Obstetric - Quality Improvement - Cesarean Section Resources

Anecdotally, it has been suggested that obstetricians of similar training and experience have different intervention rates on the labour ward. This phenomenon has not been studied in depth. The aim of this study was to record the intra-partum intervention rates for third on-call registrars and correlate this with the anxiety traits of the corresponding registrars. An analysis of births occurring during out-of-hours in the main delivery unit of a large teaching hospital during the period September 2005–September 2006 was carried out. The rate of interventions per cumulative number of deliveries that occurred specific to each doctor on-call was calculated. Anxiety traits were calculated with a validated questionnaire. There is a significant difference in the caesarean section rates between registrars of similar experience. There is also a strong correlation between the registrar’s anxiety trait level and the registrar’s emergency caesarean section rates (Pearsons correlate 0.722, p50.01).

Objectives: To investigate why some women prefer caesarean sections and how decisions to medicalise birthing are influenced by patients, doctors, and the sociomedical environment. Design: Population based birth cohort study, using ethnographic and epidemiological methods. Setting: Epidemiological study: women living in the urban area of Pelotas, Brazil who gave birth in hospital during the study. Ethnographic study: subsample of 80 women selected at random from the birth cohort. Nineteen medical staff were interviewed. Participants: 5304 women who gave birth in any of the city's hospitals in 1993. Main outcome measures Birth by caesarean section or vaginal delivery. Results: In both samples women from families with higher incomes and higher levels of education had caesarean sections more often than other women. Many lower to middle class women sought caesarean sections to avoid what they considered poor quality care and medical neglect, resulting from social prejudice. These women used medicalised prenatal and birthing health care to increase their chance of acquiring a caesarean section, particularly if they had social power in the home. Both social power and women's behaviour towards seeking medicalised health care remained significantly associated with type of birth after controlling for family income and maternal education. Conclusions: Fear of substandard care is behind many poor women's preferences for a caesarean section. Variables pertaining to women's role in the process of redefining and negotiating medical risks were much stronger correlates of caesarean section rates than income or education. The unequal distribution of medical technology has altered concepts of good and normal birthing. Arguments supporting interventionist birthing for all on the basis of equal access to health care must be reviewed.

NOTE: This article has a published correction included below: In figure 4 of this research paper by Fiona Bragg and colleagues (BMJ 2010;341:c5065, doi:10.1136/bmj.c5065) the title label for the top panel of figure 4 was inadvertently also used for the bottom panel. The label on the bottom panel should read: “Adjusted caesarean section rates” [not “Unadjusted caesarean section rates”]. Objective: To determine whether the variation in unadjusted rates of caesarean section derived from routine data in NHS trusts in England can be explained by maternal characteristics and clinical risk factors. Design: A cross sectional analysis using routinely collected hospital episode statistics was performed. A multiple logistic regression model was used to estimate the likelihood of women having a caesarean section given their maternal characteristics (age, ethnicity, parity, socioeconomic deprivation) and clinical risk factors (previous caesarean section, breech presentation, fetal distress). Adjusted rates of caesarean section for each NHS trust were produced from this model. Setting: 146 English NHS trusts. Population: Women aged between 15 and 44 years with a singleton birth between 1 January and 31 December 2008. Main outcome measure: Rate of caesarean sections per 100 births (live or stillborn). Results: Among 620 604 singleton births, 147 726 (23.8%) were delivered by caesarean section. Women were more likely to have a caesarean section if they had had one previously (70.8%) or had a baby with breech presentation (89.8%). Unadjusted rates of caesarean section among the NHS trusts ranged from 13.6% to 31.9%. Trusts differed in their patient populations, but adjusted rates still ranged from 14.9% to 32.1%. Rates of emergency caesarean section varied between trusts more than rates of elective caesarean section. Conclusion: Characteristics of women delivering at NHS trusts differ, and comparing unadjusted rates of caesarean section should be avoided. Adjusted rates of caesarean section still vary considerably and attempts to reduce this variation should examine issues linked to emergency caesarean section.

Objectives: The purpose of this study was to determine whether women's sociodemographic characteristics are independently associated with cesarean delivery. Methods: A retrospective review was conducted of hospital discharge data for singleton first births in California in 1991. Results: After insurance and personal, community, medical, and hospital characteristics had been controlled, Blacks were 24% more likely to undergo cesarean delivery than Whites; only among low-birthweight and county hospital births were Blacks not at a significantly elevated risk. Among women who resided in substantially non-English-speaking communities, who delivered high-birthweight babies, or who gave birth at for-profit hospitals, cesarean delivery appeared to be more likely among non-Whites and ws over 40% more likely among Blacks than among Whites. Conclusions: The findings cannot establish causation, but the significant racial/ethnic disparities in delivery mode, despite adjustment for social, economic, medical, and hospital factors, suggest inappropriate influences on clinical decision making that would not be addressed by changes in reimbursement. If practice variations among providers are involved, de facto racial differences in access to optimal care may be indicated. The role of provider and patient attitudes and expectations in the observed racial/ethnic differentials should also be explored.

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

OBJECTIVE. To determine the age-stratified risk of intrapartum and neonatal mortality as well as morbidities of clinical relevance after elective cesarean delivery (ECD). METHODS. This work was a cohort study including 56 549 prospectively recorded late preterm and term deliveries. We analyzed the effect of cesarean delivery (CD) before the onset of labor on the following multiple neonatal outcomes before hospital discharge, compared with planned vaginal delivery (PVD) and emergency
CD: mortality, birth depression, special care admission, and respiratory morbidity. We adjusted for confounders by multivariate analysis and stratified the risk according to gestational age (GA). RESULTS. Mortality and morbidities had a strong GA-related trend with the lowest incidences consistently found between 38 and 40 weeks of gestation independent of delivery mode. Compared with infants delivered via PVD, infants delivered via ECD had significantly higher rates of mortality (adjusted risk ratio [aRR]: 2.1), risk of special care admission (a
RR: 1.4), and respiratory morbidity (a
RR: 1.8) but not of depression at birth (a
RR: 1.1). Compared with emergency CD, newborns delivered via ECD had less depression at birth (a
RR: 0.6) and admission to special care (a
RR: 0.8), but mortality (a
RR: 0.8) and respiratory morbidity (a
RR: 1.0) rates were similar. CONCLUSIONS. Gestational age–specific risk estimates are lowest between 38 and 40 weeks and should be included in the informed-consent process. The information should also be used to allow for appropriate preparation with respect to adequate staff and equipment. ECD is consistently associated with increased intrapartum and neonatal mortality, risk of admission, and respiratory morbidity compared with PVD and has no advantage over emergency CD in terms of mortality. Neonatal morbidities are lower after ECD than emergency CD only with term births. Our data provide evidence that ECD should not be performed before term.

The willingness of individuals to engage in a harmful act may be influenced by direct personal experiences and the experiences of others, which can inform individuals about the likely consequences of their actions. In this paper, we examine how obstetricians respond to litigation. It is contended that obstetricians respond to increases in litigiousness by performing more cesarean sections. Using micro data, we examine whether physicians perform more cesareans after they or their colleagues have been contacted about a lawsuit.We observe very small, short-lived increases in cesarean section rates. It does not appear that the recent sharp rise in cesarean section rates is in direct response to litigation.

OBJECTIVE: To examine trends in primary cesarean deliveries by indications and race/ethnicity. STUDY DESIGN: We examined temporal trends in primary cesarean deliveries from 1991 through 2008 among singleton births (n
540,953) in Kaiser Permanente Southern California hospitals using information from maternal hospitalizations and infant birth certificates. In addition, relative increases and 95% confidence intervals (CIs) were used to estimate differences in primary cesarean section rates by indication for the earliest (1991-1992) and most recent (2007-2008) periods. Racial/ethnic disparities in primary cesarean deliveries were examined by comparing the relative risks from multiple logistic regression models. RESULTS: The rate of primary cesarean section among white, African American, Hispanic, and Asian/Pacific Islander women increased by 61.6%, 64.1%, 62.4%, and 70.2%, respectively, between 1991 and 2008. In comparison to the primary cesarean section rate for white women, the rate was 25% (95% confidence interval [CI], 22–29%) higher for African American women, 19% (95% CI, 16–23%) higher for Asian/Pacific Islander women, but 14% (95% CI, 13–16%) lower for Hispanic women. After adjustment for confounding factors, primary cesarean section rates remained significantly higher for African American women but lower for Hispanic women compared with white women. Indication subtypes-specific rates of primary cesarean section varied markedly across race/ethnicity. CONCLUSION: We found that the overall primary cesarean section rate has increased over time. In addition, there is a wide variability in rate of indications for primary cesarean section by race/ethnicity.

OBJECTIVES. Juggling breastfeeding and paid work can challenge breastfeeding success. We examined the relationship between breastfeeding and maternity leave before andafter delivery among working mothers in Southern California. California is 1 of only 5 states in the United States providing paid pregnancy leave that can be extended forinfant bonding. PATIENTS AND METHODS. Drawing from a case-control study of preterm birth and low birth weight, 770 full-time working mothers were compared on whether they established breastfeeding in the first month. For those who established breastfeeding, we examined duration. Eligible women participated in California’s Prenatal Screening Program; delivered live births between July 2002 and December 2003; were
18 years old; had a singleton birth without congenital anomalies; and had a US mailing address. We assessed whether maternity leave and other occupational characteristics predicted breastfeeding cessation and used multivariate regression models weighted for probability of sampling to calculate odds ratios for breastfeeding establishment and hazards ratios for breastfeeding cessation. RESULTS.A maternity leave of 6 weeks or 6 to 12 weeks after delivery was associated, respectively, with a fourfold and twofold higher odds of failure to establish breastfeeding and an increased probability of cessation after successful establishment, relative to women not returning to work, after adjusting for covariates. The impact of short postpartum leave on breastfeeding cessation was stronger among nonmanagers, women with inflexible jobs, and with high psychosocial distress. Antenatal leave in the last month of pregnancy was not associated with breastfeeding establishment or duration. CONCLUSIONS. Postpartum maternity leave may have a positive effect on breastfeeding among full-time workers, particularly those who hold nonmanagerial positions, lack job flexibility, or experience psychosocial distress. Pediatricians should encourage patients to take maternity leave and advocate for extending paid postpartum leave and flexibility in working conditions for breastfeeding women.

Purpose. The health effects of antenatal maternity leave have been scarcely evaluated. In California, women are eligible for paid benefits up to 4 weeks before delivery. We explored whether leave at36 weeks gestation increases gestation and birthweight, and reduces primary cesarean deliveries among full-time working women. Methods. Drawing from a 2002–2003 nested case-control study of preterm birth and low birthweight among working women in Southern California, we compared a cohort of women who took leave (n ¼ 62) or worked until delivery (n ¼ 385). Models weighted for probability of sampling were used to calculate hazards ratios for gestational age, odds ratios (OR) for primary cesarean delivery, and multilinear regression coefficients for birthweight. Main Findings. Leave-takers were similar to non–leave-takers on demographic and health characteristics, except that more clerical workers took leave (p ¼ .02). Compared with non–leave-takers, leave-takers had almost 4 times lower odds of cesarean delivery after adjusting for covariates (OR, 0.27; 95% confidence interval [CI], 0.08–0.94). Overall, there were no marked differences in length of gestation or mean birthweight. However, in a subgroup of women whose efforts outstripped their occupational rewards, gestation was prolonged (hazard ratio for delivery each day between 36 and 41 weeks, 0.56; 95% CI, 0.34–0.93). Conclusion. Maternity leave in late pregnancy shows promise for reducing cesarean deliveries and prolonging gestation in occupationally strained women.

OBJECTIVE: To systematically review the evidence about maternal and neonatal outcomes relating to vaginal birth after cesarean (VBAC). DATA SOURCES: Relevant studies were identified from multiple searches of MEDLINE, DARE, and the Cochrane databases (1980 to September 2009) and from recent systematic reviews, reference lists, reviews, editorials, Web sites, and experts. METHODS OF STUDY SELECTION: Inclusion criteria limited studies to the English-language and human studies conducted in the United States and developed countries specifically evaluating birth after previous cesarean delivery. Studies focusing on high-risk maternal or neonatal conditions, including breech vaginal delivery, or fewer than 10 patients were excluded. Poor-quality studies were not included in analyses. TABULATION, INTEGRATION,
AND RESULTS: We identified 3,134 citations and reviewed 963 articles for inclusion; 203 articles met the inclusion criteria and were quality rated. Overall rates of maternal harms were low for both trial of labor and elective repeat cesarean delivery. Although rare in both elective repeat cesarean delivery and trial of labor, maternal mortality was significantly increased for elective repeat cesarean delivery at 0.013% compared with 0.004% for trial of labor. The rates of maternal hysterectomy, hemorrhage, and transfusions did not differ significantly between trial of labor and elective repeat cesarean delivery. The rate of uterine rupture for all women with prior cesarean was 0.30%, and the risk was significantly increased for trial of labor (0.47% compared with 0.03% for elective repeat cesarean delivery). Perinatal mortality was also significantly increased for trial of labor (0.13% compared with 0.05% for elective repeat cesarean delivery). CONCLUSION: Overall the best evidence suggests that VBAC is a reasonable choice for the majority of women. Adverse outcomes were rare for both elective repeat cesarean delivery and trial of labor. Definitive studies are lacking to identify patients who are at greatest risk for adverse outcomes.

OBJECTIVE: To examine regional variations in rates of primary cesarean delivery and assisted vaginal delivery in the population of British Columbia, while adjusting for the maternal characteristics and conditions that increase the likelihood of operative delivery. METHODS: Using data from the British Columbia Perinatal Database Registry, we studied all deliveries in British Columbia between 2004 and 2007, excluding women who had a previous cesarean delivery (n
116,839). Our primary outcome of interest was mode of delivery, further defined as delivery by cesarean or assisted vaginal delivery. We calculated crude and risk-adjusted rates of primary cesarean delivery and assisted vaginal delivery across British Columbia’s 16 Health Service Delivery Areas and examined cesarean delivery rates by indication for the procedure. RESULTS: Crude primary cesarean delivery and assisted vaginal delivery rates varied markedly across the Health Service Delivery Areas ranging from 16.1 to 27.5 per 100 deliveries, and from 8.6 to 18.6 per 100 deliveries, respectively. The most common indication for cesarean delivery was dystocia, which accounted for 30.0% of all cesarean deliveries and varied more than fivefold across regions. After controlling for maternal characteristics and conditions known to increase the likelihood of cesarean delivery and assisted vaginal delivery, adjusted cesarean delivery rates varied twofold, ranging from 14.7 to 27.6 per 100 deliveries, while adjusted assisted vaginal delivery rates varied by more than twofold, ranging from 6.5 to 15.3 per 100 deliveries.

We performed a cross-sectional study of all Thames maternity units, 1994–96, including 540 834 live and stillbirths. In contrast to recent media speculation, no association of caesarean section rates with midwifery staffing levels was found after adjustment for confounders. The only association with staffing was with levels of junior obstetric staffing, which could be a reflection of less experienced management of labour. Caesarean section rates were also associated positively with the levels of delivery beds, which could be a reflection of the closer monitoring of labour that may result from increased bed availability. Both caesarean section and instrumental vaginal delivery rates were associated with epidural rates, which was expected from the literature. Variations in epidural rates were mainly associated with variations in demographic case-mix, due possibly to patient demand. Demographic case-mix was also associated with instrumental vaginal deliveries but not the caesarean section rate.

ABSTRACT: A recent systematic review found no ‘‘good quality evidence’’ that elective induction of labor confers substantial benefits to either mothers or babies, but concluded that elective induction is associated with a decreased risk of ‘‘cesarean delivery.’’ Admittedly, elective induction was qualified as ‘‘at 41 weeks of gestation and beyond’’ with 42 weeks being proclaimed as the cutoff point between ‘‘elective’’ and ‘‘medically indicated.’’ Major predictors of the success of any induction and the subsequent mode of delivery, such as parity and cervical status, were not taken into account. Crucial boundaries between what is elective and what is selective, what is medically indicated and what is not, and what is maternal request or persuasive coercion, remain as vague as ever.

ABSTRACT: Background: The suggestion that planned cesarean birth is gaining acceptance among women has led some physicians to advocate the need for a trial of primary planned cesarean section versus planned vaginal birth in healthy women with singleton cephalic pregnancies at term. This paper reviews published studies of nulliparous women’s views of mode of birth collected in the antenatal period, examining why women may express a preference for cesarean birth and exploring implications for the debate about the need for a trial. Methods: A systematic literature review was undertaken of Cochrane, CINAHL, EMBASE, MEDLINE, and PsycINFO using the MeSH heading ‘‘cesarean section’’ and four free text spellings of ‘‘cesarean,’’ or ‘‘birth’’ or ‘‘delivery,’’ near truncated synonyms of 17 words meaning expressed preference. Studies of nulliparous women with a medical indication for cesarean birth, studies where a woman’s preference for mode of birth was reported in the postpartum period, surveys of midwives or obstetricians, and opinion and non-English language papers were all excluded. Results: Nine papers were included in the review, which reported rates of women expressing a preference for cesarean birth that ranged from 0 to 100 percent at recruitment. However, the papers raised specific methodological, conceptual, and cultural issues that may have influenced women’s preferences for mode of birth in the populations studied. These issues included the timing and frequency of data collection, complexity of factors determining individual women’s decision making, and influence of societal norms. Conclusions: Little evidence is available that an increasing cultural acceptance of cesarean delivery will bring about support for a trial among pregnant nulliparous women. Further qualitative research investigating the influence of both obstetric and psychosocial factors on women’s views of vaginal and cesarean birth is required.

This article invokes Habermas’s ideal speech situation to analyze the controversy surrounding a recent study of pain relief for women in labor. Using Habermas’s concepts, the authors argue that distortion of scientific and medical information originated in the New England Journal of Medicine article that first reported the study’s results. Thus, their analysis aims to complicate the assumption that such distortion starts only with public reporting and to expose the ways that scientific or medical research from the beginning can be reported to either facilitate or preclude public debate and understanding of complex issues.

Deciding when and how to incorporate patient preferences regarding mode of delivery is challenging for both obstetric providers and policymakers. An analysis of current guidelines in four clinical scenarios (prior cesarean, twin delivery, breech presentation, and maternal request for cesarean) indicates that some guidelines are highly prescriptive, while others are more flexible, based on physicians’ discretion or (less frequently) patient preferences, without consistency or explicit rationale for when such flexibility is permissible, advisable, or obligatory. While patient choice advocates have called for more patient-responsive guidelines, concerns have also been raised, especially in the context of discussions of cesarean delivery on maternal request, about the dangers of unfettered patient preference-driven clinical decisions. In this article, we outline a framework for the responsible inclusion of patient preferences into decision making regarding approach to delivery. We conclude, using this framework, that more explicit incorporation of patient preferences are called for in the first three scenarios, and indicate why expanding access to cesarean delivery on maternal request is more complicated and would require more data and further consideration.

Background: There has been concern about rising rates of caesarean section worldwide. This Article reports the third phase of the WHO global survey, which aimed to estimate the rate of diff erent methods of delivery and to examine the relation between method of delivery and maternal and perinatal outcomes in selected facilities in Africa and Latin America in 2004–05, and in Asia in 2007–08. Methods: Nine countries participated in the Asia global survey: Cambodia, China, India, Japan, Nepal, Philippines, Sri Lanka, Thailand, and Vietnam. In each country, the capital city and two other regions or provinces were randomly selected. We studied all women admitted for delivery during 3 months in institutions with 6000 or fewer expected deliveries per year and during 2 months in those with more than 6000 deliveries. We gathered data for institutions to obtain a detailed description of the health facility and its resources for obstetric care. We obtained data from women’s medical records to summarize obstetric and perinatal events. Findings: We obtained data for 109 101 of 112 152 deliveries reported in 122 recruited facilities (97% coverage), and analyzed 107 950 deliveries. The overall rate of caesarean section was 27·3% (n=29 428) and of operative vaginal delivery was 3·2% (n=3465). Risk of maternal mortality and morbidity index (at least one of: maternal mortality, admission to intensive care unit [ICU], blood transfusion, hysterectomy, or internal iliac artery ligation) was increased for operative vaginal delivery (adjusted odds ratio 2·1, 95% CI 1·7–2·6) and all types of caesarean section (antepartum without indication 2·7, 1·4–5·5; antepartum with indication 10·6, 9·3–12·0; intrapartum without indication 14·2, 9·8–20·7; intrapartum with indication 14·5, 13·2–16·0). For breech presentation, caesarean section, either antepartum (0·2, 0·1–0·3) or intrapartum (0·3, 0·2–0·4), was associated with improved perinatal outcomes, but also with increased risk of stay in neonatal ICU (2·0, 1·1–3·6; and 2·1, 1·2–3·7, respectively). Interpretation: To improve maternal and perinatal outcomes, caesarean section should be done only when there is a medical indication.

Objectives. We examined the relationship between obstetrical intervention and preterm birth in the United States between 1991 and 2006. Methods. We assessed changes in preterm birth, cesarean delivery, labor induction, and associated risks. Logistic regression modeled the odds of preterm obstetrical intervention after risk adjustment. Results. From 1991 to 2006, the percentage of singleton preterm births increased 13%. The cesarean delivery rate for singleton preterm births increased 47%, and the rate of induced labor doubled. In 2006, 51% of singleton preterm births were spontaneous vaginal deliveries, compared with 69% in 1991. After adjustment for demographic and medical risks, the mother of a preterm infant was 88% (95% confidence interval [CI]=1.87, 1.90) more likely to have an obstetrical intervention in 2006 than in 1991. Using new birth certificate data from 19 states, we estimated that 42% of singleton preterm infants were delivered via induction or cesarean birth without spontaneous onset of labor. Conclusions. Obstetrical interventions were related to the increase in the US preterm birth rate between 1991 and 2006. The public health community can play a central role in reducing medically unnecessary interventions. (Am J Public Health. 2010;100:2241–2247. doi:10.2105/AJPH.2009.180570)

Objective: This study was undertaken to assess the utility of the nulliparous term singleton vertex cesarean birth (NTSV CB) measure as a quality improvement tool for use at the hospital level. Study design: We prospectively collected data on all NTSV births in Sutter Health’s 20 birthing units over a 3-year period, 2001 through 2003, totaling 41,416 births. Hospital rates of NTSV CB, obstetric practices, and infant outcomes were calculated and compared by using weighted logistic analyses. In addition, we examined the effect of maternal age on the NTSV CB measure by using direct standardization with US norms for nulliparous women. Results: There was large variation noted in the NTSV CB rate among the 20 hospitals, with unadjusted rates ranging from 10.5% to 30.2%. Strong correlations were found between CB rates and labor induction rates (r = 0.57, P ! .0001) and with early labor admission rates (r = 0.62, P ! .0001). The strongest correlation was found between NTSV CB rates and a combined measure of induction and early labor admission (r=0.73, P!.0001). Rates of term 5-minute Apgar score below 7 were not correlated with the NTSV CB rate. Hospital nulliparous maternal age distribution varied markedly and direct standardization led to significant changes in the NTSV CB rate. Conclusion: NTSV CB rate is strongly influenced by elective obstetric practices. The addition of an easily performed maternal age adjustment makes it the most promising CB quality measure for use at the hospital level.

Background: The multi-organizational collaborative is a popular model for quality improvement (QI) initiatives. It assumes organizations will share information and social support. However, there is no comprehensive documentation of the extent to which teams do interact. Considering QI collaboratives as networks, interactions among teams were documented, and the associations between network roles and performance were examined. Methods: A telephone survey of official team contact persons for 94 site teams in three QI collaboratives was conducted in 2002 and 2003. Four performance measures were used to assess the usefulness of ties to other teams and being considered a leader by peers. Results: Eighty percent of the teams said they would contact another team again if they felt the need. Teams made a change as a direct result of interaction in 86% of reported relationships. Teams typically exchanged tools such as software and interacted outside of planned activities. Having a large number of ties to other teams is strongly related to the number of mentions as a leader. Both of these variables are related to faculty-assessed performance, number of changes the team made to improve care, and depth of those changes. Discussion: The findings suggest that collaborative teams do indeed exchange important information, and the social dynamics of the collaboratives contribute to individual and collaborative success.

Background: The rate of caesarean sections is increasing worldwide, yet medical literature informing women with uncomplicated pregnancies about relative risks and benefits of elective caesarean section (CS) compared with vaginal delivery (VD) remains scarce. A decision board may address this gap, providing systematic evidence-based information so that patients can more fully understand their treatment options. The objective of our study was to design and pretest a decision board to guide clinical discussions and enhance informed decision-making related to delivery approach (CS or VD) in uncomplicated pregnancy. Methods: Development of the decision board involved two preliminary studies to determine women's preferred mode of risk presentation and a systematic literature review for the most comprehensive presentation of medical risks at the time (VD and CS). Forty women were recruited to pre-test the tool. Eligible subjects were of childbearing age (18-40 years) but were not pregnant in order to avoid raising the expectation among pregnant women that CS was a universally available birth option. Women selected their preferred delivery approach and completed the Decisional Conflict Scale to measure decisional uncertainty before and after reviewing the decision board. They also answered open-ended questions reflecting what they had learned, whether or not the information had helped them to choose between birth methods, and additional information that should be included. Descriptive statistics were used to analyse sample characteristics and women's choice of delivery approach pre/post decision board. Change in decisional conflict was measured using Wilcoxon's sign rank test for each of the three subscales. Results: The majority of women reported that they had learned something new (n = 37, 92%) and that the tool had helped them make a hypothetical choice between delivery approaches (n = 34, 85%). Women wanted more information about neonatal risks and personal experiences. Decisional uncertainty decreased (p < 0.001) and perceived effectiveness of decisions increased (p < 0.001) post-intervention. Conclusion: Non-pregnant women of childbearing age were positive about the decision board and stated their hypothetical delivery choices were informed by risk presentation, but wanted additional information about benefits and experiences. This study represents a preliminary but integral step towards ensuring women considering delivery approaches in uncomplicated pregnancies are fully informed.

OBJECTIVE: The American College of Obstetricians and Gynecologists has recommended that elective deliveries not be performed before 39 weeks of gestation, to minimize prematurity-related neonatal complications. Because a worrisome number of elective deliveries were occurring before 39 weeks of gestation in our system, we developed and implemented a program to decrease the number of these early term elective deliveries. Secondary objectives were to monitor relevant clinical outcomes.
METHODS: The electronic medical records of an integrated health care system involving nine labor and delivery units in Utah were queried to establish the incidence of patients admitted for elective induction of labor or planned elective cesarean delivery. These facilities have open staff models with obstetricians, family practitioners, and certified nurse midwives. Guidelines were developed and implemented to discourage early term elective deliveries. The prevalence of early term elective deliveries was tracked and reported back regularly to the obstetric leadership and obstetric departments at each facility.
RESULTS: The baseline prevalence of early term elective deliveries was 28% of all elective deliveries before the initiation of the program. Within 6 months of initiating the program, the incidence of near-term elective deliveries decreased to less than 10% and after 6 years continues to be less than 3%. A reduced length of stay in labor and delivery occurred with the introduction of the program, and there were no adverse effects on secondary clinical outcomes.
CONCLUSION: With institutional commitment, it is possible to substantially reduce and sustain a decline in the incidence of elective deliveries before 39 weeks of gestation.

Cesarean rates have been rising in the United States. Recently, there has been an upsurge of interest in “cesarean on maternal request” in the absence of any medical indication, a phenomenon that will further increase the cesarean rate. This trend may not be benign on a population basis, and reliable data are lacking. This article reviews reasons for the increasing cesarean rate, describes maternal and neonatal consequences likely to accrue with a policy of cesarean on demand, and explores larger implications for public health. Target Audience: Obstetricians & Gynecologists, Family Physicians Learning Objectives: After completion of this article, the reader should be able to state that there continues to be a rise in the cesarean delivery rate in the United States and summarize that cesarean delivery on maternal request (CDMR) is contributing to this rise without data to indicate a decrease in maternal and fetal mortality and morbidity, possibly with a large population cost.

In this article, the authors present the central finding of a study aimed at identifying possible relationships between the ways in which labor and delivery (L&D) nurses cognitively frame childbirth and cesarean section (CS) rates. They recruited 51 L&D nurses employed at two hospitals in a Midwestern city in the United States to participate in the study, in which they used a projective method to explore nurses’ views about the meaning of childbirth and their possible relationship to CS. The authors selected a projective method for this research to identify the preconscious beliefs that inform clinical action. Analysis of the narrative responses to the photograph demonstrated three distinct ways in which participants cognitively framed childbirth and possible ways in which acting in accordance with these belief systems might influence the use of CS.

Purpose: To ascertain any differences in foetomaternal outcomes in induced and spontaneous labour among nulliparous women delivering at term. Methods: A retrospective matched cohort study consisting of 403 nulliparous women induced at C292 days and 806 nulliparous women with spontaneous labour at 285–291 days. Results: Compared to those in spontaneous labour, women who had induction of labour were three times more likely to have a caesarean delivery (OR 3.1, 95% CI 2.4–4.1; P \ 0.001). Women who had induction of labour were 2.2 times more likely to have oxytocin augmentation (OR 2.2, 95% CI 1.7–2.8; P \ 0.001), 3.6 times more likely to have epidural anaesthesia (OR 3.6, 95% CI 2.8–4.6; P \ 0.001), 1.7 times more likely to have uterine hyperstimulation (OR 1.7, 95% CI 1.1–2.6), 2 times more likely to have a suspicious foetal heart rate trace (OR 2.0, 95% CI 1.5–2.6), 4.1 times more likely to have blood loss over 500 ml (OR 4.1, 95% CI 2.9–5.5; P \ 0.001), and 2.9 times more likely to stay in hospital beyond 5 days (OR 2.9, 95% CI 1.5–5.6; P \ 0.001). Babies born to mothers who had induction of labour were significantly more likely to have an Apgar score of \ 5 at 5 min and an arterial cord pH of \ 7.0. Conclusion: Compared to those with spontaneous labour, nulliparous women with induced labours are more likely to have uterine hyperstimulation, caesarean delivery, and babies with low Apgar scores. Nulliparous women should be made aware of this, as well as potential risks of expectant management during counseling.

Background: At 30 percent, British Columbia has the highest cesarean section rate in Canada. Little is known about the childbirth views and birthing preferences of college aged women and men. The objectives of this study were to document (a) the prevalence of cesarean versus vaginal delivery as the preferred mode of delivery among nonpregnant university students without a history of childbirth, (b) the reasons for reported childbirth preferences, and (c) confidence in vaginal birth as a predictor of childbirth preference. Methods: A cohort of 3,680 male and female university students without a history of childbirth participated in an online survey of childbirth preferences. The study used a mixed methods approach (quantitative thematic analysis and logistic regression modeling). Prevalence of, and reasons for, preferred mode of delivery were analyzed separately for male and female respondents. Results: Most men and women responded that they preferred vaginal delivery, with 9 percent stating a preference for cesarean delivery. Reasons for preferred mode of delivery were similar for men and women. For women, confidence in vaginal birth emerged as a significant predictor of childbirth preference. Conclusions: Results indicate that a preference for cesarean section is linked to fear of childbirth and driven by low confidence in vaginal birth. Educational strategies targeting university-aged men and women may be helpful in alleviating fears of vaginal birth and providing evidence-based information about different birth options.

The philosophy of “evidence-based medicine”—basing medical decisions on evidence from randomized controlled trials and other forms of aggregate data rather than on clinical experience or expert opinion—has swept U.S. medical practice in recent years. Obstetricians justify recent increases in the use of cesarean section, and dramatic decreases in vaginal birth following previous cesarean, as evidence-based obstetrical practice. Analysis of pivotal “evidence” supporting cesarean demonstrates that the data are a product of its social milieu: The mother’s body disappears from analytical view; images of fetal safety are marketing tools; technology magically wards off the unpredictability and danger of birth. These changes in practice have profound implications for maternal and child health. A feminist project within obstetrics is both feasible and urgently needed as one locus of resistance.

OBJECTIVE: To describe contemporary cesarean delivery practice in the United States. STUDY DESIGN: Consortium on Safe Labor collected detailed labor and delivery information from 228,668 electronic medical records from 19 hospitals across the United States, 2002-2008. RESULTS: The overall cesarean delivery rate was 30.5%. The 31.2% of nulliparous women were delivered by cesarean section. Prelabor repeat cesarean delivery due to a previous uterine scar contributed 30.9% of all cesarean sections. The 28.8% of women with a uterine scar had a trial of labor and the success rate was 57.1%. The 43.8% women attempting vaginal delivery had induction. Half of cesarean for dystocia in induced labor were performed before 6 cm of cervical dilation. CONCLUSION: To decrease cesarean delivery rate in the United States, reducing primary cesarean delivery is the key. Increasing vaginal birth after previous cesarean rate is urgently needed. Cesarean section for dystocia should be avoided before the active phase is established, particularly in nulliparous women and in induced labor.

OBJECTIVE: To describe contemporary cesarean delivery practice in the United States. STUDY DESIGN: Consortium on Safe Labor collected detailed labor and delivery information from 228,668 electronic medical records from 19 hospitals across the United States, 2002-2008. RESULTS: The overall cesarean delivery rate was 30.5%. The 31.2% of nulliparous women were delivered by cesarean section. Prelabor repeat cesarean delivery due to a previous uterine scar contributed 30.9% of all cesarean sections. The 28.8% of women with a uterine scar had a trial of labor and the success rate was 57.1%. The 43.8% women attempting vaginal delivery had induction. Half of cesarean for dystocia in induced labor were performed before 6 cm of cervical dilation. CONCLUSION: To decrease cesarean delivery rate in the United States, reducing primary cesarean delivery is the key. Increasing vaginal birth after previous cesarean rate is urgently needed. Cesarean section for dystocia should be avoided before the active phase is established, particularly in nulliparous women and in induced labor.