Primary focus of PQCNC SIVB initiative

MATERNAL RISKS LATER MATERNAL

ASSOCIATED WITH RISKS ASSOCIATED
CESAREAN SECTION WITH CS
•Hysterectomy
•Uterine Rupture
•Post partum hemorrhage
•Planning for timing
•Venous
and route of next
thromboembolism
•pregnancy
•Wound complications
•Placenta accreta
•Other surgical site
infections
•Decreased success at
breast feeding
•Hospital readmission
 7804 NSTV
 40% Induction rate
 40.7% had cervical ripening**
 Indications for induction
◦ Fetal indications 13.6%
◦ Fetal macrosomia 3.3%
◦ Maternal indications 24.9%
◦ “Post term” but less than 41weeks 14.3%
◦ Post term ≥ 41 weeks 18.3%
◦ Elective 25.6%
◦ Elective with cervical ripening 37%
◦ **BISHOP SCORE < 6
Indications for cesarean section

◦ Labor dystocia 75.1%

◦ Fetal distress 28.2%
◦ Maternal medical indication—1.6%
◦ “Other” 2.9%

◦ Labor dystocia 79.0% for induced, 68.9% for

spontaneous labor (p<0.05)

April 2010 Obstetrics &

Gynecology
FACTOR April 2010 Green Jl, 3) aOR
Black Race 1.44
≥35 years 1.71
BMI
< 18.5 Referent
18.5-24.9 1.36
25-29.9 1.96
30-39.9 3.24
≥40 4.51
Weight gain ≥18.14 kg 1.37
Gestational diabetes 1.38
Gestational hypertension 1.38
EGA ≥41 weeks 1.58
Induced labor 1.93
 Multivariate Analysis

 BlackRace aOR 1.35

 Age 35 or older aOR 1.83
 Wt gain >18.14kg aOR 1.28
 Induced labor aOR 2.03
 Restriction to NTSV with no
co-morbidities
 29.9% induced overall
 CS in 13.6% not induced, 25.5% induced

 CONCLUSION: 20% of all CS

among low risk women and all
NSTV women could be attributed
to labor induction!!!!
 Study of >200,000 deliveries >23 weeks, looked at
intended vaginal births across many hospitals, 2002-
2008
 36.2% induction rate overall
 Among intended vaginal births, induction rate was
43.8% (underestimate on birth certificate?)
 Overall c-section rate was 30.5%, range 20%-44%
◦ C/S rate was 21.1% for those whose labor was induced
◦ C/S rate was 11.8% for those with spontaneous labor
 Among nulliparous women with singleton, vertex
babies:
◦ C/S rate was 31.4% for those whose labor was induced
◦ C/S rate was 14.2% for those with spontaneous labor
 Almost one-third of all C/S were prelabor repeats
 47.1% of intrapartum C/S were performed for failure to
progress or cephalopelvic disproportion
 27.3% were performed for nonreassuring fetal heart rate
 Half of C/S for dystocia among inductions were done at
<6cm
◦ When is active labor? In nullips?
 One-third of 2nd stage C/S were done <3 hours in nullips
 One-fourth of 2nd stage C/S were done <2 hours in
multips
◦ This includes “decision-to-incision” time
 C/S performed at earlier cervical dilations in induction
patients than in spontaneous labor patients
 Almost 2/3 of overall CS attributed to 3 groups
with potentially modifiable risk factors:
◦ NTSV with induced labor
 Review indications/processes for induction
◦ Previous CS and singleton cephalic term pregnancy
 Provide VBAC
◦ Breech presentation
 Offer ECV if appropriate

Contribution of select maternal groups to temporal trends in rates of caesarean

section. VM Allan. J Ob Gyn Can July 2010
 PATIENT EDUCATION
Establish practice
agreements about
elective inductions,
indicated inductions.

Communicate early on in
prenatal care the policy
of preferring
spontaneous labor,
essential ban on elective
inductions prior to 39
weeks.

38 weeks is too late to

have that conversation
and to expect to have
the patient on your team
What sort of analgesia
is available and how/
when is it administered
in labor?

What sort of labor support

is available? ALL LABORS
Do your unit’s MD, CNM
and nursing staff all
share a commitment to
promoting safe vaginal
birth for patients for
whom it is not contra-
indicated?

What labor curve do you

use in your unit and how
do you functionally define
“Failure to progress”?
What is the functional definition
of “LABOR” in your unit?

What is “active labor”?

SPONTANEOUS LABOR
What do you do
with “prodromal
labor”?
Discharge to home?
Therapeutic rest?
Induce?

When, how do you

augment labor?
Who gets induced?
Do you have a policy in your
practice, labor unit
regarding elective
inductions?
INDUCED LABORS
When do you
Induce?

What method(s) of
cervical ripening do
you use?

Who gets cervical

ripening?

What are you pitocin protocols?

Ideas for Quality Projects Around Induction
of Labor for NTSV: The “Bucket List”
•Look at your data to determine the vaginal delivery rate in
your NSTV population.

•What are the key drivers of your IOL rates?

•What are the key drives of your success rates in the

population of NSTV?

•What changes in these drivers are possible to design, vet

and test in 1-2 months?

•Identify 2-4 changes in these drivers that your team will

consider for further exploration during this project.

•If there are issues in spontaneously laboring patients that

are important drives of the C/S rate at your hospital,
consider those as well.
IOL POLICIES
No electives before 39 weeks
No electives with unripe cvx
Use of cervical ripening for indicated, unripe cvx
What kind of documentation required pre-induction
Functional definitions: Labor, prodrome, failure to
progress, failed induction
IOL PROCEDURES
Cervical ripening orders, methods
Pitocoin protocols
Labor support
Use of analgesia, anesthesia
AROM use

LABOR and DELIVERY CULTURE

Is there a will to improve this at your unit?
Are all doctors, CNM’s, and nurses committed?
Do you have a communication issue on your unit?
Are patients educated in general about expectations,
processes?