SHOULD WE PROMOTE SAFE VAGINAL BIRTH

FOR WOMEN WHO ARE NULLIPAROUS, TERM,

WITH SINGLETON PREGNANCIES, AND ARE

VERTEX?

IF SO HOW AND IN WHAT MANNER?

Randall J. Morgan MD MBA

Wesley Obstetrics and Gynecology Grand Rounds March 11, 2020

Nulliparous Term Singleton Vertex

• Joint Commission Core Measure – PC 02 - perinatal care

• NSTV cesarean rate = cesarean births for NTSV population

total NTSV population

NSTV population-all women with delivery of a newborn with 37 weeks or more

of gestation completed, singleton, vertex

Excluded population-< 8 years of age, > 65 years of age, length of stay > 120

days, enrolled in clinical trials, < 37 weeks,

Goals

• Discuss nulliparous term singleton vertex (NTSV)

• Discuss quality improvement & high reliability concepts in our care

of nulliparous term singleton pregnancies

• Discuss quality improvement for publicly reported measures

• Discuss control charts and interpretation

• Common cause

• Special cause

• I have no conflicts of interest

Risk of adverse maternal & neonalt outcomes by mode

of delivery (ACOG Safe Prevention of the Primary Cesarean Mar 2014)

Outcome risk risk

Maternal Vaginal Cesarean

Overall severe morbidity &

mortality

8.6%/0.9% 9.2%/2.7%

Maternal mortality 3.6/100,000 13.3/100,000

Amniotic fluid embolism 3.377.7/100,000 13.3/100,000

3rd 4th deg perineal 1.0-3.0% NA scheduled delivery

Urinary incontinence No diff No diff

Placental abnormality C/S increased

Neonatal

Laceration NA 1.0-2%

Shoulder dystocia 1.0-2.0% 0%

Respiratory morbidity <1.0% 1.0-4.0%

Maternal morbidity and mortality associated with low-risk

planned cesarean delivery versus planned vaginal delivery at

term Liu et al CMAJ Feb 13, 2007; 176(4): 455-460

• Retrospective population-based study comparing primary cesarean

delivery for term breech (46,766) vs planned term vaginal birth(both

spontaneous & induction) (2,292,420). Study over 14 years

• Rates of maternal morbidity (cardiac arrest, wound hematoma,

hysterectomy, major puerperal infection, anesthetic complications, venous

thromboembolism, hemorrhage requiring hysterectomy, adjusted longer

hospital stay)

• Planned vaginal birth 0.9%

• Planned cesarean breech 2.7%

• Maternal mortality was not statistically different

Incidence of complications with subsequent cesarean

deliveries• Placenta Previa

• risks 1/200-overall

• 1 previous cesarean risk 1% and if 3 cesareans 3%

• If previa and 3 previous cesareans - 40 chance of placenta accreta

• Uterine rupture –• Unscarred uterus- 1/5700-20,000

• Elective repeat cesarean delivery 1.6/1000

• Trial of labor- 1 low transverse 2-3/1,000

•Once uterus has scar, risks are increased whether repeat cesarean or trial of labor

Independent risk factors for hemoglobin drop to <7g/dL postoperatively

Andrea Fullerton 2012 Presentation to Daniel K. Roberts society

1.00

2.00

3.00

4.00

5.00

6.00

Abnormalplacenta

Delivery at2-7 am

Preop. hgb<11

Labor priorto CS

EBL ≥1500 mL

5.50

4.85

4.03

2.612.31

Ad

just

ed

od

ds

rati

o

Hemoglobindrop to <7 g/dLpostoperatively

*P<.05**P<.001

**

*

*

**

Impact of nulliparous term singleton vertex cesarean

rates are most important determinant of vaginal birth

rates

• 96% of interinstitutional variance in cesarean sections is attributable to the

nullipara term singleton cesarean rate

• >60% of the rise in cesarean rates is attributable to the nulliparous term

singleton cesarean rate

• 90% of women world-wide who have a previous cesarean will deliver future

pregnancies by cesarean (NSTV focuses on her reproductive future)

• Brennan, DJ. Am J OB GYN 2009; 201: 308 e1-8

https://www.statista.com/statistics/800589/us-hospital-c-section-rates-by-state/

Nebraska 34%

Kansas 25%

New Mexico 17%

US Target 23.9%

NTSV by state 2017

West Virginia 39%

Kansas 9th 32%

California 14.3%

Source CDC 2016

Wesley Medical Center 34%

South Miami 51%

Consumer Reports Analysis: Most U.S.

Hospitals’ C-Section Rates Exceeding

National Targets

A Mother’s Risk of Having a C-section

Can Vary As Much As Ninefold Across

Hospitals in the US

Filed under: Health Release date

05/16/2017

If you paid $1.1 trillions annually would you feel you had

the right to determine, interpret & expect quality as you

defined quality?

• Treatment of acute MI, CHF,

pneumonia, surgical site

infections….

• Cesarean rate

• In determining quality &

utilization of resources what are

the decision rights of

• Patients

• Providers

• Hospital &institutions

• Payors?

Maternal Morbidity and severe mortality associated with low-risk

planned cesarean delivery versus planned vaginal delivery at

term Liu et al CMAJ Feb 13, 2007; 176(4): 455-460

• Retrospective population-based study comparing primary cesarean

delivery for term breech (46,766) vs planned term vaginal birth(both

spontaneous & induction) (2,292,420). Study over 14 years

• Rates of maternal morbidity (cardiac arrest, wound hematoma,

hysterectomy, major puerperal infection, anesthetic complications, venous

thromboembolism, hemorrhage requiring hysterectomy, adjusted longer

hospital stay)

• Planned vaginal birth 0.9%

• Planned cesarean breech 2.7%

• Maternal mortality was not statistically different

How do we make

unintended

consequences

even less

common?

DEBRIEF

•What surprised you about today’s discussion?

•What puzzled you about today’s conversation?

•If we were to discuss nulliparous term singleton

pregnancy and mode of delivery again, what

should we do differently?

Improvement Concepts Associated with Performance

Resulting in 80-90% Process Reliability

(Primarily can be described as intent, vigilance, and hard work)

• Common equipment, standard order sheets, multiple choice protocols, and written policies/procedures

• Personal check lists

• Feedback of information on compliance

• Suggestions of working harder next time

• Awareness and training

Improvement Concepts Resulting in 95%

Process Reliability

(Uses human factors and reliability science to design failure prevention, failure

identification, and mitigation)

• Decision aids and reminders built into the system

• Desired action the default (based on scientific evidence)

• Redundant processes utilized

• Scheduling used in design development

• Habits and patterns know and taken advantage of in the design

• Standardization of process

Quality improvement studies

• Historical review of previous patient care

• Initiate Process Improvement based on evidenced based data,

guidelines & study impact

• Combination of historical data and process improvement

“When Has An Induction Failed”Simon & Grobman OB GYN vol 105; No. 4; April 2005 p.705

Length of

latent phase (h)

N (%) Cesarean

delivery

0-3 63 (16) 10 (16)

3.1-6 111 (28) 15 (14)

6.1-9 106 (27) 35 (33)

9.1-12 49 (12) 10 (29)

12.1-15 35 (8) 10 (29)

15.1-18 14 (4) 5 (36)

18.1-21 13 (3) 9 (69)

21.1-24 6 (2) 4 (67)

397 nullips > 36 weeks

Latent phase defined as

beginning of

oxytocin/amniotomy until 4

cm -80% effaced or 5 cm

Median time from oxytocin

to AROM 60 minutes

32% ripened

2% didn’t achieve active

phase

Labor induction vs Expectant Management in Low Risk

Nulliparous Women Grobman NEJ Aug 9, 2018 p 513-523

Primary

outcome

Secondary

outcome

Induction

group

N=3059 (%)

Expectant

management

N=3037

Relative

risk

P

value

Composite

neonatal

132 (4.3) 164 (5.4) 0.80 (0.64-

1.00)

.049

Cesarean 569 (18.6) 674 (22.2) 0.84 (0.76-

0.93)

<0.001

Hypertension 277 (9.1) 427 (14.1) 0.64 (0.56-

0.74)

<0.001

Median duration

of stay in L&D-hr

20 (13-28) 14 (9-20) <0.001

Obstetric Care Consensus

Safe Prevention of the Primary Cesarean Delivery

March 2014• Cervical ripening methods should be used when labor is induced in

women with an unfavorable cervix. IB

• If the maternal and fetal status allow, cesarean deliveries for failed

induction of labor in the latent phase can be avoided by allowing

longer durations of the latent phase (up to 24 hours or longer) and

requiring that oxytocin be administered for at least 12-18 hours

after membrane rupture before deeming the induction a failure. IB

Obstetric Care Consensus

Safe Prevention of the Primary Cesarean Delivery

March 2014

• Before 41 0/7 weeks of gestation induction of labor generally should

be performed based and maternal and fetal medical indications.

Inductions at 41 0/7 of gestation and beyond should be performed to

reduce the risk of cesarean delivery and the risk of perinatal

morbidity and mortality. IA

Does Friedman’s data apply?

Of the 622 consecutive primigravida parturients at term,

500 analyzed

Ward patients 360 (72 %)

Private & semiprivate patients 140 (28%)

Stillbirth or neonatal death 4 (8/1000)

CPD 8 were absolute by

pelvimetry) 1.6%

Clinically Inert labor 46 (9.2%)

Pitocin 69 (13.8%)

22 times for elective induction & 47 times for stimulation

Friedman EA Dec 1955 Obstet Gynecol 6(6):567-89

Does Friedman’s data apply to

contemporary obstetrics?

Of the 622 consecutive primigravida parturients at

term, 500 analyzed.

Spontaneous vaginal delivery 202 (40.4%)

Caudal anesthesia 42 (8.4%)

Low forceps vaginal delivery 256 (51.2%)

Mid forceps vaginal delivery 19(3.8%)

Cesarean delivery 9 (1.8%)

Breech vaginal delivery 14 (2.8%)

-All rectal and vaginal examinations were carefully noted

-One individual usually performed all exams during laborFriedman EA Dec 1955 Obstet Gynecol 6(6):567-89

Obstetric Care Consensus

Safe Prevention of the Primary Cesarean Delivery

March 2014 ACOG

•Prolonged latent phase

• A prolonged latent phase (eg, greater than 20 hours in nulliparous women and

greater than 14 hours in multiparous women) should not be an indication for

cesarean delivery. IB

• Slow but progressive labor in the first stage of labor should not be an indication

for cesarean delivery. IB

Fig. 3. The 95th percentiles of cumulative duration of labor from admission among singleton

term nulliparous women with spontaneous onset of labor, vaginal delivery, and normal

neonatal outcomes.Zhang. Contemporary Labor Patterns. Obstet Gynecol 2010.

What is arrest of labor? Rouse DJ, Active-Phase Labor Arrest Oxytocin Augmentation for at least 4 hours OB GYN March 1999 vol. 93 No. 3 p 323-328

Time Eventual vagdelivery rate (%)

Chorioamnionitis (%)

Endometritis (%)

Transfusion (%)

After 2 hours oxytocin

Labor progress (159) 97 7 4 1

No labor progress (80) 74 14 7 1

No cervical exam (21) 86 0* 5 5

After 4 hours oxytocin

Labor progress (238) 94 6* 5 0

No labor progress (27) 56 22* 14 0

No cervical exam (22) 68 41* 0 0

* P< 0.001 study was prior to group B strep screening impact?

Obstetric Care Consensus

Safe Prevention of the Primary Cesarean Delivery

March 2014

•Slow but progressive labor in the first stage of labor

should not be an indication for cesarean delivery. IB

•Cervical dilation of 6 cm should be considered the

threshold for the active phase of most women in

labor. Thus, before 6 cm of dilation is achieved,

standards of active phase progress should not be

applied. IB

Obstetric Care Consensus

Safe Prevention of the Primary Cesarean Delivery

March 2014

•Cesarean delivery for active phase arrest in the first

stage of labor should be reserved for women at or

beyond 6 cm of dilation with ruptured membranes

who fail to progress despite 4 hours of adequate

uterine activity, or at least 6 hours of oxytocin

administration with inadequate uterine activity and

no cervical change. IB

Active Labor PartogramAvailable in Toolkit

Re

sp

on

se

35

Zhang et al Contemporary Patterns of Spontaneous Labor with Normal Neonatal

Outcomes Dec 2010 OB GYN

Comparison of cost for components of medical care

Harper OB GYN June 2012 Normal Labor in Induction

Time in hours for each centimeter of cervical dilation in

nulliparous women Harper OB GYN June 2012 p. 1113-

1118Cervical

dil cm

Ind labor P* Aug labor P* Spont labor

4-10 5.5 (1.8, 16.8) <.01 5.4 (1.8, 16.8) < .01 3.8 (1.2, 11.8)

3-4 1.4 (0.2, 8.1) <.01 1.2 (0.2, 6.8) <.01 0.4 (0.1, 2.3)

4-5 1.3 (0.2, 6.8) <.01 1.4 (0.3, 7.6) <.01 0.5 (0.1, 2.7)

5-6 0.6 (0.1, 4.3) 0.02 0.7 (0.1, 4.9) <.01 0.4 (0.06, 2.7)

6-7 0.4 (0.05, 2.8) 0.05 0.5 (0.06, 3.9) <.01 0.3 (0.03, 2.1)

7-8 0.2 (0.03, 1.5) .93 0.3 (0.05, 2.2) 0.01 0.3 (0.04, 1.7)

8-9 0.2 (0.03, 1.3) 0.80 0.3 (0.05, 2.0) <.01 0.2 (0.03, 1.3)

9-10 0.3 (0.04, 1.9) 0.13 0.3 (0.05, 2.4) <.01 0.3 (0.04, 1.8)