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Liu G, Zhang J, Zhou C, Yang M, Yang Z, Zhao L. External validation and updating of the Rossi nomogram for predicting cesarean delivery following induction: is the Bishop score valuable? Arch Gynecol Obstet 2024:10.1007/s00404-024-07524-z. [PMID: 38806943 DOI: 10.1007/s00404-024-07524-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 04/16/2024] [Indexed: 05/30/2024]
Abstract
OBJECTIVE This study sought to validate the Rossi nomogram in a Chinese population and then to include the Bishop score to see if it has an effect on the accuracy of the nomogram. MATERIALS AND METHODS The Rossi predictive model was applied and externally validated in a retrospective cohort from August 2017 and July 2023 in a Chinese tertiary-level medical center. For the revision and updating of the models, the regression coefficients of all the predictors (except race) were re-estimated and then the cervical Bishop score at the time of induction was added. Each model's performance was measured using the receiver-operating characteristic and calibration plots. Decision curve analysis determined the range of the probability threshold for each prediction model that would be of clinical value. RESULTS A total of 721 women met the inclusion criteria, of whom 183 (25.4%) underwent a cesarean delivery. The calibration demonstrated the underestimation of the original model, with an area under the curve (AUC) of 0.789 (95% confidence interval [CI] 0.753-0.825, p < 0.001). After recalibrating the original model, the discriminative performance was improved from 0.789 to 0.803. Moreover, the discriminatory power of the updated model was further improved when the Bishop score at the time of induction was added to the recalibrated multivariable model. Indeed, the updated model demonstrated good calibration and discriminatory power, with an AUC of 0.811. The decision curve analysis indicated that all the models (original, recalibrated, and updated) provided higher net benefits of between 0 and 60% of the probability threshold, which indicates the benefits of using the models to make decisions concerning patients who fall within the identified range of the probability threshold. The net benefits of the updated model were higher than those of the original model and the recalibrated model. CONCLUSION The nomogram used to predict cesarean delivery following induction developed by Rossi et al. has been validated in a Chinese population in this study. More specifically, adaptation to a Chinese population by excluding ethnicity and including the Bishop score prior to induction gave rise to better performance. The three models (original, recalibrated, and updated) offer higher net benefits when the probability threshold is between 0 and 60%.
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Affiliation(s)
- Guangpu Liu
- The Forth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Jingya Zhang
- The Forth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Chaofan Zhou
- Children's Hospital of Hebei Province, Shijiazhuang, China
| | - Ming Yang
- Ding Zhou City People's Hospital, Dingzhou, China
| | - Zhifen Yang
- The Forth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Ling Zhao
- The Forth Hospital of Hebei Medical University, Shijiazhuang, China.
- Department of Obstetrics, The Forth Hospital of Hebei Medical University, No. 169 Tianshan Street, Shijiazhuang, 050000, Hebei, China.
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Boie S, Glavind J, Bor P, Steer P, Riis AH, Thiesson B, Uldbjerg N. Continued versus discontinued oxytocin stimulation in the active phase of labour (CONDISOX): individual management based on artificial intelligence - a secondary analysis. BMC Pregnancy Childbirth 2024; 24:291. [PMID: 38641779 PMCID: PMC11027395 DOI: 10.1186/s12884-024-06461-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 03/28/2024] [Indexed: 04/21/2024] Open
Abstract
BACKGROUND Current guidelines regarding oxytocin stimulation are not tailored to individuals as they are based on randomised controlled trials. The objective of the study was to develop an artificial intelligence (AI) model for individual prediction of the risk of caesarean delivery (CD) in women with a cervical dilatation of 6 cm after oxytocin stimulation for induced labour. The model included not only variables known when labour induction was initiated but also variables describing the course of the labour induction. METHODS Secondary analysis of data from the CONDISOX randomised controlled trial of discontinued vs. continued oxytocin infusion in the active phase of induced labour. Extreme gradient boosting (XGBoost) software was used to build the prediction model. To explain the impact of the predictors, we calculated Shapley additive explanation (SHAP) values and present a summary SHAP plot. A force plot was used to explain specifics about an individual's predictors that result in a change of the individual's risk output value from the population-based risk. RESULTS Among 1060 included women, 160 (15.1%) were delivered by CD. The XGBoost model found women who delivered vaginally were more likely to be parous, taller, to have a lower estimated birth weight, and to be stimulated with a lower amount of oxytocin. In 108 women (10% of 1060) the model favoured either continuation or discontinuation of oxytocin. For the remaining 90% of the women, the model found that continuation or discontinuation of oxytocin stimulation affected the risk difference of CD by less than 5% points. CONCLUSION In women undergoing labour induction, this AI model based on a secondary analysis of data from the CONDISOX trial may help predict the risk of CD and assist the mother and clinician in individual tailored management of oxytocin stimulation after reaching 6 cm of cervical dilation.
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Affiliation(s)
- Sidsel Boie
- Department of Obstetrics and Gynaecology, Randers Regional Hospital, Randers, Denmark.
| | - Julie Glavind
- Department of Obstetrics and Gynaecology, Aarhus University Hospital, Aarhus, Denmark
| | - Pinar Bor
- Department of Obstetrics and Gynaecology, Aarhus University Hospital, Aarhus, Denmark
| | - Philip Steer
- Academic Department of Obstetrics and Gynaecology, Chelsea and Westminster Hospital, Imperial College London, London, UK
| | | | | | - Niels Uldbjerg
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Yu Z, Chen R, Zhao C, Zhang R, Zhou T, Zhao Y. Optimal starting dosing regimen of intravenous oxytocin for labor induction based on the population kinetic-pharmacodynamic model of uterine contraction frequency. Pharmacotherapy 2024; 44:319-330. [PMID: 38419599 DOI: 10.1002/phar.2911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 01/31/2024] [Accepted: 02/04/2024] [Indexed: 03/02/2024]
Abstract
BACKGROUND Intravenous oxytocin is commonly used for labor induction. However, a consensus on the initial dosing regimen is lac with conflicting research findings and varying guidelines. This study aimed to develop a population kinetic-pharmacodynamic (K-PD) model for oxytocin-induced uterine contractions considering real-world data and relevant influencing factors to establish an optimal starting dosing regimen for intravenous oxytocin. METHODS This retrospective study included pregnant women who underwent labor induction with intravenous oxytocin at Peking University Third Hospital in 2020. A population K-PD model was developed to depict the time course of uterine contraction frequency (UCF), and covariate screening identified significant factors affecting the pharmacokinetics and pharmacodynamics of oxytocin. Model-based simulations were used to optimize the current starting regimen based on specific guidelines. RESULTS Data from 77 pregnant women with 1095 UCF observations were described well by the K-PD model. Parity, cervical dilation, and membrane integrity are significant factors influencing the effectiveness of oxytocin. Based on the model-based simulations, the current regimens showed prolonged onset times and high infusion rates. This study proposed a revised approach, beginning with a rapid infusion followed by a reduced infusion rate, enabling most women to achieve the target UCF within approximately 30 min with the lowest possible infusion rate. CONCLUSION The K-PD model of oxytocin effectively described the changes in UCF during labor induction. Furthermore, it revealed that parity, cervical dilation, and membrane integrity are key factors that influence the effectiveness of oxytocin. The optimal starting dosing regimens obtained through model simulations provide valuable clinical references for oxytocin treatment.
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Affiliation(s)
- Zhiheng Yu
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
- National Clinical Research Center for Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
- National Center for Healthcare Quality Management in Obstetrics, Peking University Third Hospital, Beijing, China
| | - Rong Chen
- Department of Pharmaceutics, School of Pharmaceutical Sciences, Peking University, Beijing, China
| | - Cheng Zhao
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Renwei Zhang
- Department of Pharmaceutics, School of Pharmaceutical Sciences, Peking University, Beijing, China
| | - Tianyan Zhou
- Department of Pharmaceutics, School of Pharmaceutical Sciences, Peking University, Beijing, China
| | - Yangyu Zhao
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
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Fente BM, Asaye MM, Gudayu TW, Mihret MS, Tesema GA. Prediction of unplanned cesarean section using measurable maternal and fetal characteristics, Ethiopia, a retrospective cohort study. BMC Pregnancy Childbirth 2024; 24:161. [PMID: 38395796 PMCID: PMC10885460 DOI: 10.1186/s12884-024-06308-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 01/30/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND When a pregnant woman experiences unusual circumstances during a vaginal delivery, an unplanned cesarean section may be necessary to save her life. It requires knowledge and quick assessment of the risky situation to decide to perform an unplanned cesarean section, which only occurs in specific obstetric situations. This study aimed to develop and validate a risk prediction model for unplanned cesarean sections among laboring women in Ethiopia. METHOD A retrospective follow-up study was conducted. The data were extracted using a structured checklist. Analysis was done using STATA version 14 and R version 4.2.2 software. Logistic regression was fitted to determine predictors of unplanned cesarean sections. Significant variables were then used to develop a risk prediction model. Performance was assessed using Area Under the Receiver Operating Curve (AUROC) and calibration plot. Internal validation was performed using the bootstrap technique. The clinical benefit of the model was assessed using decision curve analysis. RESULT A total of 1,000 laboring women participated in this study; 28.5% were delivered by unplanned cesarean section. Parity, amniotic fluid status, gestational age, prolonged labor, the onset of labor, amount of amniotic fluid, previous mode of delivery, and abruption remained in the reduced multivariable logistic regression and were used to develop a prediction risk score with a total score of 9. The AUROC was 0.82. The optimal cut-off point for risk categorization as low and high was 6, with a sensitivity (85.2%), specificity (90.1%), and accuracy (73.9%). After internal validation, the optimism coefficient was 0.0089. The model was found to have clinical benefits. CONCLUSION To objectively measure the risk of an unplanned Caesarean section, a risk score model based on measurable maternal and fetal attributes has been developed. The score is simple, easy to use, and repeatable in clinical practice.
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Affiliation(s)
- Bezawit Melak Fente
- Department of General Midwifery, School of Midwifery, College of Medicine & Health Sciences, University of Gondar, Gondar, Ethiopia.
| | - Mengstu Melkamu Asaye
- Department of Women's and Family Health, School of Midwifery, College of Medicine & Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Temesgen Worku Gudayu
- Department of Clinical Midwifery, School of Midwifery, College of Medicine & Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Muhabaw Shumye Mihret
- Department of Clinical Midwifery, School of Midwifery, College of Medicine & Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Getayeneh Antehunegn Tesema
- Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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Zhang J, Wu N, Li M. A prediction model for cesarean delivery based on the glycemia in the second trimester: a nested case control study from two centers. J Matern Fetal Neonatal Med 2023; 36:2222208. [PMID: 37332139 DOI: 10.1080/14767058.2023.2222208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 12/20/2022] [Accepted: 06/01/2023] [Indexed: 06/20/2023]
Abstract
OBJECTIVE Maternal glycemia is associated with the risk of cesarean delivery (CD); therefore, our study aims to developed a prediction model based on glucose indicators in the second trimester to earlier identify the risk of CD. METHODS This was a nested case-control study, and data were collected from the 5th Central Hospital of Tianjin (training set) and Changzhou Second People's Hospital (testing set) from 2020 to 2021. Variables with significant difference in training set were incorporated to develop the random forest model. Model performance was assessed by calculating the area under the curve (AUC) and Komogorov-Smirnoff (KS), as well as accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). RESULTS A total of 504 eligible women were enrolled; of these, 169 underwent CD. Pre-pregnancy body mass index (BMI), first pregnancy, history of full-term birth, history of livebirth, 1 h plasma glucose (1hPG), glycosylated hemoglobin (HbA1c), fasting plasma glucose (FPG), and 2 h plasma glucose (2hPG) were used to develop the model. The model showed a good performance, with an AUC of 0.852 [95% confidence interval (CI): 0.809-0.895]. The pre-pregnancy BMI, 1hPG, 2hPG, HbA1c, and FPG were identifies as the more significant predictors. External validation confirmed the good performance of our model, with an AUC of 0.734 (95%CI: 0.664-0.804). CONCLUSIONS Our model based on glucose indicators in the second trimester performed well to predict the risk of CD, which may reach the earlier identification of CD risk and may be beneficial to make interventions in time to decrease the risk of CD.
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Affiliation(s)
- Junping Zhang
- Department of Obstetrics and Gynecology, Tianjin Fifth Central Hospital, Tianjin, P.R. China
| | - Naiqian Wu
- Department of Obstetrics and Gynecology, Tianjin Fifth Central Hospital, Tianjin, P.R. China
| | - Minhui Li
- Department of Obstetrics, The Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University, Changzhou, P.R. China
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Dorwal M, Yadav G, Singh P, Kathuria P, Gothwal M, Ghuman NK, Shekhar S. Deriving a prediction model for emergency cesarean delivery following induction of labor in singleton term pregnancies. Int J Gynaecol Obstet 2023; 160:698-706. [PMID: 35965397 DOI: 10.1002/ijgo.14403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 01/11/2022] [Accepted: 08/09/2022] [Indexed: 01/20/2023]
Abstract
OBJECTIVES To derive a prediction model combining various clinical factors associated with increased risk of emergency cesarean section following induction of labor in women with unfavorable cervix. METHODS All women with singleton term pregnancies undergoing induction of labor and fulfilling inclusion criteria were included in this cross-sectional study after supplying consent. Women with a Bishop score of 6 or less were induced with dinoprostone gel. Multiple regression analysis was used to find the most significant independent predictive factors and these factors were used to develop the predictive model and calculator. RESULTS After multiple logistic regression, risk of emergency cesarean after induction of labor was significantly associated with the following variables: height (adjusted odds ratio [aOR] 0.955, P = 0.033), nulliparity (aOR 3.987, P < 0.001), closed cervix (aOR 2.030, P = 0.030), fetal station -3 above ischial spine (aOR 2.719, P = 0.043), firm or medium cervical consistency (aOR 2.028, P = 0.004), cervical length 3 cm or longer (aOR 3.090, P = 0.015), posterior cervix (aOR 2.112, P = 0.002). CONCLUSION Use of a prediction model would help to reduce the number of emergency cesarean sections secondary to unsuccessful inductions and help in the reduction of maternal and perinatal morbidity.
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Affiliation(s)
- Manisha Dorwal
- Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, Jodhpur, India
| | - Garima Yadav
- Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, Jodhpur, India
| | - Pratibha Singh
- Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, Jodhpur, India
| | - Priyanka Kathuria
- Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, Jodhpur, India
| | - Meenakshi Gothwal
- Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, Jodhpur, India
| | - Navdeep Kaur Ghuman
- Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, Jodhpur, India
| | - Shashank Shekhar
- Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, Jodhpur, India
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Hailemeskel HS, Tiruneh SA. Development of a Nomogram for Clinical Risk Prediction of Preterm Neonate Death in Ethiopia. Front Pediatr 2022; 10:877200. [PMID: 35692976 PMCID: PMC9184443 DOI: 10.3389/fped.2022.877200] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 04/27/2022] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION In 2020, over 6,500 newborn deaths occured every day, resulting in 2.4 million children dying in their 1st month of life. Ethiopia is one of the countries that will need to step up their efforts and expedite progress to meet the 2030 sustainable development goal. Developing prediction models to forecast the mortality of preterm neonates could be valuable in low-resource settings with limited amenities, such as Ethiopia. Therefore, the study aims to develop a nomogram for clinical risk prediction of preterm neonate death in Ethiopia in 2021. METHODS A prospective follow-up study design was employed. The data were used to analyze using R-programming version 4.0.3 software. The least absolute shrinkage and selection operator (LASSO) regression is used for variable selection to be retained in the multivariable model. The model discrimination probability was checked using the ROC (AUROC) curve area. The model's clinical and public health impact was assessed using decision curve analysis (DCA). A nomogram graphical presentation created an individualized prediction of preterm neonate risk of mortality. RESULTS The area under the receiver operating curve (AUROC) discerning power for five sets of prognostic determinants (gestational age, respiratory distress syndrome, multiple neonates, low birth weight, and kangaroo mother care) is 92.7% (95% CI: 89.9-95.4%). This prediction model was particular (specificity = 95%) in predicting preterm death, with a true positive rate (sensitivity) of 77%. The best cut point value for predicting a high or low risk of preterm death (Youden index) was 0.3 (30%). Positive and negative predictive values at the Youden index threshold value were 85.4 percent and 93.3 percent, respectively. CONCLUSION This risk prediction model provides a straightforward nomogram tool for predicting the death of preterm newborns. Following the preterm neonates critically based on the model has the highest cost-benefit ratio.
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Affiliation(s)
- Habtamu Shimels Hailemeskel
- Department of Pediatrics and Neonatal Nursing, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Sofonyas Abebaw Tiruneh
- Department of Public Health, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
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D'Souza R, Ashraf R, Foroutan F. Prediction models for determining the success of labour induction: A systematic review and critical analysis. Best Pract Res Clin Obstet Gynaecol 2021; 79:42-54. [DOI: 10.1016/j.bpobgyn.2021.12.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 12/16/2021] [Accepted: 12/17/2021] [Indexed: 01/03/2023]
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López-Jiménez N, García-Sánchez F, Hernández-Pailos R, Rodrigo-Álvaro V, Pascual-Pedreño A, Moreno-Cid M, Delgado-Rodríguez M, Hernández-Martínez A. Risk of caesarean delivery in labour induction: a systematic review and external validation of predictive models. BJOG 2021; 129:685-695. [PMID: 34559942 DOI: 10.1111/1471-0528.16947] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Despite the existence of numerous published models predicting the risk of caesarean delivery in women undergoing induction of labour (IOL), validated models are scarce. OBJECTIVES To systematically review and externally assess the predictive capacity of caesarean delivery risk models in women undergoing IOL. SEARCH STRATEGY Studies published up to 15 January 2021 were identified through PubMed, CINAHL, Scopus and ClinicalTrials.gov, without temporal or language restrictions. SELECTION CRITERIA Studies describing the derivation of new models for predicting the risk of caesarean delivery in labour induction. DATA COLLECTION AND ANALYSIS Three authors independently screened the articles and assessed the risk of bias (ROB) according to the prediction model risk of bias assessment tool (PROBAST). External validation was performed in a prospective cohort of 468 pregnancies undergoing IOL from February 2019 to August 2020. The predictive capacity of the models was assessed by creating areas under the receiver operating characteristic curve (AUCs), calibration plots and decision curve analysis (DCA). MAIN RESULTS Fifteen studies met the eligibility criteria; 12 predictive models were validated. The quality of most of the included studies was not adequate. The AUC of the models varied from 0.520 to 0.773. The three models with the best discriminative capacity were those of Levine et al. (AUC 0.773, 95% CI 0.720-0.827), Hernández et al. (AUC 0.762, 95% CI 0.715-0.809) and Rossi et al. (AUC 0.752, 95% CI 0.707-0.797). CONCLUSIONS Predictive capacity and methodological quality were limited; therefore, we cannot currently recommend the use of any of the models for decision making in clinical practice. TWEETABLE ABSTRACT Predictive models that predict the risk of cesarean section in labor inductions are currently not applicable.
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Affiliation(s)
- N López-Jiménez
- Department of Obstetrics and Gynaecology, La Mancha Centro Hospital, Alcázar de San Juan, Ciudad Real, Spain
| | - F García-Sánchez
- Department of Obstetrics and Gynaecology, La Mancha Centro Hospital, Alcázar de San Juan, Ciudad Real, Spain
| | - R Hernández-Pailos
- Department of Obstetrics and Gynaecology, La Mancha Centro Hospital, Alcázar de San Juan, Ciudad Real, Spain
| | - V Rodrigo-Álvaro
- Department of Obstetrics and Gynaecology, La Mancha Centro Hospital, Alcázar de San Juan, Ciudad Real, Spain
| | - A Pascual-Pedreño
- Department of Obstetrics and Gynaecology, La Mancha Centro Hospital, Alcázar de San Juan, Ciudad Real, Spain
| | - M Moreno-Cid
- Department of Obstetrics and Gynaecology, La Mancha Centro Hospital, Alcázar de San Juan, Ciudad Real, Spain
| | - M Delgado-Rodríguez
- Consortium for Biomedical Research in Epidemiology and Public Health (CIBERESP), Madrid, Spain.,Department of Health Sciences, University of Jaen, Jaen, Spain
| | - A Hernández-Martínez
- Department of Obstetrics and Gynaecology, La Mancha Centro Hospital, Alcázar de San Juan, Ciudad Real, Spain.,Department of Nursing, Faculty of Nursing of Ciudad Real, University of Castilla-La Mancha, Ciudad Real, Spain
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Hamm RF, McCoy J, Oladuja A, Bogner HR, Elovitz MA, Morales KH, Srinivas SK, Levine LD. Maternal Morbidity and Birth Satisfaction After Implementation of a Validated Calculator to Predict Cesarean Delivery During Labor Induction. JAMA Netw Open 2020; 3:e2025582. [PMID: 33185679 PMCID: PMC7666421 DOI: 10.1001/jamanetworkopen.2020.25582] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE A previously created and validated calculator provides an individualized cesarean delivery risk score for women undergoing labor induction. A higher predicted risk of cesarean delivery on the calculator has been associated with increased maternal and neonatal morbidity regardless of ultimate delivery mode. The effect of this calculator when implemented in clinical care has yet to be evaluated. OBJECTIVE To determine whether implementation of a validated calculator that predicts the likelihood of cesarean delivery at the time of labor induction is associated with maternal morbidity and birth satisfaction. DESIGN, SETTING, AND PARTICIPANTS This prospective cohort study used medical record review to compare the 1 year before calculator implementation (July 1, 2017, to June 30, 2018) with the 1 year after implementation (July 1, 2018, to June 30, 2019) at a US urban, university labor unit. Women admitted for labor induction with singleton gestation in cephalic presentation, intact membranes, and an unfavorable cervix were included. Data were analyzed from August 1, 2019, to September 13, 2020. EXPOSURES Patient and clinician knowledge of the calculated cesarean delivery risk score based on the validated calculator. MAIN OUTCOMES AND MEASURES The primary outcomes were (1) composite maternal morbidity defined by at least 1 of the following within 30 days of delivery: endometritis, postpartum hemorrhage (estimated or quantitative blood loss >1000 mL), blood transfusion, wound infection, venous thromboembolism, hysterectomy, intensive care unit admission, and readmission and (2) patient satisfaction assessed via Birth Satisfaction Scale-Revised (BSS-R) scores. Secondary outcomes included rate of cesarean delivery and neonatal morbidity. RESULTS A total of 1610 women were included in the analysis (788 in the preimplementation and 822 in the postimplementation periods) with a median age of 29 (interquartile range [IQR], 24-34) years. There were no significant baseline differences between groups except fewer inductions at a gestational age of 40 weeks or later in the postimplementation period (256 [31.1%] vs 298 [37.8%]). Calculator implementation was associated with decreased maternal morbidity overall, even when adjusting for confounders (141 [17.9%] vs 95 [11.6%]; adjusted absolute risk difference [aARD], -6.3%; 95% CI, -9.7% to -2.8%). Although there was no difference in birth satisfaction overall, calculator implementation was associated with improvements on items pertaining to quality of care provision (median BSS-R score, 19 [IQR, 16-20] vs 19 [IQR, 17-20]; P = .006). Calculator implementation was also associated with a decrease in cesarean delivery rate (228 [28.9%] vs 167 [20.3%]; aARD, -8.5% [95% CI, -12.6% to -4.5%]). There were no significant differences in neonatal morbidity. CONCLUSIONS AND RELEVANCE These findings suggest that implementation of a validated calculator to predict risk of cesarean delivery in clinical care is associated with reduced maternal morbidity. Implementation should occur broadly to determine whether calculator use improves national maternal outcomes.
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Affiliation(s)
- Rebecca F. Hamm
- Maternal and Child Health Research Center, Department of Obstetrics and Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Jennifer McCoy
- Maternal and Child Health Research Center, Department of Obstetrics and Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Amal Oladuja
- Maternal and Child Health Research Center, Department of Obstetrics and Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Hilary R. Bogner
- Department of Family Medicine and Community Health, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Michal A. Elovitz
- Maternal and Child Health Research Center, Department of Obstetrics and Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Knashawn H. Morales
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Sindhu K. Srinivas
- Maternal and Child Health Research Center, Department of Obstetrics and Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Lisa D. Levine
- Maternal and Child Health Research Center, Department of Obstetrics and Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia
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Affiliation(s)
- Mary Catherine Tolcher
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
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