Martina Murphy

Comparative analysis of international cesarean delivery rates using 10-group classification identifies significant variation in spontaneous labor.

OBJECTIVE Cesarean section (CS) rates continue to rise throughout the developed world. The aim of this study was to highlight variations in obstetric populations and practices and to identify variations in CS rates in different institutions. STUDY DESIGN Data from 9 institutional cohorts (total, 47,402; range, 1962-7985) from 9 different countries were examined using a 10-group classification system based on 4 characteristics of every pregnancy, namely single/multiple, nulliparity/multiparity, multiparity with CS scar, spontaneous/induced labor onset and term (>or=37 weeks) gestation. RESULTS Overall CS rates correlated with CS rates in singleton cephalic nullipara (r = 0.992; P < .001). Whereas CS rates in induced labor were similar, greatest institutional variation were seen in spontaneously laboring multiparas (6.7-fold difference) and nulliparas (3.7-fold difference). CONCLUSION Ten-group analysis of international obstetric cesarean practice identifies wide variations in women in spontaneous cephalic term labor, a low-risk cohort amenable to effective intrapartum corrective intervention.

Methods of achieving and maintaining an appropriate caesarean section rate

Caesarean section rates continue to increase worldwide. The appropriate caesarean section rate remains a topic of debate among women and professionals. Evidence-based medicine has not provided an answer and depends on interpretation of the literature. Overall caesarean section rates are unhelpful, and caesarean section rates should not be judged in isolation from other outcomes and epidemiological characteristics. Better understanding of caesarean section rates, their consequences and their benefits will improve care, and enable learning between delivery units nationally and internationally. To achieve and maintain an appropriate caesarean section rate requires a Multidisciplinary Quality Assurance Programme in each delivery unit, recognising caesarean section rates as one of many factors that determine quality. Women will always choose the type of delivery that seems safest to them and their babies. Professionals need to monitor the quality of their practice continuously in a standardised way to ensure that women can make the right choice.

The Singleton, Cephalic, Nulliparous Woman After 36 Weeks of Gestation: Contribution to Overall Cesarean Delivery Rates

OBJECTIVE: To examine the contribution of singleton, cephalic, term (37 weeks or later) nulliparous cesarean rates to overall cesarean incidence in a single institution during a 35-year period. METHODS: Cesarean rates were examined for 1974, 1984, 1994, 1999, 2005, and 2008, applying a 10-group classification system. Groups 1 (spontaneously laboring, term nulliparous women) and 2 (prelabor cesarean and induced term nulliparous women) were combined as a composite variable—the term, singleton, cephalic nulliparous woman. RESULTS: Overall and term, singleton, cephalic nulliparous cesarean rates correlated throughout the 35-year period (r=0.93, P<.001). Between 1974 and 2008, overall cesarean rates increased from 5% to 19.1% and from 4.4% to 15.8% among term, singleton, cephalic nulliparous women. Term, singleton, cephalic nulliparous inductions increased from 19.7% to 32.7% (P<.001) and the intrapartum cesarean rate in term, singleton, cephalic nulliparous inductions rose from 4.1% to 27.3%. The cesarean rate in group 1 increased from 2.3% to 7.2%. CONCLUSION: The increase in term, singleton, cephalic nulliparous cesarean rates correlated with the increase in overall cesarean rates throughout 35 years in an institution with standard management of labor. This relationship was due to an increase in both the incidence and rate of cesarean delivery within term, singleton, cephalic nulliparous inductions. Examination of the different term, singleton, cephalic nullipara components (spontaneous labor, induction, or prelabor cesarean) can help to identify major variations in practice between institutions. LEVEL OF EVIDENCE: III

Quality assurance: The 10-Group Classification System (Robson classification), induction of labor, and cesarean delivery.

Quality assurance in labor and delivery is needed. The method must be simple and consistent, and be of universal value. It needs to be clinically relevant, robust, and prospective, and must incorporate epidemiological variables. The 10‐Group Classification System (TGCS) is a simple method providing a common starting point for further detailed analysis within which all perinatal events and outcomes can be measured and compared. The system is demonstrated in the present paper using data for 2013 from the National Maternity Hospital in Dublin, Ireland. Interpretation of the classification can be easily taught. The standard table can provide much insight into the philosophy of care in the population of women studied and also provide information on data quality. With standardization of audit of events and outcomes, any differences in either sizes of groups, events or outcomes can be explained only by poor data collection, significant epidemiological variables, or differences in practice. In April 2015, WHO proposed that the TGCS (also known as the Robson classification) is used as a global standard for assessing, monitoring, and comparing cesarean delivery rates within and between healthcare facilities.

Evaluating midwife-led antenatal care: choice, experience, effectiveness, and preparation for pregnancy.

OBJECTIVE to evaluate midwife-led care (MLC) antenatal care compared with antenatal care provided in traditional obstetric-led hospital antenatal clinics (usual care). DESIGN a mixed methods approach involving a chart audit, postal survey, focus group and in-depth interviews. SETTING data were collected at a large maternity hospital and satellite clinics in Dublin from women attending for antenatal care between June 2011 and May 2012. PARTICIPANTS 300 women with low-risk pregnancy who attended midwife-led antenatal care or usual clinics during the study period were randomly selected to participate. MEASUREMENTS data were collected from 292 women׳s charts and from 186 survey participants (63% response rate). Nine women participated in in-depth interviews and a focus group. FINDINGS MLC was as effective as usual care in relation to number of antenatal visits and ultrasound scans, referral to other clinicians, women׳s health in pregnancy, gestation at childbirth, and birth weight. Women attending MLC booked significantly earlier, fewer women attending MLC were admitted to hospital antenatally and more women breast fed their infant. Women attending MLC reported better choice and that shorter waiting times and having more time for discussion were important reasons for choosing MLC. Women attending MLC reported a better experience overall, and recorded better outcomes in relation to how they were treated, along with easier access to antenatal care and shorter waiting times to see a midwife. Although women attending MLC clinics reported higher satisfaction with the information that they received, they also identified that antenatal education could be improved in relation to labour, breast-feeding, depression and emotional well-being, and caring for the infant. KEY CONCLUSIONS midwife-led antenatal care was as effective as usual care for women with low-risk pregnancy and better in relation to choice, breast feeding and women׳s experience of care.

Elevated amniotic fluid lactate predicts labor disorders and cesarean delivery in nulliparous women at term

OBJECTIVE We sought to assess amniotic fluid lactate (AFL) at diagnosis of spontaneous labor at term (≥37 weeks) as a predictor of labor disorders (dystocia) and cesarean delivery (CD). STUDY DESIGN This was a single-institution, prospective cohort study of 905 singleton, cephalic, term (≥37 weeks) nulliparous women in spontaneous labor. A standard management of labor (active management of labor) including a standard oxytocin regimen up to a maximum dose of 30 mU/min was applied. AFL was measured using a point-of-care device (LMU061; ObsteCare, Stockholm, Sweden). Labor arrest in the first stage of labor was defined as the need for oxytocin when cervical dilatation was <1 cm/h over 2 hours and in the second stage of labor by poor descent and rotation over 1 hour. Standard statistical analysis included analysis of variance, Pearson correlations, and binary logistic regression. Unsupervised decision tree analysis with 10-fold cross-validation was used to identify AFL thresholds. RESULTS AFL was normally distributed and did not correlate with age, body mass index, or gestation. Unsupervised decision tree analysis demonstrated that AFL could be divided into 3 groups: 0-4.9 mmol/L (n = 118), 5.0-9.9 mmol/L (n = 707), and ≥10.0 mmol/L (n = 80). Increasing AFL was associated with higher total oxytocin dose (P = .001), labor disorders (P = .005), and CD (P ≤ .001). Multivariable regression analysis demonstrated that women with AFL ≥5.0-9.9 mmol/L (odds ratio [OR], 1.6; 95% confidence interval [CI], 1.06-2.39) and AFL ≥10.0 mmol/L (OR, 1.72; 95% CI, 1.01-2.93) were independent predictors of a labor disorder. AFL ≥5.0-9.9 mmol/L did not predict CD but multivariable analysis confirmed that AFL ≥10.0 mmol/L was an independent predictor of CD (OR, 3.35; 95% CI, 1.73-6.46). AFL ≥5.0-9.9 mmol/L had a sensitivity of 89% in predicting a labor disorder and a sensitivity of 93% in predicting CD with a 97% negative predictive value. AFL ≥10.0 mmol/L was highly specific but lacked sensitivity for CD. There was no difference in birthweight of infants according to labor disorder and delivery method. CONCLUSION AFL at diagnosis of labor in spontaneously laboring single cephalic nulliparous term women is an independent predictor of a labor disorder and CD. These data suggest that women with AFL between 5.0-9.9 mmol/L with a labor disorder may be amenable to correction using the active management of labor protocol.

A method to assess obstetric outcomes using the 10-Group Classification System: A quantitative descriptive study

Objectives Internationally, the 10-Group Classification System (TGCS) has been used to report caesarean section rates, but analysis of other outcomes is also recommended. We now aim to present the TGCS as a method to assess outcomes of labour and delivery using routine collection of perinatal information. Design This research is a methodological study to describe the use of the TGCS. Setting Stavanger University Hospital (SUH), Norway, National Maternity Hospital Dublin, Ireland and Slovenian National Perinatal Database (SLO), Slovenia. Participants 9848 women from SUH, Norway, 9250 women from National Maternity Hospital Dublin, Ireland and 106 167 women, from SLO, Slovenia. Main outcome measures All women were classified according to the TGCS within which caesarean section, oxytocin augmentation, epidural analgesia, operative vaginal deliveries, episiotomy, sphincter rupture, postpartum haemorrhage, blood transfusion, maternal age >35 years, body mass index >30, Apgar score, umbilical cord pH, hypoxic–ischaemic encephalopathy, antepartum and perinatal deaths were incorporated. Results There were significant differences in the sizes of the groups of women and the incidences of events and outcomes within the TGCS between the three perinatal databases. Conclusions The TGCS is a standardised objective classification system where events and outcomes of labour and delivery can be incorporated. Obstetric core events and outcomes should be agreed and defined to set standards of care. This method provides continuous and available observations from delivery wards, possibly used for further interpretation, questions and international comparisons. The definition of quality may vary in different units and can only be ascertained when all the necessary information is available and considered together.