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Abstract
PURPOSE Reducing primary cesarean births is a national priority in the United States. Recommendations include delaying admission of low-risk pregnant women to the hospital until they are in active labor, considered to be 6 cm cervical dilatation. How this recommendation affects decision-making during triage requires further exploration. The purpose of this study was to explore the clinician's perspective on the triage process and deferral of hospital admission for low-risk pregnant women who were not yet in active labor. METHODS A qualitative descriptive approach was used via semistructured interviews with physicians, midwives, and nurses. Data analysis used an inductive approach and identified codes, a theme and subthemes. RESULTS Twenty-five clinicians participated. A triad of decision-making occurred between three main stakeholders: the low-risk pregnant woman, the triage nurse, and the physician or midwife. One theme and four subthemes related to this triad were identified. The theme Admission of Low-Risk Pregnant Women Depends on Many Factors provides context to the maternity care triage process. There are many factors clinicians consider prior to admitting women, including situational and clinical factors. Subthemes related to the woman are her expectation and knowledge about birth and her ability to cope with labor. Subthemes associated with the provider and triage nurse are care variation and concern for maternal and fetal safety. CLINICAL IMPLICATIONS From the clinician's perspective, triage is a complex, dynamic process, even for low-risk pregnant women. There is an interplay of different factors affecting clinical decision-making, thus the decision-making triad provides a possible framework for shared decision-making.
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Abasian Kasegari F, Pazandeh F, Darvish S, Huss R, Nasiri M. Admitting women in active labour: A randomised controlled trial about the effects of protocol use on childbirth method and interventions. Women Birth 2019; 33:e543-e548. [PMID: 31892475 DOI: 10.1016/j.wombi.2019.12.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Revised: 12/07/2019] [Accepted: 12/09/2019] [Indexed: 10/25/2022]
Abstract
AIM To determine the effects of protocol of admitting women in active labour on childbirth method and interventions during labour and childbirth. METHODS This single-blind randomised clinical trial was conducted in a public hospital in Mazandaran province (Iran) in 2017. Two hundred nulliparous low-risk women were randomly assigned into intervention and control groups. The participant women were admitted in the intervention group using the admission protocol and to the group control by staff midwives and doctors. The admission criteria of the protocol were: the presence of regular, painful contractions, the cervix at least four cm dilated and at least one of the following cues: cervix effaced, and spontaneous rupture of membranes, or "show". The primary outcome measure was childbirth method. Data were analyzed in SPSS-22 using Mann-Whitney and Chi-square tests. The level of statistical significance was set as p<0.05. FINDING There were significant differences between the intervention and control groups in the number of caesarian section (CS) (p<0.001). Two groups had a statistically significant difference in amniotomy (p=0.003), augmentation by oxytocin (p<0.001), number of vaginal examinations (p<0.001) and fundal pressure (p<0.001). CONCLUSIONS Using a protocol for admission of low risk nulliparous women in active labour contributed to reduction of the primary caesarean section rate and interventions during childbirth. A risk assessment and using evidence informed guidelines in admission can contribute to reduce unsafe and harmful practices and support normalisation of birth. This is essential for demedicalisation and a useful strategy for reducing primary CS.
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Affiliation(s)
- Freshteh Abasian Kasegari
- School of Nursing and Midwifery Shahid Beheshti University of Medical Sciences, Tehran, Iran; Department of Biostatistics, Faculty of Paramedical, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Farzaneh Pazandeh
- Department of Midwifery and Reproductive Health, Midwifery and Reproductive Health Research Centre, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran; Department of Biostatistics, Faculty of Paramedical, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Soodabeh Darvish
- School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran; Department of Biostatistics, Faculty of Paramedical, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Reinhard Huss
- Nuffield Centre for International Health and Development, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK; Department of Biostatistics, Faculty of Paramedical, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Malihe Nasiri
- School of Nursing and Midwifery Shahid Beheshti University of Medical Sciences, Tehran, Iran; Department of Biostatistics, Faculty of Paramedical, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Breman RB, Low LK, Paul J, Johantgen M. Promoting active labor admission: Early labor lounge implementation barriers and facilitators from the clinician perspective. Nurs Forum 2019; 55:182-189. [PMID: 31746009 DOI: 10.1111/nuf.12414] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Revised: 10/07/2019] [Accepted: 11/04/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND The cesarean birth rate for low-risk pregnant individuals in the United States exceeds the recommended Healthy People 2020 rate. One recommended strategy to reduce cesarean in this population is delaying hospital admission until active labor commences. A quality improvement program was implemented at a community hospital using the early labor lounge (ELL) to promote admission in active labor. This study focuses on identifying the barriers and facilitators from the clinician perspective to implementing the ELL. METHODS Interviews were conducted with a purposive sample of clinicians. Interview transcripts were open coded and themes identified inductively. A framework analysis was then conducted using the Consolidated Framework for Implementation Research (CFIR). RESULTS Twenty-five staff members participated. Barriers and facilitators were identified in four of the CFIR domains. Facilitators included the strength of the evidence and the ELL itself, including the tools it contained for supporting women in latent labor. Barriers to implementation included clinician self-efficacy and perceived low usage of the ELL. CONCLUSION This analysis using, CFIR identified several barriers and facilitators to the implementation of the ELL. The context of the individual woman presenting in triage and the acceptability and self-efficacy of the individual clinicians represented important factors for implementation.
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Affiliation(s)
- Rachel B Breman
- Department of Partnerships, Professional Education and Practice, School of Nursing, University of Maryland, Baltimore, Maryland
| | - Lisa Kane Low
- Department of Health Behavior and Biological Sciences, School of Nursing, University of Michigan, Ann Arbor, Michigan
| | - Julie Paul
- Department of Obstetrics and Gynecology, South Shore Hospital, Weymouth, Massachusetts
| | - Meg Johantgen
- Department of Organizational Systems and Adult Health, School of Nursing, University of Maryland, Baltimore, Maryland
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Dawe RE, Bishop J, Pendergast A, Avery S, Monaghan K, Duggan N, Aubrey-Bassler K. Cesarean delivery rates among family physicians versus obstetricians: a population-based cohort study using instrumental variable methods. CMAJ Open 2017; 5:E823-E829. [PMID: 29233843 PMCID: PMC5741417 DOI: 10.9778/cmajo.20170081] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Previous research suggests that family physicians have rates of cesarean delivery that are lower than or equivalent to those for obstetricians, but adjustments for risk differences in these analyses may have been inadequate. We used an econometric method to adjust for observed and unobserved factors affecting the risk of cesarean delivery among women attended by family physicians versus obstetricians. METHODS This retrospective population-based cohort study included all Canadian (except Quebec) hospital deliveries by family physicians and obstetricians between Apr. 1, 2006, and Mar. 31, 2009. We excluded women with multiple gestations, and newborns with a birth weight less than 500 g or gestational age less than 20 weeks. We estimated the relative risk of cesarean delivery using instrumental-variable-adjusted and logistic regression. RESULTS The final cohort included 776 299 women who gave birth in 390 hospitals. The risk of cesarean delivery was 27.3%, and the mean proportion of deliveries by family physicians was 26.9% (standard deviation 23.8%). The relative risk of cesarean delivery for family physicians versus obstetricians was 0.48 (95% confidence interval [CI] 0.41-0.56) with logistic regression and 1.27 (95% CI 1.02-1.57) with instrumental-variable-adjusted regression. INTERPRETATION Our conventional analyses suggest that family physicians have a lower rate of cesarean delivery than obstetricians, but instrumental variable analyses suggest the opposite. Because instrumental variable methods adjust for unmeasured factors and traditional methods do not, the large discrepancy between these estimates of risk suggests that clinical and/or sociocultural factors affecting the decision to perform cesarean delivery may not be accounted for in our database.
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Affiliation(s)
- Russell Eric Dawe
- Affiliations: Discipline of Family Medicine (Dawe, Bishop, Pendergast, Avery, Monaghan, Duggan, Aubrey-Bassler) and Primary Healthcare Research Unit (Aubrey-Bassler), Memorial University of Newfoundland, St. John's, Nfld
| | - Jessica Bishop
- Affiliations: Discipline of Family Medicine (Dawe, Bishop, Pendergast, Avery, Monaghan, Duggan, Aubrey-Bassler) and Primary Healthcare Research Unit (Aubrey-Bassler), Memorial University of Newfoundland, St. John's, Nfld
| | - Amanda Pendergast
- Affiliations: Discipline of Family Medicine (Dawe, Bishop, Pendergast, Avery, Monaghan, Duggan, Aubrey-Bassler) and Primary Healthcare Research Unit (Aubrey-Bassler), Memorial University of Newfoundland, St. John's, Nfld
| | - Susan Avery
- Affiliations: Discipline of Family Medicine (Dawe, Bishop, Pendergast, Avery, Monaghan, Duggan, Aubrey-Bassler) and Primary Healthcare Research Unit (Aubrey-Bassler), Memorial University of Newfoundland, St. John's, Nfld
| | - Kelly Monaghan
- Affiliations: Discipline of Family Medicine (Dawe, Bishop, Pendergast, Avery, Monaghan, Duggan, Aubrey-Bassler) and Primary Healthcare Research Unit (Aubrey-Bassler), Memorial University of Newfoundland, St. John's, Nfld
| | - Norah Duggan
- Affiliations: Discipline of Family Medicine (Dawe, Bishop, Pendergast, Avery, Monaghan, Duggan, Aubrey-Bassler) and Primary Healthcare Research Unit (Aubrey-Bassler), Memorial University of Newfoundland, St. John's, Nfld
| | - Kris Aubrey-Bassler
- Affiliations: Discipline of Family Medicine (Dawe, Bishop, Pendergast, Avery, Monaghan, Duggan, Aubrey-Bassler) and Primary Healthcare Research Unit (Aubrey-Bassler), Memorial University of Newfoundland, St. John's, Nfld
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Javernick JA, Dempsey A. Reducing the Primary Cesarean Birth Rate: A Quality Improvement Project. J Midwifery Womens Health 2017; 62:477-483. [DOI: 10.1111/jmwh.12606] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Revised: 12/07/2016] [Accepted: 12/11/2016] [Indexed: 11/28/2022]
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Vadnais MA, Hacker MR, Shah NT, Jordan J, Modest AM, Siegel M, Golen TH. Quality Improvement Initiatives Lead to Reduction in Nulliparous Term Singleton Vertex Cesarean Delivery Rate. Jt Comm J Qual Patient Saf 2017; 43:53-61. [PMID: 28334563 PMCID: PMC5928501 DOI: 10.1016/j.jcjq.2016.11.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND The nulliparous term singleton vertex (NTSV) cesarean delivery rate has been recognized as a meaningful benchmark. Variation in the NTSV cesarean delivery rate among hospitals and providers suggests many hospitals may be able to safely improve their rates. The NTSV cesarean delivery rate at the authors' institution was higher than state and national averages. This study was conducted to determine the influence of a set of quality improvement interventions on the NTSV cesarean delivery rate. METHODS From 2008 through 2015, at a single tertiary care academic medical center, a multi-strategy approach that included provider education, provider feedback, and implementation of new policies was used to target evidence-based and inferred factors that influence the NTSV cesarean delivery rate. Data on mode of delivery, maternal outcomes, and neonatal outcomes were collected from birth certificates and administrative claims data. The Cochran-Armitage test and linear regression were used to calculate the p-trend for categorical and continuous variables, respectively. RESULTS More than 20,000 NTSV deliveries were analyzed, including more than 15,000 during the intervention period. The NTSV cesarean delivery rate declined from 35% to 21% over eight years. The total cesarean delivery rate declined as well. Increase in meconium aspiration syndrome and maternal transfusion were observed. CONCLUSION Quality improvement initiatives can decrease the NTSV cesarean delivery rate. Any increased incidence of fetal or maternal complications associated with decreased NTSV cesarean delivery rate should be considered in the context of the risks and benefits of vaginal delivery compared to cesarean delivery.
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Tilden EL, Lee VR, Allen AJ, Griffin EE, Caughey AB. Cost-Effectiveness Analysis of Latent versus Active Labor Hospital Admission for Medically Low-Risk, Term Women. Birth 2015; 42:219-26. [PMID: 26095829 DOI: 10.1111/birt.12179] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/27/2015] [Indexed: 01/17/2023]
Abstract
OBJECTIVE To assess the outcomes and costs of hospital admission during the latent versus active phase of labor. Latent labor hospital admission has been consistently associated with elevated maternal risk for increased interventions, including epidural anesthesia and cesarean delivery, longer hospital stay, and higher utilization of hospital resources. METHODS A cost-effectiveness model was built to simulate a theoretic cohort of 3.2 million term, medically low-risk women either being admitted in latent labor (< 4 cm dilation) or delaying admission until active labor (≥ 4 cm dilation). Outcomes included epidural use, mode of delivery, stillbirth, maternal death, and costs of care. All probability, cost, and utility estimates were derived from the literature, and total quality-adjusted life years were calculated. Sensitivity analyses and a Monte Carlo simulation were used to investigate the robustness of model assumptions. RESULTS Delaying admission until active labor would result in 672,000 fewer epidurals, 67,232 fewer cesarean deliveries, and 9.6 fewer maternal deaths in our theoretic cohort as compared to admission during latent labor. Additionally, delaying admission results in a cost savings of $694 million annually in the United States. Sensitivity analyses indicated the model was robust within a wide range of probabilities and costs. Monte Carlo simulation found that delayed admission was the optimal strategy in 76.79 percent of trials. CONCLUSION Delaying admission until active labor is a dominant strategy, resulting in both better outcomes and lower costs. Issues related to clinical translation of these findings are explored.
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Affiliation(s)
- Ellen L Tilden
- School of Nursing, Oregon Health and Science University, Portland, OR, USA
| | - Vanessa R Lee
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, OR, USA
| | - Allison J Allen
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, OR, USA
| | - Emily E Griffin
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, OR, USA
| | - Aaron B Caughey
- School of Medicine, Oregon Health and Science University, Portland, OR, USA
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Back to normal: A retrospective, cross-sectional study of the multi-factorial determinants of normal birth in Queensland, Australia. Midwifery 2015; 31:818-27. [PMID: 25921954 DOI: 10.1016/j.midw.2015.04.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Revised: 02/24/2015] [Accepted: 04/07/2015] [Indexed: 11/21/2022]
Abstract
BACKGROUND currently, care providers and policy-makers internationally are working to promote normal birth. In Australia, such initiatives are being implemented without any evidence of the prevalence or determinants of normal birth as a multidimensional construct. This study aimed to better understand the determinants of normal birth (defined as without induction of labour, epidural/spinal/general anaesthesia, forceps/vacuum, caesarean birth, or episiotomy) using secondary analyses of data from a population survey of women in Queensland, Australia. METHODS women who birthed in Queensland during a two-week period in 2009 were mailed a survey approximately three months after birth. Women (n=772) provided retrospective data on their pregnancy, labour and birth preferences and experiences, socio-demographic characteristics, and reproductive history. A series of logistic regressions were conducted to determine factors associated with having labour, having a vaginal birth, and having a normal birth. FINDINGS overall, 81.9% of women had labour, 66.4% had a vaginal birth, and 29.6% had a normal birth. After adjusting for other significant factors, women had significantly higher odds of having labour if they birthed in a public hospital and had a pre-existing preference for a vaginal birth. Of women who had labour, 80.8% had a vaginal birth. Women who had labour had significantly higher odds of having a vaginal birth if they attended antenatal classes, did not have continuous fetal monitoring, felt able to 'take their time' in labour, and had a pre-existing preference for a vaginal birth. Of women who had a vaginal birth, 44.7% had a normal birth. Women who had a vaginal birth had significantly higher odds of having a normal birth if they birthed in a public hospital, birthed outside regular business hours, had mobility in labour, did not have continuous fetal monitoring, and were non-supine during birth. CONCLUSIONS these findings provide a strong foundation on which to base resources aimed at increasing informed decision-making for maternity care consumers, providers, and policy-makers alike. Research to evaluate the impact of modifying key clinical practices (e.g., supporting women׳s mobility during labour, facilitating non-supine positioning during birth) on the likelihood of a normal birth is an important next step.
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King TL, Pinger W. Evidence‐Based Practice for Intrapartum Care: The Pearls of Midwifery. J Midwifery Womens Health 2014; 59:572-585. [DOI: 10.1111/jmwh.12261] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Fahey JO. The Recognition and Management of Intrapartum Fetal Heart Rate Emergencies: Beyond Definitions and Classification. J Midwifery Womens Health 2014; 59:616-623. [DOI: 10.1111/jmwh.12256] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Edmonds JK, Hawkins SS, Cohen BB. The influence of detailed maternal ethnicity on cesarean delivery: findings from the U.S. birth certificate in the State of Massachusetts. Birth 2014; 41:290-8. [PMID: 24750358 PMCID: PMC4139447 DOI: 10.1111/birt.12108] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/26/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND Our objective was to examine the likelihood of primary cesarean delivery for women at low risk for the procedure in Massachusetts. METHODS Birth certificate data for all births from 1996 to 2010 that were nulliparous, term, singleton, and vertex (NTSV; N = 427,393) were used to conduct logistic regression models to assess the likelihood of a cesarean delivery for each of the 31 ethnic groups relative to self-identified "American" mothers. The results were compared with broad classifications of race/ethnicity more commonly employed in research. RESULTS While 23.3 percent of American women had primary cesarean deliveries, cesarean delivery rates varied from 12.9 percent for Cambodian to 32.4 percent for Nigerian women. Women from 21 of 30 ethnic groups had higher odds of a primary cesarean (range of adjusted odds ratios [AORs] 1.09-1.77), while only Chinese, Cambodian, and Japanese women had lower odds (range of AORs 0.66-0.92), compared with self-identified "Americans." Using broad race/ethnicity categories, Non-Hispanic black, Hispanic, and "Other" women had higher odds of cesarean delivery relative to Non-Hispanic white women (range of AORs 1.12-1.47), while there were no differences for Asian or Pacific Islander women. CONCLUSIONS Detailed maternal ethnicity explains the variation in NTSV cesarean delivery rates better than broad race/ethnicity categories. Different patterns of cesarean delivery between ethnic groups suggest cultural specificity related to birth culture.
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Affiliation(s)
| | | | - Bruce B. Cohen
- Bureau of Health Information, Statistics, Research, and Evaluation, Massachusetts Department of Public Health, Boston, MA
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Abstract
Cesarean section rates are increasing worldwide, which has been paralelled by an increase in primary cesarean delivery and decrease in vaginal birth after cesarean section. Behind the different frequencies there is a number of interrelated factors including advanced maternal age, increasing incidence of obesity, assisted reproductive technologies, and maternal request for non-medical reasons. The sub-optimal management of labor and the concerns about medical liability claims and litigations increase the number of abdominal deliveries. The author reviews the changing indications for cesarean deliveries in the last few decades and summarizes the effects on the obstetrical clinical practice.
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Affiliation(s)
- Sándor Nagy
- Petz Aladár Megyei Oktató Kórház Szülészeti és Nőgyógyászati Osztály Győr Vasvári P. u. 2-4. 9024
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Hersh S, Megregian M, Emeis C. Intermittent auscultation of the fetal heart rate during labor: an opportunity for shared decision making. J Midwifery Womens Health 2014; 59:344-9. [PMID: 24758413 DOI: 10.1111/jmwh.12178] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Electronic fetal heart rate monitoring is the most common form of intrapartal fetal assessment in the United States. Intermittent auscultation of the fetal heart rate is an acceptable option for low-risk laboring women, yet it is underutilized in the hospital setting. Several expert organizations have proposed the use of intermittent auscultation as a means of promoting physiologic childbirth. Within a shared decision-making model, the low-risk pregnant woman should be presented with current evidence about options for fetal heart rate assessment during labor.
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Association between vaginal birth after cesarean delivery and primary cesarean delivery rates. Obstet Gynecol 2014; 122:1010-1017. [PMID: 24104780 DOI: 10.1097/aog.0b013e3182a91e0f] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To estimate the association between vaginal birth after cesarean delivery (VBAC) rates and primary cesarean delivery rates in California hospitals. METHODS Hospital VBAC rates were calculated using birth certificate and discharge data from 2009, and hospitals were categorized by quartile of VBAC rate. Multivariable logistic regression analysis was performed to estimate the odds of cesarean delivery among low-risk nulliparous women with singleton pregnancies at term in vertex presentation (nulliparous term singleton vertex) by hospital VBAC quartile while controlling for many patient-level and hospital-level confounders. RESULTS There were 468,789 term singleton births in California in 2009 at 255 hospitals, 125,471 of which were low-risk nulliparous term singleton vertex. Vaginal birth after cesarean delivery rates varied between hospitals, with a range of 0-44.6%. Rates of cesarean delivery among low-risk nulliparous term singleton vertex women declined significantly with increasing VBAC rate. When adjusted for maternal and hospital characteristics, low-risk nulliparous term singleton vertex women who gave birth in hospitals in the highest VBAC quartile had an odds ratio of 0.55 (95% confidence interval 0.46-0.66) of cesarean delivery compared with women at hospitals with the lowest VBAC rates. Each percentage point increase in a hospital's VBAC rate was associated with a 0.65% decrease in the low-risk nulliparous term singleton vertex cesarean delivery rate. CONCLUSION Hospitals with higher rates of VBAC have lower rates of primary cesarean delivery among low-risk nulliparous women with singleton pregnancies at term in vertex presentation. LEVEL OF EVIDENCE II.
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Parer JT. Standardization of fetal heart rate pattern management: Is international consensus possible? HYPERTENSION RESEARCH IN PREGNANCY 2014. [DOI: 10.14390/jsshp.2.51] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Julian T. Parer
- Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California
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