Defining a Cesarean Delivery Rate for Optimizing Maternal and Neonatal Outcomes

Vaginal Uncomplicated Delivery Rate as a Quality Indicator Compared to Cesarean Delivery Rate: A Quantitative Analysis of a Population Database

OBJECTIVE

The objective of this study is comparing the vaginal uncomplicated delivery (VUD) rate, defined as all vaginal deliveries (including forceps and vacuum) without an adverse maternal or neonatal labour outcome, to the cesarean delivery (CD) rate, as a performance indicator.

METHODS

This is a retrospective cohort analysis from a provincial database of all term deliveries by an obstetrician in a single year, excluding diagnoses preventing active labour. Most obstetricians in this jurisdiction practice consultative obstetrics, focused on supporting primary maternity care. We investigated the association of adverse delivery (AD), measured by the adverse outcome index (AOI), with CD and VUD rates.

RESULTS

We report 16 620 deliveries by 210 obstetricians, with a vaginal delivery rate of 39.6%, of which 36.6% were operative vaginal delivery. The overall AD rate was 9.9%, and the overall VUD rate was 34%. While the CD and VUD both correlated with mode of delivery, only the VUD rate was correlated to the AD rate.

CONCLUSIONS

Quality assurance in obstetrics must balance the needs of two patients based on limited data. Our data shows the shortcomings of the prevailing performance indicator, CD rate, which does not correlate with birth outcomes for the pregnant patient or infant. The VUD rate provides an alternative that assesses both mode of delivery and labour outcomes. Shifting the quality lens to focus on VUD rate will provide a better metric that measures optimal outcomes for pregnant people and their babies.

OBJECTIF

Cette étude vise à comparer le taux d'accouchement vaginal sans complications (AVSC), défini comme la proportion d'accouchements vaginaux (y compris par forceps ou ventouse) sans issue maternelle ou néonatale défavorable, au taux de césariennes en tant qu'indicateur de performance. MéTHODE: Il s'agit d'une analyse de cohorte rétrospective de données extraites d'une base de données provinciale sur tous les accouchements à terme pratiqués par un obstétricien dans une année, à l'exclusion des diagnostics empêchant le travail actif. La plupart des obstétriciens de cette province ont une pratique de consultation en obstétrique, principalement pour la prestation de soins de maternité primaires. Nous avons étudié la corrélation du taux d'événements indésirables (EI) à l'accouchement, mesuré par l'indice des issues défavorables (AOI), avec le taux de césariennes et le taux d'AVSC. RéSULTATS: Nous avons recensé 16 620 accouchements réalisés par 210 obstétriciens, pour un taux d'accouchement vaginal de 39,6 %; de ces accouchements vaginaux, 36,6 % étaient des accouchements assistés. Le taux global d'EI était de 9,9 %; le taux global d'AVSC, de 34 %. Alors que la césarienne et l'AVSC sont tous deux corrélés avec le mode d'accouchement, seul le taux d'AVSC est corrélé avec le taux d'EI.

CONCLUSIONS

L'assurance de la qualité en obstétrique doit trouver un équilibre entre les besoins de deux patientes sur la base de données limitées. Nos données montrent les lacunes du taux de césariennes comme indicateur de performance dominant, car ce taux n'est pas corrélé avec les issues maternelles ou néonatales. Le taux d'AVSC serait une meilleure option, car il évalue à la fois le mode d'accouchement et les issues de l'accouchement. En considérant la qualité des soins à travers le prisme du taux d'AVSC, on obtiendrait un meilleur indicateur des issues optimales pour les personnes enceintes et leurs bébés.

The impact of indication for cesarean on blood loss

BACKGROUND

Postpartum hemorrhage is the leading cause of maternal mortality worldwide. Quantitative blood loss assessment during cesarean delivery is a more accurate measure of blood loss than simple estimation. Risk factors for postpartum hemorrhage are well described. However, contemporary systematic investigations on the effect of indications for cesarean delivery on quantitative blood loss are lacking.

OBJECTIVE

This study aimed to investigate whether there are clinically significant differences in quantitative blood loss and postpartum hemorrhage risk based on the indication for cesarean delivery.

STUDY DESIGN

A total of 4881 cesarean deliveries performed at a large academic hospital between 2020 and 2022 were identified. Primary and repeat cesarean deliveries were analyzed separately and further subdivided into 7 indications: elective, labor arrest, fetal heart rate abnormalities, placenta previa, placenta accreta, malpresentation, and other. Quantitative blood loss and rates of postpartum hemorrhage (>1000 and >1500 mL) were compared among the different indications.

RESULTS

The mean quantitative blood loss estimates for primary, repeat, and total cesarean deliveries were 886, 697, and 792 mL, respectively. Excluding cases of placenta accreta, the greatest blood loss in both primary and repeat groups was observed in cesarean deliveries performed for labor arrest, with blood loss exceeding 1500 mL in 18% and 13% of all cases. Blood loss exceeding 1500 mL was noted in 1% and 2% of elective cesarean deliveries. The mean blood loss for planned repeat cesarean deliveries/hysterectomies for placenta accreta was <400 mL greater than that for primary cesarean deliveries performed for labor arrest (1442 vs 1065 mL, respectively), despite the addition of an often-complex hysterectomy to the procedure.

CONCLUSION

Clinically and statistically significant differences in blood loss exist based on the indication for cesarean delivery. Large differences in the rates of serious postpartum hemorrhage (>1500 mL) with negligible differences in mean quantitative blood loss suggest the presence of frequent, large clinical outliers not reflected in a statistical mean. The indication for cesarean delivery and the possibility of such outliers rather than the predicted "average blood loss for cesarean delivery" should be considered when determining risk and the degree of necessary preoperative blood preparation. These data raise questions about whether current traditional techniques of cesarean delivery not associated with placenta accreta can be justified in nonemergent cases when such procedures can be performed with significantly less blood loss using techniques specific for placenta accreta.

Caesarean section rate reduced by a redesigned birthing room. Results of a quality improvement intervention at a hospital in Democratic Republic of Congo

OBJECTIVE

To evaluate the influence of a new birthing room at a tertiary hospital in eastern Democratic Republic of Congo (DRC), on the caesarean section (CS) rate in women classified as Robson group 1, i.e., nulliparous women at term with spontaneous onset of labour of one foetus in cephalic presentation.

METHOD

As part of quality improvement interventions, a new birthing room designed to promote person-centredness was constructed at the labour ward at Panzi General Referral Hospital in DRC. In a quasi-experimental study on women classified as Robson 1, a comparison was performed between the group being cared for in the new birthing room and the group being cared for in the general birthing room. The main outcome measure was CS rate.

RESULTS

In the new person-centred birthing room, the CS rate was 17.1 % versus 28.4 % in women cared for in the general birthing room (p-value 0.001). There was also a higher presence of accompanying persons (p-value < 0.0001) and less use of synthetic oxytocin for the augmentation of labour (p-value 0.024). No difference in fear and childbirth experience was identified between women in the two rooms.

CONCLUSION

The results demonstrate that it is possible, in a low-income country as the Democratic Republic of Congo, to reduce the CS rate in women classified as Robson 1 by adapting the birthing environment to be more person-centred, without compromising other obstetric and neonatal outcomes.

Association of Maternal Comorbidity Burden With Cesarean Birth Rate Among Nulliparous, Term, Singleton, Vertex Pregnancies

IMPORTANCE

Cesarean birth rate among nulliparous, term, singleton, vertex (NTSV) pregnancies is a standard quality measure in obstetrical care. There are limited data on how the number and type of preexisting conditions affect mode of delivery among primigravidae, and it is also uncertain how maternal comorbidity burden differs across racial and ethnic groups and whether this helps to explain disparities in the NTSV cesarean birth rate.

OBJECTIVE

To determine the association between obstetric comorbidity index (OB-CMI) score and cesarean delivery among NTSV pregnancies and to evaluate whether disparities in mode of delivery exist based on race and ethnicity group after adjusting for covariate factors.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study of deliveries between January 2019 and December 2021 took place across 7 hospitals within a large academic health system in New York and included all NTSV pregnancies identified in the electronic medical record system. Exclusion criteria were fetal demise and contraindication to labor.

EXPOSURE

The OB-CMI score. Covariate factors assessed included race and ethnicity group (American Indian or Alaska Native, Asian or Pacific Islander, Hispanic, non-Hispanic Black, non-Hispanic White, other or multiracial, and declined or unknown), public health insurance, and preferred language.

MAIN OUTCOME AND MEASURES

Cesarean delivery.

RESULTS

A total of 30 253 patients (mean [SD] age, 29.8 [5.4] years; 100% female) were included. Non-Hispanic White patients constituted the largest race and ethnicity group (43.7%), followed by Hispanic patients (16.2%), Asian or Pacific Islander patients (14.6%), and non-Hispanic Black patients (12.2%). The overall NTSV cesarean birth rate was 28.5% (n = 8632); the rate increased from 22.1% among patients with an OB-CMI score of 0 to greater than 55.0% when OB-CMI scores were 7 or higher. On multivariable mixed-effects logistic regression modeling, there was a statistically significant association between OB-CMI score group and cesarean delivery; each successive OB-CMI score group had an increased risk. Patients with an OB-CMI score of 4 or higher had more than 3 times greater odds of a cesarean birth (adjusted odds ratio, 3.14; 95% CI, 2.90-3.40) than those with an OB-CMI score of 0. Compared with non-Hispanic White patients, nearly all other race and ethnicity groups were at increased risk for cesarean delivery, and non-Hispanic Black patients were at highest risk (adjusted odds ratio, 1.43; 95% CI, 1.31-1.55).

CONCLUSIONS AND RELEVANCE

In this cross-sectional study of patients with NTSV pregnancies, OB-CMI score was positively associated with cesarean birth. Racial and ethnic disparities in this metric were observed. Although differences in the prevalence of preexisting conditions were seen across groups, this did not fully explain variation in cesarean delivery rates, suggesting that unmeasured clinical or nonclinical factors may have influenced the outcome.

Impact of new labor management guidelines on Cesarean rates among low-risk births at New York City hospitals: A controlled interrupted time series analysis

PURPOSE

To examine the impact of the American College of Obstetricians and Gynecologists and Society for Maternal-Fetal Medicine (ACOG-SMFM) 2014 recommendations for preventing unnecessary primary Cesareans.

METHODS

In a population-based cohort of births in New York City from 2012 to 2016, we used controlled interrupted time series analyses to estimate changes in age-standardized Cesarean rates among nulliparous, term, singleton vertex (NTSV) deliveries.

RESULTS

Among 192,405 NTSV births across 40 hospitals, the age-standardized NTSV Cesarean rate decreased after the ACOG-SMFM recommendations from 25.8% to 24.0% (Risk ratio [RR]: 0.93; 95% CI 0.89, 0.97), with no change in the control series. Decreases were observed among non-Hispanic White women (RR: 0.89; 95% CI 0.82, 0.97), but not among non-Hispanic Black women (RR: 0.97; 95% CI 0.88, 1.07), Asian/Pacific Islanders (RR: 1.01; 95% CI 0.91, 1.12), or Hispanic women (RR: 0.94; 95% CI 0.86, 1.02). Similar patterns were observed at teaching hospitals, with no change at nonteaching hospitals.

CONCLUSIONS

While low-risk Cesarean rates may be modifiable through changes in labor management, additional research, and interventions to address Cesarean disparities, are needed.