"Doing something" about the cesarean delivery rate

A Prospective Longitudinal Quality Initiative toward Improved Enhanced Recovery after Cesarean Pathways

OBJECTIVE

This study aimed to evaluate whether enhanced recovery after cesarean (ERAC) pathways reduces inpatient and outpatient opioid use, pain scores and improves the indicators of postoperative recovery.

STUDY DESIGN

This is a prospective, longitudinal, quality improvement study of all patients older than 18 undergoing an uncomplicated cesarean delivery (CD) at an academic medical center. We excluded complicated CD, patients with chronic pain disorders, chronic opioid use, acute postpartum depression, or mothers whose neonate demised before their discharge. Lastly, we excluded non-English- and non-Spanish-speaking patients. Our study compared patient outcomes before (pre-ERAC) and after (post-ERAC) implementation of ERAC pathways. Primary outcomes were inpatient morphine milligram equivalent (MME) use and the patient's delta pain scores. Secondary outcomes were outpatient MME prescriptions and indicators of postoperative recovery (time to feeding, ambulation, and hospital discharge).

RESULTS

Of 308 patients undergoing CD from October 2019 to September 2020, 196 were enrolled in the pre-ERAC cohort and 112 in the post-ERAC cohort. Patients in the pre-ERAC cohort were more likely to require opioids in the postoperative period compared with the post-ERAC cohort (81.6 vs. 64.3%, p < 0.001). Likewise, there was a higher use of MME per stay in the pre-ERAC cohort (30 [20-49] vs. 16.8 MME [11.2-33.9], p < 0.001). There was also a higher number of patients who required prescribed opioids at the time of discharge (98 vs. 86.6%, p < 0.001) as well as in the amount of MMEs prescribed (150 [150-225] vs. 150 MME [112-150], p < 0.001; different shape of distribution). Furthermore, the patients in the pre-ERAC cohort had higher delta pain scores (3.3 [2.3-4.7] vs. 2.2 [1.3-3.7], p < 0.001).

CONCLUSION

Our study has illustrated that our ERAC pathways were associated with reduced inpatient opioid use, outpatient opioid use, patient-reported pain scores, and improved indicators of postoperative recovery.

KEY POINTS

· Implementation of ERAC pathways is associated with a higher percentage of no postpartum opioid use.. · Implementation of ERAC pathways is associated with lower delta (reported - expected) pain scores.. · The results of ERAC pathways implementation are increased by adopting a patient-centered approach..

Umbilical cord gas analysis: clinical implications of a comprehensive, contemporary determination of normal ranges

BACKGROUND

Umbilical cord gases are often used to assess the impact of labor and delivery on the fetus. However, no large series exists that reflects contemporary obstetrical practice or that analyzed blood gas ranges by route of delivery. Baseline, prelabor acid-base status in the human fetus is also poorly defined, rendering the assessment of blood gas changes during labor difficult.

OBJECTIVE

This study aimed to define normal umbilical cord gas and lactate values, stratified by mode of delivery, in a large contemporary series in which universal umbilical cord gas evaluation was dictated by protocol.

STUDY DESIGN

This was a retrospective cohort study. We analyzed the umbilical cord gas and lactate data of an unselected population of infants born between March 2012 and April 2022 at a large teaching hospital. These values were then analyzed by mode of delivery and, for cesarean deliveries, by indication for cesarean delivery and type of anesthesia. Umbilical cord gas values from infants delivered by elective cesarean delivey under general anesthesia without labor were considered representative of baseline, prelabor values.

RESULTS

Data were available for 45,475 infants. The median arterial pH values and interquartile ranges for vaginal births, elective cesarean deliveries without labor, and cesarean deliveries performed for fetal heart rate concerns were 7.27 (0.09), 7.27 (0.06), and 7.25 (0.09), respectively. Arterial lactate values for these same 3 groups were 4.1 (2.5), 2.5 (1.2), and 4.0 (2.8) mmoles/L, respectively. Because of the very large sample size, most comparisons yielded differences that were statistically significant, but clinically irrelevant. Of all the infants, 14% had an arterial pH <7.20; a pH value of 7.1 represents 2 standard deviations from the mean.

CONCLUSION

This large, population-based study of umbilical cord gas and lactate levels in an unselected population, stratified by delivery mode, represents a previously unavailable benchmark for the evaluation of umbilical cord gases. Arterial umbilical cord pH values for infants delivered by elective caesarean delivery without labor (median pH 7.28) reflect a lower prelabor fetal pH baseline than previously assumed. This finding, coupled with our determination that a 2 standard deviation below normal pH limit of 7.1, instead of the historic arbitrary pH of 7.2 threshold, helps to explain the poor positive predictive value of electronic fetal heart rate monitoring, a test designed to detect arterial pH levels that have fallen from an assumed baseline near pH 7.4 to an assumed potentially injurious pH level of <7.2. Uncomplicated labor, even when prolonged, does not generally lead to a clinically significant cumulative hypoxic stress to the human fetus. These findings, along with our determination that there is no difference in the acid-base status among infants delivered by cesarean delivery for fetal heart rate concerns, help to explain the failure of current approaches in labor and delivery management to reduce the rates of neonatal hypoxic-ischemic encephalopathy and cerebral palsy, conditions that almost always reflect developmental events rather than the effects of labor on the fetus.

Anger: an underappreciated destructive force in healthcare

Anger is an emotional state that occurs when unexpected things happen to or around oneself and is "an emotional state that varies in intensity from mild irritation to intense fury and rage." It is defined as "a strong feeling of displeasure and usually of antagonism," an emotion characterized by tension and hostility arising from frustration, real or imagined injury by another, or perceived injustice. It can manifest itself in behaviors designed to remove the object of the anger (e.g., determined action) or behaviors designed merely to express the emotion. For the Roman philosopher Seneca anger is not an uncontrollable, impulsive, or instinctive reaction. It is, rather, the cognitive assent that such initial reactions to the offending action or words are in fact unjustified. It is, rather, the cognitive assent that such initial reactions to the offending action or words are in fact unjustified. It seems that the year 2022 was a year when many Americans were plainly angry. "Why is everyone so angry?" the New York Times asked in the article "The Year We Lost It." We believe that Seneca is correct in that anger is unacceptable. Anger is a negative emotion that must be controlled, and Seneca provides us with the tools to avoid and destroy anger. Health care professionals will be more effective, content, and happier if they learn more about Seneca's writings about anger and implement his wisdom on anger from over 2000 years ago.

General versus Regional Anesthesia and Neonatal Data: A Propensity-Score-Matched Study

OBJECTIVE

This study aimed to evaluate whether there is a difference in neonatal outcomes with general anesthesia (GA) versus regional anesthesia (RA) when induction of anesthesia to delivery time (IADT) is prolonged (≥10 minutes).

STUDY DESIGN

This is a retrospective case-control study that included cases from July 2014 until August 2020. We reviewed all singleton pregnancies delivered between 24 and 42 weeks of gestation with IADT ≥ 10 minutes. Urgent deliveries, those who received RA for labor pain management or started cesarean delivery under RA and converted to GA, as well as cases with fetal anomalies, were excluded. The propensity score (PS) matching method was performed using age, ethnicity/race, body mass index, gestational age at delivery, preexisting maternal comorbidities, and pregnancy complications. Analyses were performed with SAS software version 9.4.

RESULTS

During the study period, we identified 258 cases meeting inclusion criteria. After the PS matching was applied, the study sample was reduced to 60 cases in each group. The median IADT and uterine incision to delivery time were similar between groups (41.5 [30.5, 52] vs. 46 minutes [38, 53.5], p = 0.2 and 1.5 [1, 3] vs. 2 minutes [1, 3], respectively). There was no significant difference between groups with respect to arterial or venous cord pH (7.24 [7.21, 7.26] vs. 7.23 [7.2, 7.27], p = 0.7 and 7.29 [7.26, 7.33] vs. 7.3 [7.26, 7.33], p = 0.4, respectively). Nor were there any associations between maternal characteristics and Apgar's score at 5 minutes, except for Apgar's score at 1 minute (p < 0.001). No significant difference was identified in the rate of admission to the neonatal intensive care unit (NICU; 11 [52.4%] vs. 10 [47.6%], p = 0.8) or NICU length of stay between GA and RA (4 [3, 14] vs. 4.5 [3, 11], p = 0.9).

CONCLUSION

Our data indicate that even with prolonged IADT, favorable neonatal outcomes are seen with both GA and RA, in contrast with previous studies performed decades ago.

KEY POINTS

· Improving cesarean delivery safety, including the safety of anesthesia, is of paramount importance.. · Reappraisal of historical outcomes is warranted as advances in the medical field unfold.. · Favorable neonatal outcomes are seen with both general and regional anesthesia..

Racial and Ethnic Disparities in Primary Cesarean Birth and Adverse Outcomes Among Low-Risk Nulliparous People

OBJECTIVE

To compare trend of primary cesarean delivery rate and composite neonatal and maternal adverse outcomes in low-risk pregnancies among racial and ethnic groups: non-Hispanic White, non-Hispanic Black, and Hispanic.

METHODS

This population-based cohort study used U.S. vital statistics data (2015-2019) to evaluate low-risk, nulliparous patients with nonanomalous singletons who labored and delivered at 37-41 weeks of gestation. The primary outcome was the primary cesarean delivery rate. Secondary outcomes included composite neonatal adverse outcome (Apgar score less than 5 at 5 minutes, assisted ventilation for more than 6 hours, seizure, or death), and composite maternal adverse outcome (intensive care unit admission, blood transfusion, uterine rupture, or unplanned hysterectomy), as well as infant death. Multivariable Poisson regression models were used to estimate adjusted relative risks (aRR) and 95% CIs.

RESULTS

Among 4.3 million births, 60.6% identified as non-Hispanic White, 14.6% identified as non-Hispanic Black, and 24.8% identified as Hispanic. The rate of primary cesarean delivery was 18.5% (n=804,155). An increased risk for cesarean delivery was found in non-Hispanic Black (21.7%, aRR 1.24, 95% CI 1.23-1.25) and Hispanic (17.3%, aRR 1.09, 95% CI 1.09-1.10) individuals, compared with non-Hispanic White individuals (18.1%) after multivariable adjustment. There was an upward trend in the rate of primary cesarean delivery in all racial and ethnic groups ( P for linear trend<0.001 for all groups). However, the racial and ethnic disparity in the rate of primary cesarean delivery remained stable during the study period. The composite neonatal adverse outcome was lower in Hispanic individuals in all newborns (10.7 vs 8.3 per 1,000 live births, aRR 0.74, 95% CI 0.72-0.75), and in newborns delivered by primary cesarean delivery (18.5 vs 15.0 per 1,000 live births, aRR 0.73, 95% CI 0.70-0.76), compared with non-Hispanic White individuals.

CONCLUSION

Using a nationally representative sample in the United States, we found racial and ethnic disparities in the primary cesarean delivery rate in low-risk nulliparous patients, which persisted throughout the study period.

Crucial nuances in understanding (mis)associations between the neonatal microbiome and Cesarean delivery

As rates of Cesarean delivery and common non-communicable disorders (NCDs), such as obesity, metabolic disease, and atopy/asthma, have concomitantly increased in recent decades, investigators have attempted to discern a causal link. One line of research has led to a hypothesis that Cesarean birth disrupts the presumed normal process of colonization of the neonatal microbiome with vaginal microbes, yielding NCDs later in life. However, a direct link between a disrupted microbiota transfer at time of delivery and acute and/or chronic illness in infants born via Cesarean has not been causally established. Microbiota seeding from maternal vaginal or stool sources has been preliminarily evaluated as an intervention designed to compensate for the lack of (or limited) exposure to such sources among Cesarean-delivered neonates. However, to date, clinical trials have yet to show a clear health benefit with neonatal 'vaginal seeding' practices. Until the long-term effects of these microbiome alterations can be fully determined, it is paramount to conduct parallel meaningful and mechanistic-minded interrogations of the impact of clinically modifiable maternal, nutritional, or environmental exposure on the functional microbiome over the duration of pregnancy and lactation to determine their role in the mitigation of childhood and adult NCDs.

Achieving an appropriate cesarean birth (CB) rate and analyzing the changes using the Robson Ten-Group Classification System (TGCS): Lessons from a Tertiary Care Hospital in Italy

BACKGROUND

To describe the interventions that were implemented at a Tertiary University Hospital and how they affected the rate of cesarean birth (CB) and main obstetrics and neonatal outcomes.

STUDY DESIGN

An analysis of the contemporaneously collected data from all deliveries that occurred from 2014 to 2018. Major obstetric and neonatal outcomes were analyzed and grouped according to the Ten-Group Classification System (TGCS).

RESULTS

A significant decrease in CB rates, from 28.4% to 23.0% (P < 0.001), was found over the study period. Although the relative sizes of both nulliparous (groups 1 + 2) and multiparous (groups 3 + 4) women remained stable over the study period, a significantly higher incidence of CB was reported in 2014 for both groups, compared with 2018 (2.6% vs. 13.0%, P < 0.001 for nulliparous women and 7.5% vs. 3.3%, P < 0.001 for multiparous women). In contrast, the relative size of Group 5 was significantly lower in 2014 than in 2018 (9.9% vs. 11.5%, P = 0.003), but a 13.3% reduction in CB was also reported for this group. No significant differences were noted in the occurrence of major obstetrics and neonatal outcomes that were reported.

CONCLUSIONS

A reduction in CB rate may be safely achieved through implementing a multifaceted strategy.

Impact of cesarean versus vaginal delivery on the risk of postpartum acute kidney injury: A retrospective database controlled study in 116,876 parturients

STUDY OBJECTIVE

The rate of cesarean delivery is increasing globally but the risk of perioperative organ injury associated with cesarean delivery is not well defined. The objective of this study was to determine the risk of postpartum acute kidney injury, a peripartum complication defined by an acute decrease in kidney function, associated with cesarean delivery compared to vaginal delivery.

SETTING

Population-based discharge database.

PATIENTS

The Optum Clinformatics® Data Mart was queried for parturients that underwent cesarean or vaginal delivery between January 2016 to January 2018. Using a propensity score model based on 27 antepartum characteristics, we generated a final matched cohort of 116,876 parturients.

INTERVENTION/EXPOSURE

Cesarean delivery as the mode of delivery.

MEASUREMENTS

The risk of acute kidney injury associated with each delivery mode and the effect of acute kidney injury on the length of hospital stay for parturients.

MAIN RESULTS

The matched cohort consisted of 116,876 deliveries, with 58,438 cases in each group. In the cesarean delivery group, the incidence of postpartum acute kidney injury was 24.5 vs. 7.9 per 10,000 deliveries in the vaginal delivery group (adjusted odds ratio = 3; 95% CI, 2.13-4.22; P < .001). The median of the length of hospital stay [interquartile range] was longer by 50% in parturients who developed postpartum acute kidney injury after vaginal delivery (3 [2-4] days vs. those who did not, 2 [2, 3] days; P < .001) and by 67% after cesarean delivery (5 [4-7] days vs. 3 [3, 4] days; P < .001).

CONCLUSIONS

Cesarean delivery is associated with a significantly increased risk of postpartum acute kidney injury as compared to vaginal delivery. The development of postpartum acute kidney injury is associated with prolonged length of hospital stay.

Review of optical methods for fetal monitoring in utero

The current technology for monitoring fetal wellbeing during child birth is cardiotocography. However, CTG has high false positive rates that lead to unnecessary emergency Cesarean deliveries and false negatives that result in birth injuries. To curtail these issues, fetal pulse oximetery has been a topic of interest for many decades. Fetal pulse oximetry would yield the oxygen saturation of the fetus in utero and provide a more robust marker for clinicians to make decisions about performing emergency Cesarean deliveries. Here, we present a review of biomedical optical developments related to transabdominal fetal pulse oximetery in the biophotonics field and the challenges that must be overcome to make transabdominal pulse oximetry a clinical reality.

Category II Intrapartum Fetal Heart Rate Patterns Unassociated With Recognized Sentinel Events: Castles in the Air

The evolution of continuous electronic fetal heart rate (FHR) monitoring has presented the obstetrician with a critical clinical conundrum: basic science observations suggest that such monitoring might be associated with improved long-term neurologic outcomes, yet, after a half century of use and millions of cesarean deliveries based on FHR monitoring, evidence for such improvement remains absent. This dichotomy appears to be related to widespread misconceptions regarding the physiology underlying various FHR patterns and the developmental origins of cerebral palsy. These misconceptions are strengthened by a reliance on anecdotal experience and tradition in lieu of evidence-based medicine, the confusing "category II" FHR designation, medical-legal considerations, and our tendency to view fetal monitoring, as originally conceptualized, as a single, indivisible entity whose concepts must be accepted or rejected en bloc. Ill-defined and largely imaginary conditions such as "depletion of fetal reserve" are particularly harmful and their use in clinical medicine uniquely not evidence based. A solution to this self-inflicted injury to our specialty will require a concerted effort involving teachers, authors, and researchers.

Monofilament vs multifilament suture for uterine closure at the time of cesarean delivery: a randomized clinical trial

BACKGROUND

Different factors may influence the closure of the uterine wall, including suture material. Suture materials may indeed influence tissue healing and therefore the development of scar defects.

OBJECTIVE

To test whether uterine closure using synthetic absorbable monofilament sutures at the time of cesarean delivery would reduce the rate of cesarean scar defects compared with uterine closure using synthetic absorbable multifilament sutures.

STUDY DESIGN

Parallel-group, nonblinded, randomized clinical trial of women with singleton pregnancies undergoing cesarean delivery at term in a single center in Italy. The inclusion criteria were singleton pregnancy, first or second cesarean delivery, scheduled and emergent or urgent cesarean deliveries, and gestational age between 37 0/7 and 42 0/7 weeks. Eligible participants were randomly allocated in a 1:1 ratio to either the monofilament group (polyglytone 6211 [Caprosyn]; Covidien, Dublin, Ireland) or the multifilament suture group (coated polyglactin 910 suture with Triclosan [Vicryl Plus]; Ethicon, Inc, Raritan, NJ). The primary outcome was the incidence of cesarean scar defect at ultrasound at the 6-month follow-up visit. The secondary outcomes were residual myometrial thickness and symptoms.

RESULTS

Overall, 300 women were included in the trial. Of the randomized women, 151 were randomized to the monofilament group and 149 to the multifilament group. However, 27 women were lost to follow-up: 15 in the monofilament group and 12 in the multifilament group. Of note, 6 months after delivery, the incidence rates of cesarean scar defect were 18.4% (25 of 136 patients) in the monofilament group and 23.4% (32 of 137 patients) in the multifilament group (relative risk, 0.79; 95% confidence interval, 0.41-1.25; P=.31). The mean residual myometrial thicknesses were 7.6 mm in the monofilament group and 7.2 mm in the multifilament group (mean difference, +0.40 mm; 95% confidence interval, -0.23 to 1.03). There was no between-group substantial difference found in the incidence of symptoms, including pelvic pain, painful periods, and dyspareunia.

CONCLUSION

In singleton pregnancies undergoing primary or second cesarean delivery, the use of synthetic absorbable monofilament sutures at the time of uterine wall closure was not associated with a reduction in the rate of cesarean scar defect 6 months after delivery compared with the use of synthetic absorbable multifilament sutures.

The Risk of Postpartum Hemorrhage Following Prior Prelabor Cesarean Delivery Stratified by Abnormal Placentation: A Multicenter Historical Cohort Study

Background: Prior prelabor cesarean delivery (CD) was associated with an increase in the risk of placenta previa (PP) in a second delivery, whether it may impact postpartum hemorrhage (PPH) independent of abnormal placentation. This study aimed to assess the risk of PPH stratified by abnormal placentation following a first CD before the onset of labor (prelabor) or intrapartum CD.

Methods: This multicenter, historical cohort study involved singleton, pregnant women at 28 weeks of gestation or greater with a CD history between January 2017 and December 2017 in 11 public tertiary hospitals within 7 provinces of China. PPH was analyzed in the subsequent pregnancy between women with prior prelabor CD and women with intrapartum CD. Furthermore, PPH was analyzed in pregnant women stratified by complications with PP alone [without placenta accreta spectrum (PAS) disorders], complications with PP and PAS, complications with PAS alone (without PP), and normal placentation. We performed multivariate logistic regression to calculate adjusted odds ratios (aOR) and 95% CI controlling for predefined covariates.

Results: Out of 10,833 pregnant women, 1,197 (11%) women had a history of intrapartum CD and 9,636 (89%) women had a history of prelabor CD. Prior prelabor CD increased the risk of PP (aOR 1.91, 95% CI 1.40–2.60), PAS (aOR 1.68, 95% CI 1.11–2.24), and PPH (aOR 1.33, 95% CI 1.02–1.75) in a subsequent pregnancy. After stratification by complications with PP alone, PP and PAS, PAS alone, and normal placentation, prior prelabor CD only increased the risk of PPH (aOR 3.34, 95% CI 1.35–8.23) in a subsequent pregnancy complicated with PP and PAS.

Conclusion: Compared to intrapartum CD, prior prelabor CD increased the risk of PPH in a subsequent pregnancy only when complicated by PP and PAS.

Clinical evaluation of labor: an evidence- and experience-based approach

During labor mother and fetus are evaluated at intervals to assess their well-being and determine how the labor is progressing. These assessments require skillful physical diagnosis and the ability to translate the acquired information into meaningful prognostic decision-making. We describe a coordinated approach to the assessment of labor. Graphing of serial measurements of cervical dilatation and fetal station creates "labor curves," which provide diagnostic and prognostic information. Based on these curves we recognize nine discrete labor abnormalities. Many may be related to insufficient or disordered contractile mechanisms. Several factors are strongly associated with development of labor disorders, including cephalopelvic disproportion, excess analgesia, fetal malpositions, intrauterine infection, and maternal obesity. Clinical cephalopelvimetry involves assessing pelvic traits and predicting their effects on labor. These observations must be integrated with information derived from the labor curves. Exogenous oxytocin is widely used. It has a high therapeutic index, but is easily misused. Oxytocin treatment should be restricted to situations in which its potential benefits clearly outweigh its risks. This requires there be a documented labor dysfunction or a legitimate medical reason to shorten the labor. Normal labor and delivery pose little risk to a healthy fetus; but dysfunctional labors, especially if stimulated excessively by oxytocin or terminated by complex operative vaginal delivery, have the potential for considerable harm. Conscientiously implemented, the approach to the evaluation of labor outlined in this review will result in a reasonable cesarean rate and minimize risks that may accrue from the labor and delivery process.

Cervical Ripening and Labor Induction and Augmentation, 5th Edition

Cervical ripening and induction and augmentation of labor are common procedures in labor and birth units. The potential risks and benefits for the procedure should be explained to women so that they can make informed decisions. Clinicians should be knowledgeable about the methods and medications used and be skilled in maternal-fetal assessment. Adequate nurse staffing is required to monitor the mother and fetus to promote the best possible outcomes. This practice monograph includes information on mechanical and pharmacologic methods for cervical ripening; labor induction and augmentation with oxytocin, a high alert drug; and nurse staffing levels and skills needed to provide safe and effective care during cervical ripening and labor induction and augmentation.

Safety and feasibility of trial of vaginal labor after cesarean section: A retrospective study

By observing and analyzing the success rate of Tai'an City central hospital TOLAC and VBNC and various indicators after delivery, we make sure whether TOLAC is safe and feasible to be promoted in Tai'an area.Between January and December 2017, data of 144 cases undergoing TOLAC, 152 cases undergoing VBNC, 152 cases undergoing RCS and 142 case undergoing PCS in Tai'an City Central Hospital were retrospectively analyzed. The success rate of vaginal delivery, labor time, 24 hours postpartum hemorrhage, hospital stay, Apgar score of newborns and puerperal morbidity were observed.Primary study outcomes: The success rates of the TOLAC and VBNC groups were 93.06% and 93.42%, respectively, where the difference was not statistically significant (P = .901). Secondary study outcomes: There were no significant differences in labor time (P = .0249), amount of 24 hours postpartum hemorrhage (P = .206), Apgar score of newborns (P = .582), hospital stay (P = .194) and puerperal morbidity (P = .942) between the VBAC group and VBNC group. There were statistically significant differences in amount of 24 hours postpartum hemorrhage (P < .001), hospital stay (P < .001) and puerperal morbidity (P = .018), but no difference in Apgar score of newborns (P = .228) between the VBAC group and RCS group. There were significant differences in operation time (P = .011), amount of 24 hours hemorrhage (P = .001), hospital stay (P = .001) and puerperal morbidity (P = .041), but no significant difference in Apgar score of newborns (P = .300) between the RCS and PCS groups.The TOLAC is as safe and feasible as VBNC, and more favorable to the safety of mother and fetus than RCS in Tai'an area.

Determinants of length of stay after cesarean sections in the Friuli Venezia Giulia Region (North-Eastern Italy), 2005-2015

Since Italy has the highest cesarean section (CS) rate (38.1%) among all European countries, the containment of health care costs associated with CS is needed, along with control of length of hospital stay (LOS) following CS. This population based cross-sectional study aims to investigate LoS post CS (overall CS, OCS; planned CS, PCS; urgent/emergency CS, UCS), in Friuli Venezia Giulia (a region of North-Eastern Italy) during 2005-2015, adjusting for a considerable number factors, including various obstetric conditions/complications. Maternal and newborn characteristics (health care setting and timeframe; maternal health factors; child's size factors; child's fragility factors; socio-demographic background; obstetric history; obstetric conditions) were used as independent variables. LoS (post OCS, PCS, UCS) was the outcome measure. The statistical analysis was conducted with multivariable linear (LoS expressed as adjusted mean, in days) as well as logistic (adjusted proportion of LoS > 4 days vs. LoS ≤ 4 days, using a 4 day cutoff for early discharge, ED) regression. An important decreasing trend over time in mean LoS and LoS > ED was observed for both PCS and UCS. LoS post CS was shorter with parity and history of CS, whereas it was longer among non-EU mothers. Several obstetric conditions/complications were associated with extended LoS. Whilst eclampsia/pre-eclampsia and preterm gestations (33-36 weeks) were predominantly associated with longer LoS post UCS, for PCS LoS was significantly longer with birthweight 2.0-2.5 kg, multiple birth and increasing maternal age. Strong significant inter-hospital variation remained after adjustment for the major clinical conditions. This study shows that routinely collected administrative data provide useful information for health planning and monitoring, identifying inter-hospital differences that could be targeted by policy interventions aimed at improving the efficiency of obstetric care. The important decreasing trend over time of LoS post CS, coupled with the impact of some socio-demographic and obstetric history factors on LoS, seemingly suggests a positive approach of health care providers of FVG in decision making on hospitalization length post CS. However, the significant role of several obstetric conditions did not influence hospital variation. Inter-hospital variations of LoS could depend on a number of factors, including the capacity to discharge patients into the surrounding non-acute facilities. Further studies are warranted to ascertain whether LoS can be attributed to hospital efficiency rather than the characteristics of the hospital catchment area.

Real-time data analysis using a machine learning model significantly improves prediction of successful vaginal deliveries

BACKGROUND

The process of childbirth is one of the most crucial events in the future health and development of the offspring. The vulnerability of parturients and fetuses during the delivery process led to the development of intrapartum monitoring methods and to the emergence of alternative methods of delivery. However, current monitoring methods fail to accurately discriminate between cases in which intervention is unnecessary, partly contributing to the high rates of cesarean deliveries worldwide. Machine learning methods are applied in various medical fields to create personalized prediction models. These methods are used to analyze abundant, complex data with intricate associations to aid in decision making. Initial attempts to predict vaginal delivery vs cesarean deliveries using machine learning tools did not utilize the vast amount of data recorded during labor. The data recorded during labor represent the dynamic process of labor and therefore may be invaluable for dynamic prediction of vaginal delivery.

OBJECTIVE

We aimed to create a personalized machine learning-based prediction model to predict successful vaginal deliveries using real-time data acquired during the first stage of labor.

STUDY DESIGN

Electronic medical records of labor occurring during a 12-year period in a tertiary referral center were explored and labeled. Four different models were created using input from multiple maternal and fetal parameters. Initial risk assessments for vaginal delivery were calculated using data available at the time of admission to the delivery unit, followed by models incorporating cervical examination data and fetal heart rate data, and finally, a model that integrates additional data available during the first stage of labor was created.

RESULTS

A total of 94,480 cases in which a trial of labor was attempted were identified. Based on approximately 180 million data points from the first stage of labor, machine learning models were developed to predict successful vaginal deliveries. A model using data available at the time of admission to the delivery unit yielded an area under the curve of 0.817 (95% confidence interval, 0.811-0.823). Models that used real-time data increased prediction accuracy. A model that includes real-time cervical examination data had an initial area under the curve of 0.819 (95% confidence interval, 0.813-0.825) at first examination, which increased to an area under the curve of 0.917 (95% confidence interval, 0.913-0.921) by the end of the first stage. Adding the real-time fetal heart monitor data provided an area under the curve of 0.824 (95% confidence interval, 0.818-0.830) at first examination, which increased to an area under the curve of 0.928 (95% confidence interval, 0.924-0.932) by the end of the first stage. Finally, adding additional real-time data increased the area under the curve initially to 0.833 (95% confidence interval, 0.827-0.838) at the first cervical examination and up to 0.932 (95% confidence interval, 0.928-0.935) by the end of the first stage.

CONCLUSION

Real-time data acquired throughout the process of labor significantly increased the prediction accuracy for vaginal delivery using machine learning models. These models enable translation and quantification of the data gathered in the delivery unit into a clinical tool that yields a reliable personalized risk score and helps avoid unnecessary interventions.

Cervical Ripening and Labor Induction and Augmentation, 5th Edition

Cervical ripening and induction and augmentation of labor are common procedures in labor and birth units. The potential risks and benefits for the procedure should be explained to women so that they can make informed decisions. Clinicians should be knowledgeable about the methods and medications used and be skilled in maternal-fetal assessment. Adequate nurse staffing is required to monitor the mother and fetus to promote the best possible outcomes. This practice monograph includes information on mechanical and pharmacologic methods for cervical ripening; labor induction and augmentation with oxytocin, a high alert drug; and nurse staffing levels and skills needed to provide safe and effective care during cervical ripening and labor induction and augmentation.

Prediction of vaginal birth after cesarean deliveries using machine learning

BACKGROUND

Efforts to reduce cesarean delivery rates to 12-15% have been undertaken worldwide. Special focus has been directed towards parturients who undergo a trial of labor after cesarean delivery to reduce the burden of repeated cesarean deliveries. Complication rates are lowest when a vaginal birth is achieved and highest when an unplanned cesarean delivery is performed, which emphasizes the need to assess, in advance, the likelihood of a successful vaginal birth after cesarean delivery. Vaginal birth after cesarean delivery calculators have been developed in different populations; however, some limitations to their implementation into clinical practice have been described. Machine-learning methods enable investigation of large-scale datasets with input combinations that traditional statistical analysis tools have difficulty processing.

OBJECTIVE

The aim of this study was to evaluate the feasibility of using machine-learning methods to predict a successful vaginal birth after cesarean delivery.

STUDY DESIGN

The electronic medical records of singleton, term labors during a 12-year period in a tertiary referral center were analyzed. With the use of gradient boosting, models that incorporated multiple maternal and fetal features were created to predict successful vaginal birth in parturients who undergo a trial of labor after cesarean delivery. One model was created to provide a personalized risk score for vaginal birth after cesarean delivery with the use of features that are available as early as the first antenatal visit; a second model was created that reassesses this score after features are added that are available only in proximity to delivery.

RESULTS

A cohort of 9888 parturients with 1 previous cesarean delivery was identified, of which 75.6% of parturients (n=7473) attempted a trial of labor, with a success rate of 88%. A machine-learning-based model to predict when vaginal delivery would be successful was developed. When features that are available at the first antenatal visit are used, the model showed a receiver operating characteristic curve with area under the curve of 0.745 (95% confidence interval, 0.728-0.762) that increased to 0.793 (95% confidence interval, 0.778-0.808) when features that are available in proximity to the delivery process were added. Additionally, for the later model, a risk stratification tool was built to allocate parturients into low-, medium-, and high-risk groups for failed trial of labor after cesarean delivery. The low- and medium-risk groups (42.4% and 25.6% of parturients, respectively) showed a success rate of 97.3% and 90.9%, respectively. The high-risk group (32.1%) had a vaginal delivery success rate of 73.3%. Application of the model to a cohort of parturients who elected a repeat cesarean delivery (n=2145) demonstrated that 31% of these parturients would have been allocated to the low- and medium-risk groups had a trial of labor been attempted.

CONCLUSION

Trial of labor after cesarean delivery is safe for most parturients. Success rates are high, even in a population with high rates of trial of labor after cesarean delivery. Application of a machine-learning algorithm to assign a personalized risk score for a successful vaginal birth after cesarean delivery may help in decision-making and contribute to a reduction in cesarean delivery rates. Parturient allocation to risk groups may help delivery process management.

The impact of cesarean section on neonatal outcomes at a university-based tertiary hospital in Jordan

Background

Over the past two decades, there has been a steady rise in the rate of Cesarean section delivery globally. As a result, short-term and long-term maternal and neonatal complications are rising. The objective of this study is to determine the rate and indications for Cesarean section at King Abdullah University Hospital (KAUH) in Jordan and to assess the resulting neonatal outcomes.

Methods

A retrospective chart review was conducted for all women and neonates delivered by Cesarean section during the period January 2016 to July 2017 at KAUH tertiary academic center. Collected data include demographic characteristics, indication for delivery, and neonatal outcomes such as NICU admission, respiratory complications, sepsis, mortality, and length of hospitalization.

Results

Two thousand five hundred ninety-five Cesarean section deliveries were performed over 18 months representing a rate of 50.5% of all deliveries. Sixty percent were scheduled procedures. Seventy-two percent were performed at full term gestation. The most common indication was previously scarred uterus (42.8%) followed by fetal distress (15.5%). The rate of admission to the neonatal ICU was 30% (800/2595). After multilogistic conditional regression analysis, the factors associated with increased risk of neonatal ICU admission were found to include grandmultiparity (Adjusted OR 1.46), gestational diabetes (Adjusted OR 1.92), maternal employment (Adjusted OR 1.84), prolonged rupture of membranes (Adjusted OR 5), fetal distress (Adjusted OR 1.84), prematurity (Adjusted OR 43.78), low birth weight (Adjusted OR 42), high order multiple gestation (Adjusted OR 9.58) and low 5-min APGAR score (Adjusted OR 10). Among the babies electively delivered at early term (37–38.6 weeks), 16% were admitted to the NICU for a median length of stay of 4 days (IQR 2, 8). The most common diagnoses for admitted term neonates were transient tachypnea of newborns and respiratory distress syndrome.

Conclusions

CS deliveries account for more than half the number of deliveries at our institution and almost one third of the delivered babies are admitted to the NICU. Together with the resulting maternal and neonatal consequences, this carries a major burden on the newborns, health care facilities, and involved families. Local strategies and policies should be established and implemented to improve the outcome of births.

Guidelines for labor assessment: failure to progress?

The ongoing debate about what models of cervical dilatation and fetal descent should guide clinical decision-making has sown uncertainty among obstetric practitioners. We previously argued that the adoption of recently published labor assessment guidelines promoted by the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine may have been premature. Before accepting any new clinical approaches as the standard of care, their underlying hypotheses should be thoroughly tested to ensure they are at least equivalent (or, preferably, superior) to existing management paradigms. Some of the apparent urgency to subscribe to new clinical tactics has been fueled by legitimate concerns about the rise in the cesarean delivery rate over the past several decades. A major contributor to this change in practice patterns is that more cesarean deliveries are being done for diagnoses that fall under the rubric of dystocia than ever before. As a consequence, traditional labor curves-fundamental for assessing labor progress-and the practice paradigms associated with them have received intense scrutiny as a possible contributor to this delivery trend. Moreover, the recent proposal of new labor curves and accompanying management guidelines has, understandably, fed the appetite to correct a perceived problem. However, the cesarean delivery rate rose most rapidly during decades when there was no major change in traditional labor curves or in the guidelines for their interpretation. Also, during the years since the new guidelines were first published, there has been no major fall in cesarean delivery frequency. This raises the question of whether there was truly a fundamental flaw in the traditional labor management paradigms or whether their proper interpretation and use had been somehow forgotten, ignored, or corrupted. More important, existing studies have shown that application of the new guidelines often (but not always) results in a modest fall in the cesarean delivery rate, but that this change may be accompanied by significant increases in maternal and neonatal morbidity. These results strongly suggest more caution in the adoption of the American College of Obstetricians and Gynecologists / Society for Maternal-Fetal Medicine labor assessment recommendations. They are based on a hypothesis that has yet to undergo thorough evaluation of its risks and benefits.

Patient and Hospital Factors Associated With Unexpected Newborn Complications Among Term Neonates in US Hospitals

IMPORTANCE

Unexpected complications in term newborns have been recently adopted by the Joint Commission as a marker of obstetric care quality.

OBJECTIVE

To understand the variation and patient and hospital factors associated with severe unexpected complications in term neonates among hospitals in the United States.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study collected data from all births in US counties with 1 obstetric hospital using county-identified birth certificate data and American Hospital Association annual survey data from January 1, 2015, through December 31, 2017. All live-born, term, singleton infants weighing at least 2500 g were included. The data analysis was performed from December 1, 2018, through June 30, 2019.

EXPOSURES

Severe unexpected newborn complication, defined as neonatal death, 5-minute Apgar score of 3 or less, seizure, use of assisted ventilation for at least 6 hours, or transfer to another facility.

MAIN OUTCOMES AND MEASURES

Between-hospital variation and patient and hospital factors associated with unexpected newborn complications.

RESULTS

A total of 1 754 852 births from 576 hospitals were included in the analysis. A wide range of hospital complication rates was found (range, 0.6-89.9 per 1000 births; median, 15.3 per 1000 births [interquartile range, 9.6-22.0 per 1000 births]). Hospitals with high newborn complication rates were more likely to care for younger, white, less educated, and publicly insured women with more medical comorbidities compared with hospitals with low complication rates. In the adjusted models, there was little effect of case mix to explain the observed between-county variation (11.3%; 95% CI, 10.0%-12.6%). Neonatal transfer was the primary factor associated with complication rates, especially among hospitals with the highest rates (66.0% of all complications). The risk for unexpected neonatal complication increased by more than 50% for those neonates born at hospitals without a neonatal intensive care unit compared with those with a neonatal intensive care unit (adjusted odds ratio, 1.55; 95% CI, 1.38-1.75).

CONCLUSIONS AND RELEVANCE

In this study, severe unexpected complication rates among term newborns varied widely. When included in the metric numerator, neonatal transfer was the primary factor associated with complications, especially among hospitals with the highest rates. Transfers were more likely to be necessary when infants were born in hospitals with lower levels of neonatal care. Thus, if this metric is to be used in its current form, it would appear that accreditors, regulatory bodies, and payers should consider adjusting for or stratifying by a hospital's level of neonatal care to avoid disincentivizing against appropriate transfers.

Second-stage labor: consensus versus science

There has been a recent significant evolution in suggested practices for the management of labor because of the increased national cesarean delivery rate. One of the most significant changes was promulgated by the 2014 Obstetric Care Consensus entitled, "Safe Prevention of Primary Cesarean Delivery," which recommended reconsideration of the upper limits of the length of labor in the second stage as well as the first stage. We previously published a 2016 Clinical Opinion challenging the second-stage practice change. Over the past 2 years, there have been at least 5 reports as well as 2 national organization statements supporting revised management of second-stage labor. We now revisit the second-stage issue because we believe that it is important to carefully clarify the current status resulting from consensus statements as well as the evolving current status of scientific evidence. We structured this Clinical Opinion using questions in an effort to chronicle the story of how obstetric precepts on second-stage labor in use for more than 50 years were being replaced. How did we get here? What is the current evidence? What can be learned from this experience? Should American obstetrics now "fall back" to pre-existing obstetric precepts for the management of second-stage labor after having "sprung forward" an additional hour-namely, lengthening the duration of acceptable second-stage labor to 4 hours as recommended by the Obstetric Care Consensus? We believe that the data published since our 2016 Clinical Opinion buttress our original position that prolongation of the second stage beyond historical precepts is unsafe.

Understanding Factors Leading to Primary Cesarean Section and Vaginal Birth After Cesarean Delivery in the Friuli-Venezia Giulia Region (North-Eastern Italy), 2005-2015

Although there is no evidence that elevated rates of cesarean sections (CS) translate into reduced maternal/child perinatal morbidity or mortality, CS have been increasingly overused almost everywhere, both in high and low-income countries. The primary cesarean section (PCS) has become a major driver of the overall CS (OCS) rate, since it carries intrinsic risk of repeat CS (RCS) in future pregnancies. In our study we examined patterns of PCS, pl compared with planned TOLAC anned PCS (PPCS), vaginal birth after 1 previous CS (VBAC-1) and associated factors in Friuli Venezia Giulia (FVG), a region of North-Eastern Italy, collecting data from its 11 maternity centres (coded from A to K) during 2005-2015. By fitting three multiple logistic regression models (one for each delivery mode), we calculated the adjusted rates of PCS and PPCS among women without history of CS, whilst the calculation of the VBAC rate was restricted to women with just one previous CS (VBAC-1). Results, expressed as odds ratio (OR) with 95% confidence interval (95%CI), were controlled for the effect of hospital, calendar year as well as several factors related to the clinical and obstetric conditions of the mothers and the newborn, the obstetric history and socio-demographic background. In FVG during 2005-2015 there were 24,467 OCS (rate of 24.2%), 19,565 PCS (19.6%), 7,736 PPCS (7.7%) and 2,303 VBAC-1 (28.4%). We found high variability of delivery mode (DM) at hospital level, especially for PCS and PPCS. Breech presentation was the strongest determinant for PCS as well as PPCS. Leaving aside placenta previa/abuptio placenta/ante-partum hemorrhage, further significant factors, more importantly associated with PCS than PPCS were non-reassuring fetal status and obstructed labour, followed by (in order of statistical significance): multiple birth; eclampsia/pre-eclampsia; maternal age 40-44 years; placental weight  600-99 g; oligohydramios; pre-delivery LoS 3-5 days; maternal age 35-39 years; placenta weight 1,000-1,500 g; birthweight < 2,000 g; maternal age ≥ 45 years; pre-delivery LoS ≥ 6 days; mother's age 30-34 years; low birthweight (2,000-2,500 g); polyhydramnions; cord prolaspe; ≥6 US scas performed during pregnancy and pre-term gestations (33-36 weeks). Significant factors for PPCS were (in order of statistical significance): breech presentation; placenta previa/abruptio placenta/ante-partum haemorrhage; multiple birth; pre-delivery LoS ≥ 3 days; placental weight ≥ 600 g; maternal age  40-44 years; ≥6 US scans performed in pregnancy; maternal age ≥ 45 and 35-39 years; oligohydramnios; eclampsia/pre-eclampsia; mother's age 30-34 years; birthweight <2,000 g; polyhydramnios and pre-term gestation (33-36 weeks). VBAC-1 were more likely with gestation ≥ 41 weeks, placental weight <500 g and especially labour analgesia. During 2005-2015 the overall rate of PCS in FVG (19.6%) was substantially lower than the corresponding figure reported in 2010 for the entire Italy (29%) and still slightly under the most recent national PCS rate for 2017 (22.2%). The VBAC-1 rate on women with history of one previous CS in FVG was 28.4% (25.3% considering VBAC on all women with at least 1 previous CS), roughly three times the Italian national rate of 9% reported for 2017. The discrepancy between the OCS rate at country level (38.1%) and FVG's (24.2%) is therefore mainly attributable to RCS. Although there was a marginal decrease of PCS and PPCS crudes rates over time in the whole region, accompained by a progressive enhancement of the crude VBAC rate, we found remarkable variability of DM across hospitals. To further contain the number of unnecessary PCS and promote VBAC where appropriate, standardized obstetric protocols should be introduced and enforced at hospital level. Decision-making on PCS should be carefully scrutinized, introducing a diagnostic second opinion for all PCS, particularly for term singleton pregancies with cephalic presentation and in case of obstructed labour as well as non-reassuring fetal status, grey areas potentially affected by subjective clinical assessment. This process of change could be facilitated with education of staff/patients by opinion leaders and prenatal counseling for women and partners, although clinical audits, financial penalties and rewards to efficient maternity centres could also be considered.

"New or not-so-new" labor management practices and cesarean delivery for arrest of progress

BACKGROUND

Because nearly one-third of births in the United States are now achieved by cesarean delivery, comprising more than 1.27 million women each year, national organizations have recently published revised guidelines for the management of labor. These new guidelines stipulate that labor arrest should not be diagnosed unless ≥6 cm cervical dilatation has been reached or labor has been stimulated for at ≥6 hours.

OBJECTIVE

To determine the cervical dilatation and hours of labor stimulation prior to cesarean delivery for arrest of dilatation.

MATERIALS AND METHODS

Between January 1, 1999, andDecember 31, 2000, a prospective observational study of all primary cesarean deliveries was conducted at 13 university centers comprising the Eunice Kennedy Shriver National Institute for Child Health and Human Development, Maternal-Fetal Medicine Units Network. This secondary analysis includes all live-born, singleton, nonanomalous, cephalic gestations delivered by primary cesarean delivery at ≥37 weeks. A cesarean delivery was considered to have been performed for arrest of dilatation if the indication for the procedure was failure to progress, cephalopelvic disproportion, or failed induction. Augmentation was defined as stimulation after spontaneous labor had been previously diagnosed. Analysis included both the latent and active phases of labor. The active phase of labor was diagnosed when cervical dilatation was ≥4 cm in the presence of uterine contractions.

RESULTS

A total of 13,269 primary cesarean deliveries were available for analysis, 8,546 (65%) of which were performed for inadequate progress of labor with cervical dilatation recorded at the time of cesarean delivery. Of these cesarean deliveries for labor arrest, a total of 719 (8%) were performed in the latent phase of labor and 7827 (92%) were performed when cervical dilatation was ≥4 cm (active phase). Approximately two-thirds (n = =5876; 69%) received intrauterine pressure monitoring. A total of 5636 women (66% of those reaching the active phase of labor) had reached ≥6 cm cervical dilatation before cesarean delivery was performed. Moreover, 7440 (95%) of the 7827 women in active labor had ≥6 cm dilatation or had received labor stimulation ≥6 hours prior to cesarean delivery for arrest of dilatation.

CONCLUSION

Women undergoing primary cesarean delivery for arrest of dilatation 15 years before the recommendations of the Obstetrics Care Consensus had received bona fide efforts to achieve adequate labor consistent with the recommendations of the Consensus. Because 95% of these women had ≥6 cm dilatation or had received labor stimulation ≥6 hours prior to cesarean delivery for arrest of dilatation, these new recommendations are unlikely to change the cesarean delivery rates.

A Systematic Evaluation of Hospital Performance of Childbirth Delivery Modes and Associated Factors in the Friuli Venezia Giulia Region (North-Eastern Italy), 2005-2015

Cesarean sections (CS) have become increasingly common in both developed and developing countries, raising legitimate concerns regarding their appropriateness. Since improvement of obstetric care at the hospital level needs quantitative evidence, using routinely collected health data we contrasted the performance of the 11 maternity centres (coded with an alphabetic letter A to L) of an Italian region, Friuli Venezia Giulia (FVG), during 2005-15, after removing the effect of several factors associated with different delivery modes (DM): spontaneous vaginal delivery (SVD), instrumental vaginal delivery (IVD), overall CS (OCS) and urgent/emergency CS (UCS). A multivariable logistic regression model was fitted for each individual DM, using a dichotomous outcome (1 = each DM; 0 = rest of hospital births) and comparing the stratum specific estimates of every term with their respective reference categories. Results were expressed as odds ratios (OR) with 95% confidence intervals (95%CI). The Benjamini-Hochberg (BH) false discovery rates (FDR) approach was applied to control alpha error due to the large number of statistical tests performed. In the entire FVG region during 2005-2015, SVD were 75,497 (69.1% out of all births), IVD were 7,281 (6.7%), OCS were 26,467 (24.2%) and UCS were 14,106 (12.9% of all births and 53.3% out of all CS). SVD were more likely (in descending order of statistical significance) with: higher number of previous livebirths; clerk/employed occupational status of the mother; gestational age <29 weeks; placentas weighing <500 g; stillbirth; premature rupture of membranes (PROM). IVD were predominantly more likely (in descending order of statistical significance) with: obstructed labour, non-reassuring fetal status, history of CS, labour analgesia, maternal age ≥35 and gestation >40 weeks. The principal factors associated with OCS were (in descending order of statistical significance): CS history, breech presentation, non-reassuring fetal status, obstructed labour, multiple birth, placental weight ≥ 600 g, eclampsia/pre-eclampsia, maternal age ≥ 35 and oligohydramnios. The most important risk factors for UCS were (in descending order of statistical significance): placenta previa/abruptio placenta/ antepartum hemorrage; non-reassuring fetal status, obstructed labour; breech presentation; PROM, eclampsia/pre-eclampsia; gestation 33-36 weeks; gestation 41+ weeks; oligohydramnios; birthweight <2,500 g, maternal age ≥ 35 and cord prolapse. After removing the effects of all other factors, we found great variability of DM rates across hospitals. Adjusting for all risk factors, all hospitals had a OCS risk higher than the referent (hospital G). Out of these 10 hospitals with increased adjusted risk of OCS, 9 (A, B, C, D, E, F, I, J, K) performed less SVD and 5 (A, C, D, I, J) less IVD. In the above 5 centres CS was therefore probably overused. The present study shows that routinely collected administrative data provide useful information for health planning and monitoring. Although the overall CS rate in FVG during 2005-15 was 24.2%, well below the corresponding average Italian national figure (38.1%), the variability of DM rates across FVG maternity centres could be targeted by policy interventions aimed at reducing the recourse to unnecessary CS. In some clinical conditions such as obstructed labor, non-reassuring fetal status, breech presentation, history of CS, higher maternal age and multiple birth, consideration may be given to more conservative DM. The overuse of CS in nulliparas and repeat CS (RCS) should be carefully monitored and subject to audit.

Combined prenatal and postnatal prediction of early neonatal compromise risk

OBJECTIVE

Electronic fetal monitoring/cardiotocography (EFM) is nearly ubiquitous, but almost everyone acknowledges there is room for improvement. We have contextualized monitoring by breaking it down into quantifiable components and adding to that, other factors that have not been formally used: i.e. the assessment of uterine contractions, and the presence of maternal, fetal, and obstetrical risk factors. We have created an algorithm, the Fetal Reserve Index (FRI) that significantly improves the detection of at-risk cases. We hypothesized that extending our approach of monitoring to include the immediate newborn period could help us better understand the physiology and pathophysiology of the decrease in fetal reserve during labor and the transition from fetal to neonatal homeostasis, thereby further honing the prediction of outcomes. Such improved and earlier understanding could then potentiate earlier, and more targeted use of neuroprotective attempts during labor treating decreased fetal reserve and improving the fetus' transition from fetal to neonatal life minimizing risk of neurologic injury.

STUDY DESIGN

We have analyzed a 45-year-old research database of closely monitored labors, deliveries, and an additional hour of continuous neonatal surveillance. We applied the FRI prenatally and created a new metric, the INCHON index that combines the last FRI with umbilical cord blood and 4-minute umbilical artery blood parameters to predict later neonatal acid/base balance. Using the last FRI scores, we created 3 neonatal groups. Umbilical cord and catheterized umbilical artery bloods at 4, 8, 16, 32, and 64 minutes were measured for base excess, pH, and PO₂. Continuous neonatal heart rate was scored for rate, variability, and reactivity.

RESULTS

Neonates commonly do not make a smooth transition from fetal to postnatal physiology. Even in low risk babies, 85% exhibited worsening pH and base excess during the first 4 minutes; 34% of neonates reached levels considered at high risk for metabolic acidosis (≤-12 mmol/L) and neurologic injury. Neonatal heart rate commonly exhibited sustained, significant tachycardia with loss of reactivity and variability. One quarter of all cases would be considered Category III if part of the fetal tracing. Our developed metrics (FRI and INCHON) clearly discriminated and predicted low, medium, and high-risk neonatal physiology.

CONCLUSIONS

The immediate neonatal period often imposes generally unrecognized risks for the newborn. INCHON improves identification of decreased fetal reserve and babies at risk, thereby permitting earlier intervention during labor (intrauterine resuscitation) or potentially postnatally (brain cooling) to prevent neurologic injury. We believe that perinatal management would be improved by routine, continuous neonatal monitoring - at least until heart rate reactivity is restored. FRI and INCHON can help identify problems much earlier and more accurately than currently and keep fetuses and babies in better metabolic shape.

Labor progress determined by ultrasound is different in women requiring cesarean delivery from those who experience a vaginal delivery following induction of labor

BACKGROUND

The diagnosis of labor dystocia generally is determined by the deviation of labor progress, which is assessed by the use of a partogram. Recently, intrapartum transperineal ultrasound for the assessment of fetal head descent has been introduced to assess labor progress in the first stage of labor in a more objective and noninvasive way.

OBJECTIVE

The objective of the study was to determine the differences in labor progress by the use of serial transperineal ultrasound assessment of fetal head descent between women having vaginal and cesarean delivery.

STUDY DESIGN

This was a prospective longitudinal study performed in 315 women with singleton pregnancy who were undergoing labor induction at term between December 2016 and December 2017. Paired assessment of cervical dilation and fetal head station by vaginal examination and transperineal ultrasonographic assessment of parasagittal angle of progression and head-perineum distance were made serially after the commencement of labor induction. According to the hospital protocol, assessment was performed every 24 hours and 4 hours, respectively, during latent and active phases of labor. The researchers and the clinical team were blinded to each other's findings. The repeated measures data were analyzed by mixed effect models. To determine the effect of mode of delivery on the association between parasagittal angle of progression and head-perineum distance against fetal head station and cervical dilation, the significance of the interaction term between each mode of delivery and fetal head station or cervical dilation was determined, which accounted for parity and obesity. Area under receiver-operating characteristic curve was used to evaluate the performance of serial intrapartum sonography in predicting women with cesarean delivery because of failure to progress.

RESULTS

The total number of paired vaginal examination and ultrasound assessments was 1198, with a median of 3 per woman. The median assessment-to-assessment interval was 4.6 hours (interquartile range, 4.3-5.1 hours). Women who achieved vaginal delivery (n=261) had steeper slopes of parasagittal angle of progression and head-perineum distance against fetal head station and cervical dilation than those who achieved cesarean delivery (n=54). Objectively, an additional decrease of 5.11 and 1.37 degrees in parasagittal angle of progression was observed for an unit increase in fetal head station and cervical dilation, respectively, in women who required cesarean delivery (P<.01; P=.01), compared with women who achieved vaginal delivery, after taking account of repeated measures from individuals and confounding factors. The respective additional increases in head-perineum distance for a unit increase in fetal head station and cervical dilation were 0.27 cm (P<.01) and 0.12 cm (P<.01). A combination of maternal characteristics with the temporal changes of parasagittal angle of progression for an unit increase in fetal head station achieved an area under receiver-operating characteristic curve of 0.85 (95% confidence interval, 0.76-0.94), with sensitivity of 79% and specificity of 80%, for the prediction of women who required cesarean delivery because of failure to progress.

CONCLUSION

The differences in labor progress between vaginal and cesarean delivery have been illustrated objectively by serial intrapartum transperineal ultrasonographic assessment of fetal head descent. This tool is potentially predictive of women who will require cesarean delivery because of failure to progress.

Povidone-iodine 1% is the most effective vaginal antiseptic for preventing post-cesarean endometritis: a systematic review and network meta-analysis

BACKGROUND

Direct comparison metaanalyses have reported benefits with presurgical vaginal preparation before cesarean delivery for the reduction of endometritis. These reports did not perform a multitreatment comparison of the various antiseptic solutions assessed in previous studies.

OBJECTIVE

The purpose of this study was to review the literature systematically and quantitate and summarize indirectly the comparative efficacy of antiseptic formulations and their concentrations that are used for the preparation of the vagina before cesarean delivery in the prevention of endometritis and other infectious complications.

STUDY DESIGN

We used MEDLINE, EMBASE (from their inception to November 2018) and Cochrane databases, biographies, and conference proceedings. We used randomized clinical trials of patients who underwent surgical preparation of the vagina with antiseptic formulations before cesarean delivery with the aim of reducing the risk of infectious morbidity. Our systematic review was registered and followed the Preferred Reporting Items for Systematic Review and Meta-analysis Extension for network meta-analysis guidelines. Network meta-analysis was performed with computerized software and used user-written programs to assess consistency, inconsistency, ranking probabilities, and graphing results. Direct and indirect pairwise comparisons of the various formulations and their concentrations were performed with the use of multivariate random-effects models and metaregression. A frequentist inference method was employed for the fitted model to estimate the ranking probabilities. Subgroup analyses for patients in labor, not in labor, and with ruptured membranes were conducted.

RESULTS

For the prevention of endometritis, we identified 23 studies that comprised 7097 women who were allocated to the following treatments: povidone-iodine (1%, 5%, 10%), chlorhexidine (0.2%, 0.4%), metronidazole gel, cetrimide, or normal saline solution/no treatment. Direct and indirect pairwise comparisons indicated that, when compared with saline solution or no treatment, all antiseptic formulations decreased rates of endometritis (5.2% vs 9.1%; odds ratio, 0.48; 95% confidence interval, 0.35-0.65; 22 studies/6994 women). Individually, povidone-iodine (odds ratio, 0.43; 95% confidence interval, 0.28-0.64; 16 studies/5968 women), cetrimide (odds ratio, 0.34; 95% confidence interval, 0.13-0.90; 1 study/200 women), and metronidazole (odds ratio, 0.38; 95% confidence interval, 0.16-0.90; 1 study/224 women) significantly reduced the risk of endometritis. Rankings of vaginal preparations indicated that povidone-iodine 1% had the highest probability (72.7%) of being the most effective treatment for the prevention of endometritis. For the secondary outcomes of postoperative wound infection and fever, a significant reduction was found only with povidone-iodine (odds ratio, 0.61; 95% confidence interval, 0.48-0.78; 16 studies/5968 women; and odds ratio, 0.58; 95% confidence interval, 0.40-0.83; 12 studies/4667 women). Subgroup analyses also found that povidone-iodine significantly reduced risk of endometritis for women in labor (odds ratio, 0.42; 95% confidence interval, 0.20-0.88; 5 studies/1211 women), with ruptured membranes(odds ratio, 0.21; 95% confidence interval, 0.10-0.44; 4 studies/476 women), and undergoing planned cesarean delivery (odds ratio, 0.39; 95% confidence interval, 0.27-0.57; 8 studies/1825 women).

CONCLUSION

Among patients who underwent cesarean delivery, presurgical vaginal irrigation with povidone-iodine had the highest probability of reducing the risk of endometritis, postoperative wound infections, and fever.

Better late than never: why obstetricians must implement enhanced recovery after cesarean

Despite persistent concerns about high cesarean delivery rates internationally, there has been less attention on improving perioperative outcomes for the millions of women who will experience a cesarean delivery each year. Enhanced recovery after surgery, a standardized, evidence-based, interdisciplinary protocol, has been successfully used in other surgical specialties including gynecology to improve quality of care and patient satisfaction while reducing overall health care costs through reduced length of stay. Enhanced recovery after surgery society guidelines for cesarean delivery were just released in August 2018. Obstetric patients, who face the dual challenge of being postpartum and postoperative, could benefit greatly from protocols that optimize their return to physiological function and reduce surgical morbidity. Although enhanced recovery after surgery has been widespread in other surgical specialties, uptake of this protocol in obstetrics has lagged behind. We believe enhanced recovery after surgery for cesarean delivery can effectively address 3 challenges faced by obstetrician/gynecologists. These are: (1) improving care for the high number of women undergoing cesarean deliveries; (2) using evidence-based care bundles to prevent maternal morbidity and mortality, address disparities, and reduce costs; and (3) limiting postoperative opioid prescribing in response to the opioid crisis. Enhanced recovery after surgery for cesarean delivery and other standardized care protocols have the potential to reduce the disproportionately high rates of maternal morbidity and mortality in the United States, and ensure all patients, regardless of demographics or location, receive the same level of high-quality peripartum care.

Term cesarean delivery in the first pregnancy is not associated with an increased risk for preterm delivery in the subsequent pregnancy

BACKGROUND

Prior studies have reported an increased risk for preterm delivery following a term cesarean delivery. However, these studies did not adjust for high-risk conditions related to the first cesarean delivery and are known to recur.

OBJECTIVE

The objective of the study was to determine whether there is an association between term cesarean delivery in the first pregnancy and subsequent spontaneous or indicated preterm delivery.

STUDY DESIGN

This was a retrospective cohort study of women with the first 2 consecutive singleton deliveries (2007-2014) identified through a linked pregnancy database at a single institution. Women with a first pregnancy that resulted in cesarean delivery at term were compared with women whose first pregnancy resulted in a vaginal delivery at term. Exclusion criteria were known to recur medical or obstetrical complications during the first pregnancy. A propensity score analysis was performed by matching women who underwent a cesarean delivery with those who underwent a vaginal delivery in the first pregnancy. The association between cesarean delivery in the first pregnancy and preterm delivery in the second pregnancy in this matched set was examined using conditional logistic regression. The primary outcome was overall preterm delivery <37 weeks in the second pregnancy. Secondary outcomes included type of preterm delivery (spontaneous vs indicated), late preterm delivery (34-36 6/7 weeks), early preterm delivery (<34 weeks), and small-for-gestational-age birth.

RESULTS

Of a total of 6456 linked pregnancies, 2284 deliveries were matched; 1142 were preceded by cesarean delivery and 1142 were preceded by vaginal delivery. The main indications for cesarean delivery in the first pregnancy were dystocia in 703 (61.5%), nonreassuring fetal status in 222 (19.4%), breech presentation in 100 (8.8%), and other in 84 (7.4%). The mean (SD) gestational ages at delivery for the second pregnancy was 38.8 (1.8) and 38.9 (1.7) weeks, respectively, for prior cesarean delivery and vaginal delivery. The risks of preterm delivery in the second pregnancy among women with a previous cesarean and vaginal delivery were 6.0% and 5.2%, respectively (adjusted odds ratio, 1.46, 95% confidence interval, [CI] 0.77-2.76). In an analysis stratified by the type of preterm delivery in the second pregnancy, no associations were seen between cesarean delivery in the first pregnancy and spontaneous preterm delivery (4.6% vs 3.9%; adjusted odds ratio, 1.40, 95% confidence interval, 0.59-3.32) or indicated preterm delivery (1.6% vs 1.4%; adjusted odds ratio, 1.21, 95% confidence interval, 0.60-2.46). Similarly, no significant differences were found in late preterm delivery (4.6% vs 4.1%; adjusted odds ratio, 1.13, 95% confidence interval, 0.55-2.29), early preterm delivery (1.6% vs 1.2%; adjusted odds ratio, 1.25, 95% confidence interval, 0.59-2.67), or neonates with birthweight less than the fifth percentile for gestational age (3.6% vs 2.2%; adjusted odds ratio, 1.26, 95% confidence interval, 0.52-3.06).

CONCLUSION

After robust adjustment for confounders through a propensity score analysis related to the indication for the first cesarean delivery at term, cesarean delivery is not associated with an increase in preterm delivery, spontaneous or indicated, in the subsequent pregnancy.

Factors that affect ultrasound-determined labor progress in women undergoing induction of labor

BACKGROUND

The traditional approach to the assessment of labor progress is by digital vaginal examination; however, it is subjective and imprecise. Recent studies have investigated the role of transperineal ultrasonographic assessment of fetal head descent by measuring the angle of progression and head-perineum distance.

OBJECTIVE

The objective of this study was to evaluate factors that affected labor progress, which were defined by the transperineal ultrasonographic parameters, in women who achieved vaginal delivery.

STUDY DESIGN

This was a prospective longitudinal study performed in 315 women with singleton pregnancy who underwent labor induction at term between December 2016 and December 2017. Paired assessment of cervical dilation and fetal head station by vaginal examination and transperineal ultrasonographic assessment of fetal head descent (parasagittal angle of progression and head-perineum distance) were made serially after the commencement of labor induction until full cervical dilation. The researchers were blinded to the findings of the clinical team's vaginal examination and vice versa. The repeated measure data were analyzed by mixed effect models to identify the significant factors (age ≥35 years, obesity, parity, methods of labor induction, and epidural anesthesia) that affected the relationship between parasagittal angle of progression and head-perineum distance against fetal head station and cervical dilation.

RESULTS

The total number of paired vaginal examination and transperineal ultrasonographic assessments among the 261 women (82.9%) with vaginal delivery was 945, with a median of 3 per woman. The median assessment-to-assessment interval was 4.6 hours (interquartile range, 4.3-5.2). Multiparity and mechanical methods of labor induction were associated with a faster rate of fetal head descent, which was determined by head-perineum distance against fetal head station, than nulliparity and the use of a slow-release vaginal pessary, respectively. An additional increase of 0.10 cm in head-perineum distance was observed, for an unit increase in fetal head station in nulliparous women (P=.03) and women who had a slow-release vaginal pessary (P=.02), compared with multiparous women and those who had mechanical methods for labor induction. The use of epidural anesthesia was associated with a slower rate of fetal head descent, which was determined by both parasagittal angle of progression and head-perineum distance, against fetal head station. An additional decrease of 3.66 degrees in parasagittal angle of progression (P=.04) and an additional increase in 0.33 cm in head-perineum distance (P≤.001) were observed for a unit increase in fetal head station in women with the use of epidural anesthesia, compared with those without. Obese women had higher head-perineum distance overall, compared with normal weight women; at different cross-sections of time periods, obesity appeared to be associated with a slower rate of change between head-perineum distance and cervical dilation. Advanced maternal age did not affect transperineal ultrasound-determined labor progress (P>.05).

CONCLUSION

Parity, methods of labor induction, the use of epidural anesthesia, and obesity affect labor progress, which has been illustrated objectively by serial transperineal ultrasonographic assessment of fetal head descent.

Unexpected term NICU admissions: a marker of obstetrical care quality?

BACKGROUND

Unexpected admissions of term neonates to the neonatal intensive care unit and unexpected postnatal complications have been proposed as neonatal-focused quality metrics for intrapartum care. Previous studies have noted significant variation in overall hospital neonatal intensive care unit admission rates; however, little is known about the influence of obstetric practices on these rates or whether variation among unanticipated admissions in low-risk, term neonates can be attributed to systemic hospital practices.

OBJECTIVE

The objective of the study was to examine the relative effects of patient characteristics and intrapartum events on unexpected neonatal intensive care unit admissions and to quantify the between-hospital variation in neonatal intensive care unit admission rates among this group of neonates.

STUDY DESIGN

We performed a retrospective cross-sectional study using data collected as part of the Consortium for Safe Labor study. Women who delivered term (≥37 weeks), singleton, nonanomalous, liveborn infants without an a priori risk for neonatal intensive care unit admission were included. The primary outcome was neonatal intensive care unit admission among this population. Multilevel mixed-effect models were used to calculate adjusted odds ratios for demographics (age, race, insurer), pregnancy characteristics (parity, gestational age, tobacco use, birthweight), maternal comorbidities (chronic and pregnancy-induced hypertension), hospital characteristics (delivery volume, hospital and neonatal intensive care unit level, academic affiliation), and intrapartum events (prolonged second stage, induction of labor, trial of labor after cesarean delivery, chorioamnionitis, meconium-stained amniotic fluid, and abruption). Intraclass correlation coefficients were used to estimate the between-hospital variance in a series of hierarchical models.

RESULTS

Of the 143,951 infants meeting all patient and hospital inclusion criteria, 7995 (5.6%) were admitted to the neonatal intensive care unit after birth. In the fully adjusted model, the factors associated with the highest odds for neonatal intensive care unit admission included: nulliparity (adjusted odds ratio, 1.62 [95% confidence interval, 1.53-1.71]), large for gestational age (adjusted odds ratio, 1.59 [95% confidence interval, 1.47-1.71]), and small for gestational age (adjusted odds ratio, 1.60 [95% confidence interval, 1.47-1.73]). Induction of labor (adjusted odds ratio, 0.95 [95% confidence interval, 0.89-1.01]) was not associated with increased odds of neonatal intensive care unit admission compared with women who labored spontaneously. The events associated with higher odds of neonatal intensive care unit admission included: prolonged second stage (adjusted odds ratio, 1.66 [95% confidence interval, 1.51-1.83]); chorioamnionitis (adjusted odds ratio, 3.89 [95% confidence interval, 3.42-4.44]), meconium-stained amniotic fluid (adjusted odds ratio, 1.96 [95% confidence interval, 1.82-2.10]), and abruption (adjusted odds ratio, 2.64 [95% confidence interval, 2.16-.21]). Compared with women who did not labor, the odds of neonatal intensive care unit admission were lower for women who labored: adjusted odds ratio, 0.48 (95% confidence interval, 0.45-0.52) for women with no uterine scar and adjusted odds ratio, 0.83 (95% confidence interval, 0.73-0.94) for women with a uterine scar. There was significant variation in neonatal intensive care unit admission rates by hospital, ranging from 2.9% to 11.2%. After accounting for case mix and hospital characteristics, the between-hospital variance was 1.9%, suggesting that little of the variation was explained by the effect of the hospital.

CONCLUSION

This study contributes to the currently limited understanding of term, neonatal intensive care unit admission rates as a marker of obstetrical care quality. We demonstrated that significant variation exists in hospital unexpected neonatal intensive care unit admission rates and that certain intrapartum events are associated with an increased risk for neonatal intensive care unit admission after delivery. However, the between-hospital variation was low. Unmeasured confounders and extrinsic factors, such as neonatal intensive care unit bed availability, may limit the ability of unexpected term neonatal intensive care unit admissions to meaningfully reflect obstetrical care quality.

Length of stay following cesarean sections: A population based study in the Friuli Venezia Giulia region (North-Eastern Italy), 2005-2015

BACKGROUND

Births by cesarean section (CS) usually require longer recovery time, and as a result women remain hospitalized longer following CS than vaginal delivery (VD). A number of strategies have been proposed to reduce avoidable health care costs associated with childbirth. Among these, the containment of length of hospital stay (LoS) has been identified as an important quality indicator of obstetric care and performance efficiency of maternity centres. Since improvement of obstetric care at hospital level needs quantitative evidence, we compared the maternity services of an Italian region on LoS post CS.

METHODS

We conducted a population-based study in Friuli Venezia Giulia (FVG), a region of North-Eastern Italy, collecting data from all its 12 maternity centres (coded from A to K) during 2005-2015. We fitted a multivariable logistic regression using LoS as a binary outcome, higher/lower than the international early discharge (ED) cutoffs for CS (4 days), controlling for hospitals as well as several factors related to the clinical conditions of the mothers and the newborn, the obstetric history and socio-demographic background. Results were expressed as adjusted odds ratios (aOR) with 95% confidence interval (95%CI). Population attributable risks (PARs) were also calculated as proportional variation of LoS>ED for each hospital in the ideal scenario of having the same performance as centre J (the reference) during calendar year 2015. Results were expressed as PAR with 95%CI. Differences in mean LoS were also investigated with a multivariable linear regression model including the same explanatory factors of the above multiple logistic regression. Results were expressed as adjusted regression coefficients (aRC) with 95%CI.

RESULTS

Although decreasing over the years (5.0 ± 1.7 days in 2005 vs. 4.4 ± 1.7 days in 2015), the pooled mean LoS in the whole FVG during these 11 years was still 4.7 ± 1.7 days, higher than respective international ED benchmark. The significant decreasing trend of LoS>ED over time in FVG (aOR = 0.89; 95%CI: 0.88; 0.90) was marginal as compared to the variability of LoS>ED observed among the various maternity services. Regardless it was expressed as aRC or aOR, LoS after CS was lowest in hospital C, highest in hospital D and intermediate in centres I, K, G, F, A, H, E, B and J (in descending order). The aOR of LoS being longer than ED ranged from 1.63 (95%CI:1.46; 1.81) in hospital B up to 32.09 (95%CI: 25.68; 40.10) in facility D. When hospitals were ranked by PAR the same pattern was found, even if restricting the analysis to low risk pregnancies.

CONCLUSIONS

Although significantly decreasing over time, the mean LoS in FVG during 2005-2015 was 4.7 days, higher than the international threshold recommended for CS. There was substantial variability in LoS by facility centre, suggesting that internal organizational processes of single hospitals should be improved by enforcing standardized guidelines and using audits, economic incentives and penalties if need be.