Using active management of labor and vaginal birth after previous cesarean delivery to lower cesarean delivery rates: aA 10-year experience

Interventions in Reducing Caesarean Section in the World: A Systematic Review

Caesarean section without medical indication imposes many problems to families, personnel and medical equipment causing some side effects to pregnant woman and foetus, compared to natural childbirth. The present study aimed to evaluate the interventions in reducing caesarean section in the world. This study was a systematic review using Embase, PubMed, Scopus, Web of Science, Science Direct, Magiran and SID databases and grey literature. All studies conducted during 2000-2018 were reviewed and finally the studies with inclusion and exclusion criteria were selected. A total of 19 studies were selected among 5,559 studies. The interventions conducted for reducing caesarean section included training the specialists and women by using Six Sigma method, changing the guidelines, reviewing the definition of natural childbirth various stages, encouraging the natural childbirth and expanding painless childbirth. All interventions were divided into educational strategy and managerial strategy. The interventions can be implemented to change the behaviour of physicians and attitude of pregnant women in order to reduce caesarean section. In this regard, the authorities are recommended to make more efforts.

Differences Between Hospitals in Cesarean Rates for Term Primigravidas With Cephalic Presentation

OBJECTIVE

The purpose of this study was to quantify patient populations and practice patterns at perinatal centers with the highest and lowest cesarean delivery rates.

METHODS

The 2 perinatal centers in our state with the lowest (Hospital A-16.6%) and highest (Hospital B-20.3%) overall cesarean rates for Robson group 1 (term primigravidas, vertex, spontaneous labor) and group 2 (term primigravidas, vertex, induced labor) were identified. A total of 174 medical records at Hospital A and 150 records at Hospital B were reviewed. Statistical analysis was performed using independent-sample t tests, chi(2), and multiple logistic regression.

RESULTS

Indications for cesarean delivery were not different between the 2 groups, with the majority being for failure to progress in labor and nonreassuring fetal status. There were no differences between groups in rates of postpartum hemorrhage, chorioamnionitis, or endometritis. There were no differences in neonatal outcomes. Although women delivering in hospital A were not more likely to receive oxytocin augmentation (P = .291), their mean maximal oxytocin dosage was higher (14.5 units compared with 11.6 units, P < .001), and they were more likely to receive both fetal scalp electrodes (60.9% compared with 37.3%, P < .001) and intrauterine pressure catheters (63.8% compared with 26.0%, P < .001).

CONCLUSION

Because safe reduction in cesarean delivery rates for primigravidas will proportionately reduce the number of repeat cesarean delivery required, benchmarking practices as described in this study can be considered in obstetric practices interested in long-term reductions of their cesarean delivery rates.

LEVEL OF EVIDENCE

III.

Physician contribution to a cesarean delivery risk model

OBJECTIVE

The purpose of this study was to assess the contribution of physician management to the probability of cesarean delivery.

STUDY DESIGN

A prospective cohort study was performed of all live births who weighed > or =500 g for a 2-year period (1999-2000) at a large metropolitan hospital (n = 10,027 births). Factors that were associated significantly with cesarean delivery at one time excluded cases in which cesarean delivery was a necessary or probable outcome. In the planned vaginal delivery sample (n = 7940 births), a risk-adjusted logistic regression model was used to assess the prediction of cesarean delivery. To test for the effect of physician-management physician, we used the subset of physicians with > or =45 deliveries in the 2-year time period (n = 6563 deliveries).

RESULTS

When physician-management physician data were added to the use of forward stepwise regression, entry order was abnormal position, nulliparity, birth weight of >4000 g, and physician. The model's predictive ability improved from 43.8% to 50.2%.

CONCLUSION

Physician management adds a significant independent effect to the cesarean delivery risk model.

Vaginal birth after cesarean birth: a national survey of U.S. midwifery practice

Midwives have been providing care for women choosing vaginal birth after cesarean birth (VBAC) for over 20 years. The 1999 American College of Obstetrician Gynecologist (ACOG) guidelines and recent studies questioning the relative safety of VBAC have raised concerns about continuing to offer this option. As part of an effort to understand VBAC care provided by midwives, this study used a national survey sample to examine practices, scope, and recent changes in the provision of VBAC care. The survey, which included demographic and practice items was mailed in late 2000 to a purposeful sample of 325 midwifery practices. The return rate was 62%. Nearly all (94%) of the responding practices were providing VBAC care, and almost half of them (43%) stated that their ability to do so had changed within the past 2 years secondary to recent studies in the obstetric literature, the 1999 ACOG statement, and concerns from third-party payers. Criteria for offering VBAC are stricter, and consent forms are more extensive. Other changes included the need for additional or more intensive support services, in-house anesthesia, and surgery backup. Midwives continue to provide VBAC care, although with some increased restrictions. This study provides background for future research that will determine how midwifery care affects the rate of successful VBACs.