National Partnership for Maternal Safety: Consensus Bundle on Safe Reduction of Primary Cesarean Births—Supporting Intended Vaginal Births

Quality-Improvement Strategies for Safe Reduction of Primary Cesarean Birth: ACOG Committee Statement No. 17

The nulliparous, term, singleton, vertex (NTSV) cesarean birth rate is a metric that may be used to evaluate obstetric care and compare performance across similar hospitals and regions. Safe reduction of primary cesarean birth prevents the need for future cesarean births and associated maternal morbidity risk. Quality-improvement methodologies such as optimizing culture of care; practice environment; data collection and monitoring, including monitoring of data by race and ethnicity; and proactive management and planning for known and unanticipated drivers of cesarean birth may safely reduce NTSV cesarean birth rates. Obstetrician-gynecologists should engage with patients in informed decision making, informed consent, and birth preference conversations, particularly related to induction of labor and cesarean birth, to support equitable and respectful obstetric care and outcomes related to NTSV cesarean birth.

Trends in induction of labour and associated co-morbidities and demographics in Queensland, Australia from 2001 to 2020: a population-based study

BACKGROUND

Amongst women who plan a vaginal birth at term, previous studies have reported that rates of induction of labour are increasing potentially impacting other labour and birth outcomes. Indications for induction of labour (IOL) have changed over time though the influences of parity and demographic factors such as age, ethnicity and regionality are not often considered. The aim of this study was to describe the changes in demographic, co-morbidity, IOL indication and clinical outcomes in women undertaking a planned cephalic vaginal birth at term over a 20 year period.

METHODS

A retrospective population-based study was undertaken using routinely collected anonymised perinatal data from Queensland, Australia from January 2001 to December 2020. We included all singleton term (≥ 37 weeks) planned vaginal births. A total of 836,065 births met the study criteria. Data for pregnancy complications and IOL indications were grouped by ICD-10 codes. Analysis was stratified by parity and presented as frequency and percentages over time and the difference in percentages between two defined years.

RESULTS

Rates of IOL increased by 15.5% (31.6 to 47.1%) in nulliparous and 14.6% (26.2 to 40.8% in multiparous women, most notable from 2015 onwards. Over the same period infants born between 37 and 38 weeks gestation increased by 13.9%. (18.1-32%). Amongst co-morbidities gestational diabetes increased from 3.8 to 12.8% and anaemia from 1.7 to 8.1%. As an indication for IOL prolonged pregnancy decreased from 41.0 to 11.2%. In nulliparous women the percentage of intact perineum decreased from 21.3 to 6.7% while episiotomy increased from 20.2 to 38.8%.

CONCLUSIONS

We conclude that for women planning a vaginal birth not only has the rate of IOL increased substantially over the last two decades there also appears to be considerable interaction between demographic, co-morbidity, IOL indications and clinical outcomes that warrants further large population-based research.

Unplanned Cesarean for Abnormal or Indeterminate Fetal Heart Tracing Varies Significantly by Race and Ethnicity

INTRODUCTION

The US maternity care system achieves worse outcomes for birthing people identifying as Black versus White. Assessment of fetal well-being in labor is an area of perinatal care subject to significant interobserver variability and therefore may be at particular risk of medical racism influencing care.

METHODS

Statewide collaborative quality initiative data, focused on decreasing the nulliparous, term, singleton, vertex (NTSV) cesarean birth rate, were used to conduct a retrospective cohort study to assess differences in cesarean birth for nonreassuring fetal status between birthing people identifying as Black compared with White. Generalized linear mixed modeling with hospital as a random intercept was used for multivariate analyses accounting for birthing people clustering within hospitals.

RESULTS

Between March 1, 2020, and December 31, 2022, 69,622 births were identified, 8291 (11.9%) of which were an unplanned cesarean with a primary indication of nonreassuring fetal heart tracing (cesarean for FHT). Race and ethnicity were significantly associated with a higher risk, after controlling for covariates: compared with White birthing people, birthing people of unknown race or ethnicity had 1.23 (95% CI 1.13-1.35) and Asian Pacific Islander birthing people had 1.55 times the odds (95% CI 1.37-1.76), whereas Black birthing people had 1.71 times the odds (95% CI 1.59-1.83) of birthing via unplanned cesarean for FHT. In adjusted analysis, prepregnancy diabetes, positive COVID-19 status at admission, elevated body mass index, and birthing in the Detroit Metro area were associated with cesarean for FHT. In an unplanned subgroup analysis of births within the Detroit Metro region, Black individuals remained significantly more likely to have an unplanned cesarean for FHT (aOR 1.63, 95% CI 1.48-1.79).

DISCUSSION

After controlling for individual and hospital-level factors, cesarean for FHT was more common among non-Hispanic Black vs non-Hispanic White birthing people in this statewide cohort of NTSV births.

Pelvic Diameters and Their Association With Maternal Body Mass Index, Parity, and Delivery Outcomes: A Cross-Sectional Study

Background In addition to age, body mass index (BMI), abdominal circumference, and parity, measuring the mother's pelvic diameters is a non-invasive, cost-effective method that can assist gynecologists in determining the optimal management of labor. Our study aimed to examine the associations between maternal age, pelvic diameters, BMI, abdominal circumference, and parity with delivery outcomes and investigate differences in pelvic diameters in relation to maternal age, BMI, delivery outcomes, parity, and episiotomy. Materials and methods The observational, cross-sectional study included 108 pregnant women in the active phase of labor who were admitted to the Gynecological Clinic at the Clinical Center University of Sarajevo. During admission, maternal data were registered: age, body height, body weight, abdominal circumference, and BMI. Using a pelvinometer, pelvic diameters were recorded: interspinous diameter (DS), intertrochanteric diameter (DT), intercristal diameter (DC), and external conjugate (CE). The Anterior Pelvic Index (API) was calculated by dividing the DS by the participants' height and multiplying the result by 100. Data were analyzed using SPSS Statistics for Windows, Version 17 (Released 2008; SPSS Inc., Chicago, United States). Results Women who underwent cesarean section were significantly older compared to those with spontaneous vaginal delivery. A significant correlation was observed between maternal age, BMI, and delivery outcomes. Obese women had significantly higher DT compared to women with normal or overweight BMI. Primiparous and multiparous women differed significantly in CE, while other pelvic diameters did not differ. Women with episiotomy had significantly lower DS and CE diameters compared to those without episiotomy during vaginal delivery. Conclusion Maternal age, BMI, and pelvic diameters are significant delivery outcome determinants; our findings suggest that these parameters deserve to be included in delivery outcome assessment as they provide substantial information in the journey of achieving personalized delivery care and decision-making.

Relationships Among Mode of Birth, Onset of Labor, and Bishop Score

OBJECTIVE

To investigate mode of birth in relation to onset of labor and Bishop score.

DESIGN

Retrospective observational cohort design.

SETTING

A 434-bed Magnet redesignated community hospital.

PARTICIPANTS

Nulliparous women, 18 years of age or older, who gave birth at 37 to 41 weeks gestation to live, singleton fetuses in the vertex presentation (N = 701).

METHODS

We conducted a retrospective chart review and used chi-square analysis to measure the associations among mode of birth, onset of labor, and Bishop score. We used logistic regression to test the probability of cesarean birth for women undergoing elective induction of labor.

RESULTS

Most participants (n = 531, 75.7%) gave birth vaginally. Significant findings included the following relationships: spontaneous onset of labor and vaginal birth (χ2 = 22.2, Ø = 0.18, p < .001) and Bishop score of greater than or equal to 8 and vaginal birth (χ2 = 4.9, Ø = .14, p = .028). Induction of labor was a significant predictor in cesarean birth when controlling for age and body mass index (OR = 2.1, 95% confidence interval [1.5, 3.1], p < .001).

CONCLUSION

Reducing elective induction of labor in women with low-risk pregnancies may help lower the risk of cesarean birth. Clinically, Bishop score and mode of birth have a weak association, particularly when induction includes cervical ripening.

Comparison of two labor induction regimens with intravaginal misoprostol 25 μg and adverse perinatal outcomes

OBJECTIVE

The aim of the study was to compare two labor induction regimens (4 and 6 h), to determine predictors of successful labor induction with intravaginal misoprostol 25 μg tablets, and to evaluate the association with adverse perinatal outcomes.

METHODS

This was a retrospective cohort study that included singleton pregnancies undergoing induction of labor with an intravaginal misoprostol 25 μg tablet between 37 and 42 weeks of gestation. The pregnant women were divided into two groups: Group 1-intravaginal misoprostol 25 μg every 4 h and Group 2-intravaginal misoprostol 25 μg every 6 h.

RESULTS

Pregnant women were divided into Group 1 (n=289) and Group 2 (n=278). Group 1 had a higher median number of intravaginal misoprostol 25 μg tablets (3.0 vs. 2.0 tablets, p<0.001), a lower prevalence of postpartum hemorrhage (7.6 vs. 32.7%, p<0.001), and a higher need for oxytocin (odds ratio [OR]: 2.1, 95%CI: 1.47-2.98, p<0.001) than Group 2. Models including intravaginal misoprostol 25 μg tablets every 4 and 6 h [x2(1)=23.7, OR: 4.35, p<0.0001], parity [x2(3)=39.4, OR: 0.59, p=0.031], and Bishop's score [x2(4)=10.8, OR: 0.77, p=0.019] were the best predictors of failure of labor induction. A statistically significant difference between groups was observed between the use of the first intravaginal misoprostol 25 μg tablet at the beginning (Breslow p<0.001) and the end of the active labor phase (Long Hank p=0.002).

CONCLUSION

Pregnant women who used intravaginal misoprostol 25 μg every 4 h had a longer time from the labor induction to the beginning of the active phase of labor and higher rates of adverse perinatal outcomes than women who used intravaginal misoprostol 25 μg every 6 h.

Expanding Labor Support Education to Nurses Caring for Women in Labor

The ability to provide emotional and physical support to a patient during one of the most significant moments of her life is a privilege afforded to intrapartum nurses who attend to laboring and delivering patients. Labor support improves birth outcomes, reduces cesarean birth rates, and decreases anesthesia use. Within the hospital context, this quality improvement project investigated the effects of educating intrapartum nurses about labor support and providing them with hands-on training. Surveys, including the Self-Efficacy Labor Support Scale, were given preeducation and posteducation to evaluate and document knowledge acquisition. Results support teaching intrapartum nurses learning evidence-based labor comfort strategies to support a woman's labor preference.

Relationships Among Individual and Hospital Characteristics and Self-Efficacy in Labor Support Among Intrapartum Nurses in Texas

OBJECTIVE

To explore the relationships among individual and workplace characteristics and self-efficacy in labor support among intrapartum nurses.

DESIGN

Cross-sectional survey.

SETTING

Online distribution from April to August 2020.

PARTICIPANTS

Members of the Texas section of the Association for Women's Health, Obstetric, and Neonatal Nurses (N = 106).

METHODS

I conducted descriptive analysis on individual and workplace characteristics, including scores on the Self-Efficacy Labor Support Scale. I conducted backward stepwise multivariate linear regression to assess the factors associated with self-efficacy in providing labor support.

RESULTS

Years as an intrapartum nurse had a positive association with self-efficacy in labor support. Experience with open-glottis pushing, the overall cesarean birth rate, and the use of upright positioning during labor and birth were also positively associated with self-efficacy in labor support. Conversely, lack of recognition by providers was negatively associated with self-efficacy in labor support.

CONCLUSION

Findings suggest that modifiable factors at the individual and hospital levels are associated with nurses' self-efficacy in labor support. Hospitals must work to engage in obstetric practices that are congruent with providing labor support, including the use of experienced nurses to mentor new nurses and the creation of a unit culture to reinforce the intent of individual nurses to provide labor support.

Factors associated with spontaneous vaginal birth in nulliparous women: A descriptive systematic review

PROBLEM

Spontaneous vaginal birth (SVB) rates for nulliparous women are declining internationally.

BACKGROUND

There is inadequate understanding of factors affecting this trend overall and limited large-scale responses to improve women's opportunity to birth spontaneously.

AIM

To undertake a descriptive systematic review identifying factors associated with spontaneous vaginal birth at term, in nulliparous women with a singleton pregnancy.

METHODS

Quantitative studies of all designs, of nulliparous women with a singleton pregnancy and cephalic presentation, who experienced a SVB at term were included. Nine databases were searched (inception to October 2022). Two reviewers undertook quality appraisal; Randomised Controlled Trials (RCTs) with high risk of bias (ROB 2.0) and other designs with (QATSDD) scoring ≤ 50% were excluded.

FINDINGS

Data were abstracted from 90 studies (32 RCTs, 39 cohort, 9 cross-sectional, 4 prevalence, 5 case control, 1 quasi-experimental). SVB rates varied (13%-99%). Modifiable factors associated with SVB included addressing fear of childbirth, low impact antenatal exercise, maternal positioning during second-stage labour and midwifery led care. Complexities arising during pregnancy and regional analgesia were shown to decrease SVB and other interventions, such as routine induction of labour were equivocal.

DISCUSSION

Antenatal preparation (low impact exercise, childbirth education, addressing fear of childbirth) may increase SVB, as does midwifery continuity-of-care. Intrapartum strategies to optimise labour progression emerged as promising areas for further research.

CONCLUSION

Declining SVB rates may be improved through multi-factorial approaches inclusive of maternal, fetal and clinical care domains. However, the variability of SVB rates testifies to the complexity of the issue.

Nulliparous Women's Expectations and Experiences of Early Labor

PURPOSE

To describe the expectations of early labor by nulliparous pregnant women in their third trimester and first-time mothers' experiences of early labor after they had given birth.

STUDY DESIGN AND METHODS

A descriptive qualitative approach involving semi-structured, video-call interviews conducted between September 2020 and April 2021. Data were analyzed using content analysis.

RESULTS

Twenty-two women took part in this study. Only 3 of the 10 nulliparous pregnant participants reported pain as an expected symptom of early labor. There were two themes identified from interviews with pregnant participants: Desire to stay at home in early labor and Lack of knowledge and two themes from interviews from postpartum participants: Expectations didn't match experiences and Feelings of anxiety and uncertainty during early labor .

CLINICAL IMPLICATIONS

Nulliparous women lack knowledge of and skills to effectively cope with pain during early labor while at home. There is a need for an innovative labor support program for childbearing women to remain safely at home in early labor.

FIGO good practice recommendations for cesarean delivery: Prep-for-Labor triage to minimize risks and maximize favorable outcomes

Cesarean delivery is an abdominal surgical procedure performed for child delivery when the vaginal route is not feasible or desired due to maternal/fetal indications. All childbirth facilities should be able to safely perform a cesarean, which is not the current reality. For planned cesarean delivery, the facility must be prepared for the patient. In contrast, for unplanned arrivals at the facility, FIGO's Prep-for-Labor triage method allows rapid decision-making on whether cesarean delivery can be safely performed on site or whether transfer to an advanced care center is needed. A checklist of staff/tools for safe on-site cesarean delivery is provided to enable timely decision-making. Maternal complications following cesarean are three-fold higher than vaginal delivery. To prevent nonmedically indicated cesarean by favoring vaginal delivery, up-to-date safe and effective guidance is provided, defining labor, second stage length, and status before an arrested labor is confirmed. Whether cesarean delivery is planned or emergency, the Misgav Ladach simplified procedure is proposed as it is suitable for both low- and high-risk cases, including twins, thereby reducing both operative morbidity and postoperative recovery. A trial of labor after first cesarean (TOLAC) should be pursued when feasible, for which the indications, contraindications, safeguards, and steps of safe labor induction are delineated. Implementation of these good practice recommendations will improve childbirth by reducing excessive nonindicated cesareans, while precisely defining the resources and postoperative care required for safe performance on site. Enabling safe childbirth by cesarean and TOLAC, even at sites with low rates currently, will significantly improve maternal and fetal outcomes.

Statewide Perinatal Quality Improvement, Teamwork, and Communication Activities in Oklahoma and Texas

BACKGROUND AND OBJECTIVE

The purpose of this study was to describe statewide perinatal quality improvement (QI) activities, specifically implementation of Alliance for Innovation on Maternal Health (AIM) patient safety bundles and use of teamwork and communication tools in obstetric units in Oklahoma and Texas.

METHODS

In January-February 2020, we conducted a survey of AIM-enrolled hospitals in Oklahoma (n = 35) and Texas (n = 120) to gather data on obstetric unit organization and QI processes. Data were linked to hospital characteristics information from the 2019 American Hospital Association survey and hospitals' maternity levels of care from state agencies. We generated descriptive statistics for each state and created an index to summarize adoption of QI processes. We fitted linear regression models to examine how this index varied by hospital characteristics and self-reported ratings for patient safety and AIM bundle implementation.

RESULTS

Most obstetric units had standardized clinical processes for obstetric hemorrhage (94% Oklahoma; 97% Texas), massive transfusion (94% Oklahoma; 97% Texas), and severe hypertension in pregnancy (97% Oklahoma; 80% Texas); regularly conducted simulation drills for obstetric emergencies (89% Oklahoma; 92% Texas); had multidisciplinary QI committees (61% Oklahoma; 83% Texas); and conducted debriefs after major obstetric complications (45% Oklahoma; 86% Texas). Few obstetric units offered recent staff training on teamwork and communication to their staff (6% Oklahoma; 22% Texas); those who did were more likely to employ specific strategies to facilitate communication, escalate concerns, and manage staff conflicts. Overall, adoption of QI processes was significantly higher in hospitals in urban than rural areas, teaching than nonteaching, offering higher levels of maternity care, with more staff per shift, and greater delivery volume (all P < .05). The QI adoption index scores were strongly associated with respondents' ratings for patient safety and implementation of maternal safety bundles (both P < .001).

CONCLUSIONS

Adoption of QI processes varies across obstetric units in Oklahoma and Texas, with implications for implementing future perinatal QI initiatives. Notably, findings highlight the need to reinforce support for rural obstetric units, which often face greater barriers to implementing patient safety and QI processes than urban units.

Implementation and outcomes of a system-wide women’s health ‘team goal’ to reduce maternal morbidity for black women: a prospective quality improvement study

Objective

In response to the unacceptable racial disparities in US obstetric outcomes, our health system established a formal goal to reduce maternal morbidity for black women. Here, we describe our process for meeting this equity-focused goal in the context of diverse implementation climates at 5 inpatient sites.

Study design

To meet the system goal, we established a collaborative of multidisciplinary, site-based teams. The validated 18-question Implementation Climate Scale (ICS) was distributed to site clinicians at baseline. Sites focused on haemorrhage, performing case reviews of black women meeting morbidity criteria. Comparing cases by site, site-specific areas for improvement in haemorrhage risk assessment, prevention and management emerged. Evidence-based practices (EBPs) were then selected, tailored and implemented by site. Monthly system-wide team meetings included (1) metric tracking and (2) site presentations with discussions around barriers/facilitators to EBP implementation. Maternal morbidity rates among black women were compared the year before goal development (1 July 2019–30 June 2020) to the year after (1 July 2020–30 June 2021).

Results

Mean ICS scores for inpatient obstetric units differed by site (p=0.005), with climates more supportive of implementation at urban/academic hospitals. In response to case reviews, sites reported implementing 2 to 8 EBPs to meet the goal. Despite different ICS scores, this process was associated with significant reductions in maternal morbidity for black women from pregoal to postgoal development overall and at sites 1, 2 and 3, with non-statistically significant reductions at sites 4 and 5 (overall: −29.4% reduction, p<0.001).

Conclusions

A health system goal of reducing maternal morbidity for black women led to a data-driven, collaborative model for implementing site-tailored interventions. If health systems prioritise equity-focused goals, sites can be supported in implementing EBPs that improve care.

Reduction in Cesarean Delivery Rates Associated With a State Quality Collaborative in Maryland

OBJECTIVE

To assess the extent to which hospitals participating in the MDPQC (Maryland Perinatal-Neonatal Quality Care Collaborative) to reduce primary cesarean deliveries adopted policy and practice changes and the association of this adoption with state-level cesarean delivery rates.

METHODS

This prospective evaluation of the MDPQC includes 31 (97%) of the birthing hospitals in the state, which all voluntarily participated in the 30-month collaborative from June 2016 to December 2018. Hospital teams agreed to implement practices from the "Safe Reduction of Primary Cesarean Births" patient safety bundle, developed by the Council on Patient Safety in Women's Health Care. Each hospital's implementation of practices in the bundle was measured through surveys of team leaders at 12 months and 30 months. Half-yearly cesarean delivery rates were calculated from aggregate birth certificate data for each hospital, and differences in rates between the 6 months before the collaborative (baseline) and the 6 months afterward (endline) were tested for statistical significance.

RESULTS

Among the 26 bundle practices that were assessed, participating hospitals reported having a median of seven practices (range 0-23) already in place before the collaborative and implementing a median of four (range 0-17) new practices during the collaborative. Across the collaborative, the cesarean delivery rates decreased from 28.5% to 26.9% (P=.011) for all nulliparous term singleton vertex births and from 36.1% to 31.3% (P<.001) for nulliparous, term, singleton, vertex inductions. Five hospitals had a statistically significant decrease in nulliparous, term, singleton, vertex cesarean delivery rates and four had a significant increase. Nulliparous, term, singleton, vertex cesarean delivery rates were significantly lower across hospitals that implemented more practices in the "Response" domain of the bundle.

CONCLUSION

The MDPQC was associated with a statewide reduction in cesarean delivery rates for nulliparous, term, singleton, vertex births.

Intrapartum Nurses' Beliefs Regarding Birth, Birth Practices, and Labor Support

OBJECTIVES

To examine the relationships among intrapartum (IP) nurses' beliefs regarding birth (physiologic birth/medicalized birth) and their experience, education, and certification; to assess IP nurses' beliefs about birth practices and labor support; to describe the birth practices of the most effective IP nurses; and to elicit recommendations from IP nurses for quality improvement in IP nursing practice.

DESIGN

Cross-sectional, descriptive study.

SETTING

Three urban hospitals from one state in the northeastern United States.

PARTICIPANTS

One hundred twelve IP registered nurses who were primarily staff nurses.

METHODS

We collected quantitative and qualitative data using a Web-based survey that included the Intrapartum Nurses' Beliefs Related to Birth Practice-Modified scale. We used Burgess's conceptual definition of laborsupport as the framework to analyze findings.

RESULTS

Participants favored physiologic birth and not medicalized birth, and their beliefs were associated with experience (p = .01) and certification (p = .04). Participants reported that effective IP nurses demonstrate labor practices supportive of physiologic birth. Recommendations from participants for quality improvement in IP nursing practice included ways to optimize physical support, emotional support, informational support, and advocacy for women during labor. Participants made no recommendations related to partner support.

CONCLUSION

Participants held beliefs that favored physiologic birth and supported many labor practices that can facilitate physiologic birth. However, some labor practices associated with medicalized birth were also supported. Further quality improvement strategies to provide partner support during labor are needed.

Clinical Effects of Form-Based Management of Forceps Delivery under Intelligent Medical Model

Background

Forceps delivery is one of the most important measures to facilitate vaginal delivery. It can reduce the rate of first cesarean delivery. Frustratingly, adverse maternal and neonatal outcomes associated with forceps delivery have been frequently reported in recent years. There are two major reasons: one is that the abilities of doctors and midwives in forceps delivery vary from hospital to hospital and the other one is lack of regulations in the management of forceps delivery. In order to improve the success rate of forceps delivery and reduce the incidence of maternal and neonatal complications, we applied form-based management to forceps delivery under an intelligent medical model. The aim of this work is to explore the clinical effects of form-based management of forceps delivery.

Methods

Patients with forceps delivery in Maternal and Child Health Hospital Affiliated to Nanchang University were divided into two groups: form-based patients from January 1, 2019, to December 31, 2020, were selected as the study group, while traditional protocol patients from January 1, 2017, to December 31, 2018, were chosen as the control group. Then, we compared the maternal and neonatal outcomes of these two groups.

Results

There were significant differences in the maternal and neonatal adverse outcomes such as rate of postpartum hemorrhage, degree of perineal laceration, and incidence of neonatal facial skin abrasions between the two groups, whereas differences in the incidence of asphyxia and intracranial hemorrhage were not significant.

Conclusions

Form-based management could help us assess the security of forceps delivery comprehensively, as it could not only improve the success rate of the one-time forceps traction scheme but also reduce the incidence of maternal and neonatal adverse outcomes effectively.

Nursing Support During Latent Phase Labor: A Scoping Review

PURPOSE

The purpose of this scoping review was to synthesize the literature on nursing support during the latent phase of the first stage of labor. In 2014, the definition of the beginning of active labor changed from 4 centimeters (cm) to 6 cm cervical dilation. More women may have an induction of labor based on results of recent research showing no causal increase in risk of cesarean birth with elective induction of labor for low-risk nulliparous women. Therefore, in-hospital latent phase labor may be longer, increasing the need for nursing support.

DESIGN

Scoping review of the literature from 2009 to present.

METHODS

We conducted the review using key words in PubMed, CINAHL, and Scopus. Search terms included different combinations of "latent or early labor," "birth," "support," "nursing support," "obstetrics," and "onset of labor." Peer-reviewed research and quality improvement articles from 2009 to present were included if they had specific implications for nursing care during the latent phase of labor. Articles were excluded if they were not specific to nursing, focused exclusively on tool development, or were from the perspective of pregnant women or providers only.

RESULTS

Ten articles were included. Results were synthesized into six categories; support of physiologic labor and birth, the nurse's own personal view of labor, birth environment, techniques and tools, decision-making, and importance of latent labor discussion during the prenatal period.

CLINICAL IMPLICATIONS

Support for physiologic labor and birth is an important consideration for use of nonpharmacological methods during latent labor. The nurse's own personal view on labor support can influence the support that laboring women receive. Nurses may need additional education on labor support methods.

Assessing the regional policies of Italian regions in managing the Cesarean delivery phenomenon: a fractal analysis

Objectives.

Assessing the 2017 administrative data on Cesareans delivery in Italy by using fractal statistic.

Methods.

2017 administrative data on Italian Cesarean deliveries are freely available as crude numbers and rates according to each Italian region, according to Italian health institute type and according to first or repeated Cesarean. As already reported, the Italian Cesarean delivery phenomenon is in relationship with hospital, regional, cultural perspectives in caring pregnancy and delivery. Fractal statistics can best assess the biocomplexity underlying the Italian Cesarean section phenomenon. Fractal shapes and self-organized criticality of the Cesarean section phenomenon for each Italian region were done. Fractal shapes were compared to find similarities by using global test of coincidence among regression lines.

Results.

In the regions where the health care institutes are more than a type, there are evanescent similar fractal shapes. Self-organized criticality assessment demonstrates that chaos is largely involved in Cesarean delivery phenomenon in all Italian regions and in Italy. The fractal images for each region are able to highlight the item causing the deviation from fractal shapes in each region.

Conclusion.

Fractal statistics could be used to compare regional or hospital policies in performing Cesareans, starting from Cesareans rates extracted from administrative data. (www.actabiomedica.it)

Enhancing Obstetric Safety Through Best Practices

The pregnancy-related mortality rate in the US exceeds that of other developed nations and is marked by significant disparities in outcome by race. This article reviews the evidence supporting the implementation of a variety of best practices designed to reduce maternal mortality. Evidence from maternal mortality review committees suggests that delays in diagnosis, delays in initiation of treatment and use of ineffective treatments contribute to preventable cases of maternal death. We review several protocols for maternal warning signs that have been used successfully to facilitate early identification and intervention. Care bundles, a collection of best practices, have been developed and implemented to address several maternal emergencies. We review the evidence that supports reduction in adverse outcomes with consistent implementation of obstetric hemorrhage and severe hypertension bundles in a collaborative, team-based setting. The article concludes with suggestions for the future.

Mid forceps did not cause "compromised babies" - "compromise" caused forceps: an approach toward safely lowering the cesarean delivery rate

OBJECTIVE

Over 5 decades, Cesarean Delivery rates (CDR) have risen 6-fold while vaginal operative deliveries [VODs] decreased from >20% to ∼3%. Poor outcomes (HIE and cerebral palsy) haven't improved. Potentiating the virtual abandonment of forceps (F), particularly midforceps (Mid), were allegations about various poor neonatal outcomes. Here, we evaluate VOD and CDR outcomes controlling for prior fetal risk metrics (PR) ascertained an hour before birth.

METHODS

Our 45-year-old database from a labor research unit of moderate/high risk laboring patients (288 NSVDs, 120 Lows, 30 Mids, and 32 CDs) had multiple fetal scalp samples for base excess (BE), pH, cord blood gases (CB), and umbilical artery bloods. ANOVA established relationships between birth methods and outcomes (Cord blood BE and pH and 1 and 5 min Apgar scores); correlations, and two-step multiple regression assessed PR for delivery method and neonatal outcomes. The main outcome measures were correlations of outcome measures with fetal scalp sample BE and pH up to an hour before delivery and fetal reserve index scores scored concurrently.

RESULTS

NSVDs had the best immediate neonatal outcomes with significantly higher CB pH and BE as compared to forceps and CDs. However, controlling for PR revealed: (1) PR at 1 h before delivery correlated with delivery mode, i.e. the decrements in outcomes were already present before the delivery was performed; and (2) The presumed deleterious effects of interventional deliveries, per se, were significantly reduced, and (3) Fetal Reserve Index predicted neonatal outcomes better than fetal scalp sample BE, pH, or delivery mode.

CONCLUSION

The historical belief that MF deliveries caused poorer outcomes than NSVDs seems mostly backwards. Appreciating PR's impact on delivery routes, and when appropriate, properly performing VODs could safely reduce CDR. If our approach lowered CDR by only ∼2%, in the United States about 80,000 CDs might be avoided, saving ∼$750 Million yearly. In the post pandemic world, safely apportioning medical expenses will be even more critical than previously.

Association between Neuraxial Labor Analgesia and Neonatal Morbidity after Operative Vaginal Delivery

BACKGROUND

Up to 84% of women who undergo operative vaginal delivery receive neuraxial analgesia. However, little is known about the association between neuraxial analgesia and neonatal morbidity in women who undergo operative vaginal delivery. The authors hypothesized that neuraxial analgesia is associated with a reduced risk of neonatal morbidity among women undergoing operative vaginal delivery.

METHODS

Using United States birth certificate data, the study identified women with singleton pregnancies who underwent operative vaginal (forceps- or vacuum-assisted delivery) in 2017. The authors examined the relationships between neuraxial labor analgesia and neonatal morbidity, the latter defined by any of the following: 5-min Apgar score less than 7, immediate assisted ventilation, assisted ventilation greater than 6 h, neonatal intensive care unit admission, neonatal transfer to a different facility within 24 h of delivery, and neonatal seizure or serious neurologic dysfunction. The authors accounted for sociodemographic and obstetric factors as potential confounders in their analysis.

RESULTS

The study cohort comprised 106,845 women who underwent operative vaginal delivery, of whom 92,518 (86.6%) received neuraxial analgesia. The proportion of neonates with morbidity was higher in the neuraxial analgesia group than the nonneuraxial group (10,409 of 92,518 [11.3%] vs. 1,271 of 14,327 [8.9%], respectively; P < 0.001). The unadjusted relative risk was 1.27 (95% CI, 1.20 to 1.34; P < 0.001); after accounting for confounders using a multivariable model, the adjusted relative risk was 1.19 (95% CI, 1.12 to 1.26; P < 0.001). In a post hoc analysis, after excluding neonatal intensive care unit admission and neonatal transfer from the composite outcome, the effect of neuraxial analgesia on neonatal morbidity was not statistically significant (adjusted relative risk, 1.07; 95% CI, 1.00 to 1.16; P = 0.054).

CONCLUSIONS

In this population-based cross-sectional study, a neonatal benefit of neuraxial analgesia for operative vaginal delivery was not observed. Confounding by indication may explain the observed association between neuraxial analgesia and neonatal morbidity, however this dataset was not designed to evaluate such considerations.

EDITOR’S PERSPECTIVE

Advances in Maternal Fetal Medicine: Perinatal Quality Collaboratives Working Together to Improve Maternal Outcomes

State-based perinatal quality collaboratives (PQCs) address preventable causes of maternal and infant morbidity and mortality by implementing statewide quality improvement (QI) initiatives. They work with hospital clinical teams, obstetric provider and nursing leaders, patients and families, public health officials, and other stakeholders to provide opportunities for collaborative learning, rapid-response data, and QI science support to achieve clinical culture change. PQCs show that the application of collaborative improvement science methods to advance evidence-informed clinical practices using QI strategies contributes to improved perinatal outcomes. With appropriate staffing, infrastructure, and partnerships, PQCs can achieve sustainable improvements in perinatal care.

Variability in cesarean delivery rates among individual labor and delivery nurses compared to physicians at three attribution time points

OBJECTIVE

To examine the variability in the cesarean delivery (CD) rates of individual labor and delivery nurses compared with physicians at three attribution time points.

DATA SOURCES

Medical record data from nine hospitals in Washington State from January 2016 through September 2018.

STUDY DESIGN

Retrospective, observational cohort design using an aggregated database of birth records.

DATA COLLECTION/EXTRACTION METHODS

Chart-abstracted clinical data from a subset of nulliparous, term, singleton, vertex births attributed at admission, labor management, and delivery to nurses and physicians. Two classification methods were used to categorize nurse- and physician-level CD rates at three attribution time points and the reliability of these methods compared.

PRINCIPAL FINDINGS

The sample included 12 556 births, 319 nurses, and 126 physicians. Overall, variation in nurse-level CD rates did not differ significantly across the three attribution time points, and the extent of variation was similar to that observed in physicians. However, agreement between attribution time points varied between 35 percent and 65 percent when classifying individual nurses into the top and bottom deciles. The average reliability of nurse-level CD rates was 32 percent at admission (IQR 22.0 percent to 38.7 percent), 32.6 percent at labor (IQR 23.1 percent to 40.9 percent), and 29.3 percent (IQR 20.9 percent to 35.8 percent) at delivery. The average reliability of physician-level CD rates was higher: 54.2 percent (IQR 38.7 percent to 71.4 percent) at admission, 62.5 percent (IQR 49.0 percent to 79.6 percent) at labor management, and 66.1 percent (IQR 53.7 percent to 81.2 percent) at delivery.

CONCLUSION

Feedback on nurse-level CD rates as part of routine clinical quality audits can provide insight into nurse performance in the context of other individual-level and unit-level information. To reliably distinguish individual nurse performance, larger sample sizes are needed.

Maternal mortality, abortion access, and optimizing care in an increasingly restrictive United States: A review of the current climate

The United States is facing a national crisis related to increasing rates of maternal morbidity and mortality. Over the past few years, significant focus has been turned to initiatives that aim to address maternal morbidity and mortality rates. In parallel, the United States has seen a significant increase in restrictive abortion access state laws. The link between abortion restrictions and worsening maternal outcomes has been proposed. This review article outlines the national crisis of maternal morbidity and mortality, the potential role of limiting abortion access in this crisis, and the significant racial, socioeconomic, and geographical disparities that exist.

SMFM Special Statement: Who's who in patient safety and quality for maternal healthcare in the United States

There are many organizations in the United States concerned with the improvement of patient safety and healthcare quality. In this overview, we provide a synopsis of the major entities whose work is relevant to maternal healthcare. For each organization, we summarize its mission, vision, major programs, and relationships with other entities. We include 13 entities with broad scope covering all types of healthcare; 9 organizations whose focus is maternal-child health; 6 women's health professional organizations with committees on patient safety, quality, or both; 12 organizations that offer accreditation, certification, or special distinction based on quality; and 5 organizations that rate, rank, or report quality metrics.

Application of Implementation Science to OB/GYN Quality Improvement Efforts

Although there is no shortage of guidelines and toolkits outlining clinical practices that are evidence-based and have been shown to improve outcomes, many hospitals, and L&D units struggle to figure out exactly how to implement strategies that have been shown to work. This paper will describe suggestions to help obstetrics and gynecology units successfully implement evidence-based strategies to improve quality and safety based on the theoretical framing structures of implementation science, including theories such as the Health Beliefs Model, the Theory of Planned Behavior, Ecological Perspectives, COM-B, CFIR, and tools such as Driver Diagrams.

SMFM Special Statement: Operative vaginal delivery: checklists for performance and documentation

The frequency of operative vaginal delivery has been declining, even though it can be an attractive alternative to cesarean delivery in selected cases. Performance of operative vaginal delivery required consideration of many indications, contraindications, and prerequisites. Optimal documentation of operative vaginal delivery requires the recording of several specific elements that are unique to forceps or vacuum delivery. A cognitive aid such as a checklist is well suited to this situation in which there are numerous elements to consider, a low frequency of performance, and teams with variable expertise. We propose 2 checklists to help ensure that all relevant elements are considered for every operative vaginal delivery: (1) a checklist for preparation and performance of the procedure and (2) a checklist for documentation. We suggest practical tips to help facilities adapt these checklists to their own circumstances and implement them on their units.

Enhanced recovery after cesarean delivery: a challenge for anesthesiologists

Enhanced recovery after cesarean (ERAC) delivery is an evidence-based, multi-disciplinary approach throughout pre-, intra-, post-operative period. The ultimate goal of ERAC is to enhance recovery and improve the maternal and neonatal outcomes. This review highlights the role of anesthesiologist in ERAC protocols. This review provided a general introduction of ERAC including the purposes and the essential elements of ERAC protocols. The tool used for evaluating the quality of ERAC (ObsQoR-11) was discussed. The role of anesthesiologist in ERAC should cover the areas including management of peri-operative hypotension, prevention and treatment of intra- and post-operative nausea and vomiting, prevention of hypothermia and multi-modal peri-operative pain management, and active pre-operative management of unplanned conversion of labor analgesia to cesarean delivery anesthesia. Although some concerns still remain, ERAC implementation should not be delayed. Regular assessment and process improvement should be imbedded into the protocol. Further high-quality studies are warranted to demonstrate the effectiveness and efficacy of the ERAC protocol.

Safety Assessment of a Large-Scale Improvement Collaborative to Reduce Nulliparous Cesarean Delivery Rates

OBJECTIVE

To evaluate maternal and neonatal safety measures in a large-scale quality improvement program associated with reductions in nulliparous, term, singleton, vertex cesarean delivery rates.

METHODS

This is a cross-sectional study of the 2015-2017 California Maternal Quality Care Collaborative (CMQCC) statewide collaborative to support vaginal birth and reduce primary cesarean delivery. Hospitals with nulliparous, term, singleton, vertex cesarean delivery rates greater than 23.9% were solicited to join. Fifty-six hospitals with more than 119,000 annual births participated; 87.5% were community facilities. Safety measures were derived using data collected as part of routine care and submitted monthly to CMQCC: birth certificates, maternal and neonatal discharge diagnosis and procedure files, and selected clinical data elements submitted as supplemental data files. Maternal measures included chorioamnionitis, blood transfusions, third- or fourth-degree lacerations, and operative vaginal delivery. Neonatal measures included the severe unexpected newborn complications metric and 5-minute Apgar scores less than 5. Mixed-effect multivariable logistic regression model was used to calculate odds ratios (Ors) and 95% CIs.

RESULTS

Among collaborative hospitals, the nulliparous, term, singleton, vertex cesarean delivery rate fell from 29.3% in 2015 to 25.0% in 2017 (2017 vs 2015 adjusted OR [aOR] 0.76, 95% CI 0.73-0.78). None of the six safety measures showed any difference comparing 2017 to 2015. As a sensitivity analysis, we examined the tercile of hospitals with the greatest decline (31.2%-20.6%, 2017 vs 2015 aOR 0.54, 95% CI 0.50-0.58) to evaluate whether they had greater risk of poor maternal and neonatal outcomes. Again, no measure was statistically worse, and the severe unexpected newborn complications composite actually declined (3.2%-2.2%, aOR 0.71, 95% CI 0.55-0.92).

CONCLUSION

Mothers and neonates participating in a large-scale Supporting Vaginal Birth collaborative had no evidence of worsened birth outcomes, even in hospitals with large cesarean delivery rate reductions, supporting the safety of efforts to reduce primary cesarean delivery using American College of Obstetricians and Gynecologists and Society for Maternal-Fetal Medicine guidelines and enhanced labor support.

Combined prenatal and postnatal prediction of early neonatal compromise risk

OBJECTIVE

Electronic fetal monitoring/cardiotocography (EFM) is nearly ubiquitous, but almost everyone acknowledges there is room for improvement. We have contextualized monitoring by breaking it down into quantifiable components and adding to that, other factors that have not been formally used: i.e. the assessment of uterine contractions, and the presence of maternal, fetal, and obstetrical risk factors. We have created an algorithm, the Fetal Reserve Index (FRI) that significantly improves the detection of at-risk cases. We hypothesized that extending our approach of monitoring to include the immediate newborn period could help us better understand the physiology and pathophysiology of the decrease in fetal reserve during labor and the transition from fetal to neonatal homeostasis, thereby further honing the prediction of outcomes. Such improved and earlier understanding could then potentiate earlier, and more targeted use of neuroprotective attempts during labor treating decreased fetal reserve and improving the fetus' transition from fetal to neonatal life minimizing risk of neurologic injury.

STUDY DESIGN

We have analyzed a 45-year-old research database of closely monitored labors, deliveries, and an additional hour of continuous neonatal surveillance. We applied the FRI prenatally and created a new metric, the INCHON index that combines the last FRI with umbilical cord blood and 4-minute umbilical artery blood parameters to predict later neonatal acid/base balance. Using the last FRI scores, we created 3 neonatal groups. Umbilical cord and catheterized umbilical artery bloods at 4, 8, 16, 32, and 64 minutes were measured for base excess, pH, and PO₂. Continuous neonatal heart rate was scored for rate, variability, and reactivity.

RESULTS

Neonates commonly do not make a smooth transition from fetal to postnatal physiology. Even in low risk babies, 85% exhibited worsening pH and base excess during the first 4 minutes; 34% of neonates reached levels considered at high risk for metabolic acidosis (≤-12 mmol/L) and neurologic injury. Neonatal heart rate commonly exhibited sustained, significant tachycardia with loss of reactivity and variability. One quarter of all cases would be considered Category III if part of the fetal tracing. Our developed metrics (FRI and INCHON) clearly discriminated and predicted low, medium, and high-risk neonatal physiology.

CONCLUSIONS

The immediate neonatal period often imposes generally unrecognized risks for the newborn. INCHON improves identification of decreased fetal reserve and babies at risk, thereby permitting earlier intervention during labor (intrauterine resuscitation) or potentially postnatally (brain cooling) to prevent neurologic injury. We believe that perinatal management would be improved by routine, continuous neonatal monitoring - at least until heart rate reactivity is restored. FRI and INCHON can help identify problems much earlier and more accurately than currently and keep fetuses and babies in better metabolic shape.

Guidelines for intraoperative care in cesarean delivery: Enhanced Recovery After Surgery Society Recommendations (Part 2)

The Enhanced Recovery After Surgery Society guideline for intraoperative care in cesarean delivery will provide best practice, evidenced-based, recommendations for intraoperative care, with primarily a maternal focus. The "focused" pathway process for scheduled and unscheduled cesarean delivery for this Enhanced Recovery After Surgery cesarean delivery guideline will consider procedure from the decision to operate (starting with the 30-60 minutes before skin incision) through the surgery. The literature search (1966-2017) used Embase and PubMed to search medical subject headings including "cesarean section," "cesarean section," "cesarean section delivery," and all pre- and intraoperative Enhanced Recovery After Surgery items. Study selection allowed titles and abstracts to be screened by individual reviewers to identify potentially relevant articles. Metaanalyses, systematic reviews, randomized controlled studies, nonrandomized controlled studies, reviews, and case series were considered for each individual topic. Quality assessment and data analyses evaluated the quality of evidence and recommendations were evaluated according to the Grading of Recommendations, Assessment, Development and Evaluation system as used and described in previous Enhanced Recovery After Surgery Society guidelines. The Enhanced Recovery After Surgery cesarean delivery guideline/pathway has created a maternal focused pathway (for scheduled and unscheduled surgery starting from 30-60 minutes before skin incision to maternal discharge) with Enhanced Recovery After Surgery-directed preoperative elements, intraoperative elements, and postoperative elements. Specifics of the intraoperative care included the use of prophylactic antibiotics before the cesarean delivery, appropriate patient warming intraoperatively, blunt expansion of the transverse uterine hysterotomy, skin closure with subcuticular sutures, and delayed cord clamping. A number of specific elements of intraoperative care of women who undergo cesarean delivery are recommended based on the evidence. The Enhanced Recovery After Surgery Society guideline for intraoperative care in cesarean delivery will provide best practice, evidenced-based, recommendations for intraoperative care with primarily a maternal focus. When the cesarean delivery pathway (elements/processes) is studied, implemented, audited, evaluated, and optimized by maternity care teams, this will create an opportunity for the focused and optimized areas of care and recommendations to be further enhanced.

Guidelines for Antenatal and Preoperative care in Cesarean Delivery: Enhanced Recovery After Surgery Society Recommendations (Part 1)

This Enhanced Recovery After Surgery (ERAS) Guideline for perioperative care in cesarean delivery will provide best practice, evidenced-based, recommendations for preoperative, intraoperative, and postoperative phases with, primarily, a maternal focus. The focused pathway process for scheduled and unscheduled cesarean delivery for this ERAS Cesarean Delivery Guideline will consider from the time from decision to operate (starting with the 30-60 minutes before skin incision) to hospital discharge. The literature search (1966-2017) used Embase and PubMed to search medical subject headings that included "Cesarean Section," "Cesarean Section," "Cesarean Section Delivery" and all pre- and intraoperative ERAS items. Study selection allowed titles and abstracts to be screened by individual reviewers to identify potentially relevant articles. Metaanalyses, systematic reviews, randomized controlled studies, nonrandomized controlled studies, reviews, and case series were considered for each individual topic. Quality assessment and data analyses that evaluated the quality of evidence and recommendations were evaluated according to the Grading of Recommendations, Assessment, Development and Evaluation system, as used and described in previous ERAS Guidelines. The ERAS Cesarean Delivery Guideline/Pathway has created a maternal focused pathway (for scheduled and unscheduled surgery starting from 30-60 minutes before skin incision to maternal discharge) with ERAS cesarean delivery consensus recommendations preoperative elements (anesthetic medications, fasting, carbohydrate supplementation, prophylactic antibiotics/skin preparation, ), intraoperative elements (anesthetic management, maternal hypothermia prevention, surgical technique, hysterotomy creation and closure, management of peritoneum, subcutaneous space, and skin closure), perioperative fluid management, and postoperative elements (chewing gum, management of nausea and vomiting, analgesia, timing of food intake, glucose management, antithrombotic prophylaxis, timing of ambulation, urinary management, and timing of maternal and neonate discharge). Limited topics for optimized care and for antenatal education and counselling and the immediate neonatal needs at delivery are discussed. Strong recommendations for element use were given for preoperative (antenatal education and counselling, use of antacids and histamine, H2 receptor antagonists, 2-hour fasting and small meal within 6 hours surgery, antimicrobial prophylaxis and skin preparation/chlorhexidine-alcohol), intraoperative (regional anesthesia, prevention of maternal hypothermia [forced warm air, warmed intravenous fluids, room temperature]), perioperative (fluid management for euvolemia and neonatal immediate care needs that include delayed cord clamping), and postoperative (fluid management to prevent nausea and vomiting, antiemetic use, analgesia with nonsteroidal antiinflammatory drugs/paracetamol, regular diet within 2 hours, tight capillary glucose control, pneumatic compression stocking for venous thromboembolism prophylaxis, immediate removal of urinary catheter). Recommendations against the element use were made for preoperative (maternal sedation, bowel preparation), intraoperative (neonatal oral suctioning or increased inspired oxygen), and postoperative (heparin should not be used routinely venous thromboembolism prophylaxis). Because these ERAS cesarean delivery pathway recommendations (elements/processes) are studied, implemented, audited, evaluated, and optimized by the maternity care teams, this will create an opportunity for the focused and optimized areas of care research with further enhanced care and recommendation.