of obstetrical care had a higher induction rate (59% vs. 16.3%, p < 0.001), a more frequent use of prostaglandins for cervical ripening (32% vs. 13%, p < 0.001), and a lower cesarean delivery rate (7% vs. 20.3%, p = 0.002). Exposed women did not experience higher rates of other adverse birth outcomes. CONCLUSIONS Exposure to an alternative method of obstetrical care that used high levels of risk-driven prostaglandin-assisted labor was again associated with two findings: a lower group cesarean delivery rate and no increases in levels of other adverse birth outcomes. An adequately powered randomized controlled trial is needed to further explore this alternative method of care.

The association between the regular use of preventive labour induction and improved term birth outcomes: findings of a systematic review and meta‐analysis

Despite a lack of high‐quality evidence, the use of ‘non‐indicated’ term labour induction is increasingly restricted throughout the world.

New Definition of Term Pregnancy

In Reply Dr Young points out that we did not examine endof-life care and suggests that we may have underestimated preventable spending. We agree that high-quality hospice or palliative care may reduce admissions at the end of life, including for conditions that are considered nonpreventable. The frequency with which these costly inpatient services, such as hip replacement or major cardiac surgery, are occurring in people with advanced terminal illness is unknown. On the other hand, patients at the end of life may be sufficiently sick that their ED admission for typically preventable conditions, such as urinary tract infections, may actually be more difficult to avoid. Because of the difficulty in assessing these complex issues in administrative data, we chose instead to exclude these patients from this study but agree with Young that better understanding of the preventability of spending at the end of life is important. Drs Weiner and Smulowitz express concerns that the algorithm created by Billings et al may overstate the preventability of ED visits. The difficulty with this algorithm is primarily that visits deemed preventable based on the final diagnosis (eg, costochondritis) might not be preventable based on the presenting complaint (eg, chest pain).1 We attempted to account for this by conducting sensitivity analyses in which preventability was assessed based on the diagnosis code for each service (eg, if a stress test was ordered with chest pain as a diagnosis), but agree that this is likely an incomplete fix. On the other hand, both Weiner and Smulowitz and Young suggest that the potential savings from preventable ED visits may have been larger if we had included the downstream effect on hospitalizations. The costs of any ED visit leading to a hospitalization are rolled into the inpatient costs for that hospitalization with Medicare; thus, these downstream costs were largely captured by our analysis of preventable inpatient care. Furthermore, as Smulowitz et al2 pointed out, even if we prevent 10% to 25% of hospitalizations that come from “intermediate/complex” ED visits, those savings will account for a small proportion of total health care spending. Young also points out that there are differences among primary care physicians in terms of costs and quality. Although a more detailed breakdown of costs for patients of family practitioners vs internists was not available for this analysis, we concur that this may be an important area of study in the future. In addition, we agree that, even though we found that only 10% of spending was preventable using existing algorithms, investing in outpatient care is still an extremely important strategy for reducing health care costs, especially over the longer run. Furthermore, our findings suggest that for the other 90% of spending, achieving cost savings safely would likely require new strategies, including care redesign. Improving care for high-cost patients represents an important opportunity to reduce waste in the US health care system. Given the complexity of the task, our data suggest that we need a multifaceted approach.

A Multi-State Analysis of Early-Term Delivery Trends and the Association With Term Stillbirth Trends in Stillbirth by Gestational Age in the United States, 2006-2012 Stillbirth and the 39-Week Rule: Can We Be Reassured?

2015. That this is seen across populations and decades demonstrates this risk of stillbirth as the inherent biology of pregnancy and independent of arbitrary definitions of “term” or of some point in gestational age, whether 39 weeks or 38 or 40 weeks. This continued failure to recognize that, at term, remaining undelivered results in an ever-increasing risk of stillbirth does not serve our patients well. Biology rarely pays much heed to arbitrary rules and definitions, as this latest report documents. The challenge we face becomes not only to understand and recognize the underlying phenomena of term stillbirth, but to develop a reasonable and coherent approach to patient management as it relates to gestational age, incorporating the known data of fetal, maternal, and neonatal outcomes. It is unlikely any one-sizefits-all recommendation regarding management at term will be best. Individualized determinations based on patientspecific factors likely will be the preferred approach. It is essential that this discussion takes place.

The Active Management of Impending Cephalopelvic Disproportion in Nulliparous Women at Term: A Case Series

Background. The Active Management of Risk in Pregnancy at Term (AMOR-IPAT) protocol has been associated in several studies with significant reductions of group cesarean delivery rate. Present within each of these studies were nulliparous women with risk factors for cephalopelvic disproportion. Risk factors for cephalopelvic disproportion in nulliparous women are especially important because they represent the precursors for the most common indication for primary cesarean delivery. Cases. Three examples of exposure of urban nulliparous women to the AMOR-IPAT protocol are presented. Each womans risk factor profile for Cephalopelvic Disproportion (CPD) was used to estimate her Upper Limit of Optimal Time of Vaginal Delivery for CPD (UL-OTDcpd). Labor management and clinical outcomes for each case are presented. A simple table summarizing induction rates and birth outcome rates of exposed versus nonexposed nulliparous women is also presented. Conclusion. Because the mode of delivery of the first birth substantially impacts birth options in later pregnancies, the impact of AMOR-IPAT on nulliparous patients is particularly important. Determining the UL-OTDcpd in nulliparous patients, and carefully inducing each patient who has not entered labor by her UL-OTDcpd, may be an effective way of lowering rates of cesarean delivery in nulliparous women.