Hospital-Level Variation in the Frequency of Cesarean Delivery Among Nulliparous Women Who Undergo Labor Induction.

OBJECTIVE: To evaluate the use of administrative data for identification of labor induction and to estimate the variation in cesarean delivery rates among low-risk women who underwent labor induction. METHODS: A cross-sectional study was performed examining live births in California hospitals during 2016 and 2017 using birth certificate data linked with maternal patient discharge records. Initially, eight hospitals performed medical record reviews by using reVITALize definitions on 46,916 deliveries to assess the validity of induction identification by birth certificate or discharge diagnosis records or both. Hospital-level variation in cesarean delivery rates was then assessed among all California hospitals for women with low-obstetric-risk first births before and after further risk adjustment and after the exclusion of potential medical and obstetric indications for induction. Variation in physician-level cesarean delivery rates after induction at four large hospitals also was examined. The relationships between cesarean delivery rates among women with induced labors compared with noninduced labors and with the hospital rate of induction also were explored. RESULTS: Identifying induction by a combination of discharge diagnosis codes and birth certificate data had the highest accuracy (92.9%, 95% CI 92.7-93.2). Among 917,225 births at 238 birthing hospitals, there were 99,441 nulliparous women with term, singleton, vertex pregnancies who were induced. The median cesarean delivery rate after labor induction for nulliparous women with term, singleton, vertex pregnancies was 32.2%, with a range of 18.5-84.6%. This wide variation was not reduced after risk adjustment or after exclusion of all women with induction indications. A similar wide variation was noted within geographic regions, neonatal intensive care levels, and among individual physicians in the same facility. Only very weak associations were found for the cesarean delivery rate after labor induction and either the rate after noninduced labor (R<0.08) or the rate of nulliparous labor induction (R<0.12). CONCLUSION: The large variation of cesarean delivery rates after induction of labor suggests that clinical management plays an important role in achieving induction success.

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

Cesarean births and associated morbidity and mortality have reached near epidemic proportions. The National Partnership for Maternal Safety under the guidance of the Council on Patient Safety in Women's Health Care responded by developing a patient safety bundle to reduce the number of primary cesarean births. Safety bundles outline critical practices to implement in every maternity unit. This National Partnership for Maternity Safety bundle, as with other bundles, is organized into four domains: Readiness, Recognition and Prevention, Response, and Reporting and Systems Learning. Bundle components may be adapted to individual facilities, but standardization within an institution is advised. Evidence-based resources and recommendations are provided to assist implementation.

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

Cesarean births and associated morbidity and mortality have reached near epidemic proportions. The National Partnership for Maternal Safety under the guidance of the Council on Patient Safety in Women's Health Care responded by developing a patient safety bundle to reduce the number of primary cesarean births. Safety bundles outline critical practices to implement in every maternity unit. This National Partnership for Maternity Safety bundle, as with other bundles, is organized into four domains: Readiness, Recognition and Prevention, Response, and Reporting and Systems Learning. Bundle components may be adapted to individual facilities, but standardization within an institution is advised. Evidence-based resources and recommendations are provided to assist implementation.

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

Cesarean births and associated morbidity and mortality have reached near epidemic proportions. The National Partnership for Maternal Safety under the guidance of the Council on Patient Safety in Women's Health Care responded by developing a patient safety bundle to reduce the number of primary cesarean births. Safety bundles outline critical practices to implement in every maternity unit. This National Partnership for Maternity Safety bundle, as with other bundles, is organized into four domains: Readiness, Recognition and Prevention, Response, and Reporting and Systems Learning. Bundle components may be adapted to individual facilities, but standardization within an institution is advised. Evidence-based resources and recommendations are provided to assist implementation.

Accuracy of Blood Loss Measurement during Cesarean Delivery.

Objective This study aims to compare the accuracy of visual, quantitative gravimetric, and colorimetric methods used to determine blood loss during cesarean delivery procedures employing a hemoglobin extraction assay as the reference standard. Study Design In 50 patients having cesarean deliveries blood loss determined by assays of hemoglobin content on surgical sponges and in suction canisters was compared with obstetricians' visual estimates, a quantitative gravimetric method, and the blood loss determined by a novel colorimetric system. Agreement between the reference assay and other measures was evaluated by the Bland-Altman method. Results Compared with the blood loss measured by the reference assay (470 ± 296 mL), the colorimetric system (572 ± 334 mL) was more accurate than either visual estimation (928 ± 261 mL) or gravimetric measurement (822 ± 489 mL). The correlation between the assay method and the colorimetric system was more predictive (standardized coefficient = 0.951, adjusted R2 = 0.902) than either visual estimation (standardized coefficient = 0.700, adjusted R2 = 00.479) or the gravimetric determination (standardized coefficient = 0.564, adjusted R2 = 0.304). Conclusion During cesarean delivery, measuring blood loss using colorimetric image analysis is superior to visual estimation and a gravimetric method. Implementation of colorimetric analysis may enhance the ability of management protocols to improve clinical outcomes.

Standardizing Maternity Care Data to Improve Coordination of Care.

The amount of data generated by health information technology systems is staggering, and using those data to make meaningful care decisions that improve patient outcomes is difficult. The purpose of this article is to describe the Maternal Health Information Initiative, a multidisciplinary group of maternity care stakeholders charged with standardizing maternity care data. Complementary strategies that practicing clinicians can use to support this initiative and improve the usability of maternity care data are provided.

Cost comparison of robotic-assisted laparoscopic hysterectomy versus standard laparoscopic hysterectomy.

The aim of the study was to assess if the cost of robotic-assisted total laparoscopic hysterectomy is similar to the cost of standard laparoscopic hysterectomy when performed by surgeons past their initial learning curve. A retrospective chart review of all hysterectomies was performed for benign indications without concomitant major procedures at Orange Coast Memorial Medical Center (OCMMC) and Saddleback Memorial Medical Center between January 1, 2013 and September 30, 2013. Robotic-assisted total laparoscopic hysterectomies (RTLH) and standard laparoscopic hysterectomies (LAVH and TLH) were compared. Data analyzed included only those hysterectomies performed by surgeons past their initial learning curve (minimum of 30 previous robotic cases). The primary outcome was the direct total cost of patient's hospitalization related to hysterectomy. The secondary outcomes were estimated blood loss, surgery time, and days in hospital post-surgery. A multiple linear regression model was applied to evaluate the difference between RTLH and LAVH/TLH in hospital cost, blood loss, and surgery time, while adjusting for hospital, patient's age, body mass index (BMI), whether or not the patient had previous abdominal/pelvic surgery, and uterine weight. The χ (2) test was applied to examine the association between hospital stay and surgery type. There were 93 hysterectomies (5 LAVH, 88 RTLH) performed at OCMMC and 90 hysterectomies (6 LAVH, 17 TLH, 67 RTLH) performed at Saddleback Memorial Medical Center. The hospitalization total cost result showed that, after adjusting for hospital, age, BMI, previous abdominal/pelvic surgery, and uterine weight, RTLH was not significantly more expensive than LAVH/TLH (mean diff. = $283.1, 95 % CI = [-569.6, 1135.9]; p = 0.51) at the 2 study hospitals. However, the cost at OCMMC was significantly higher than Saddleback Memorial Medical Center (mean diff. = $2008.7, 95 % CI = [1380.6, 2636.7]; p < 0.0001); and the cost increased significantly with uterine weight (ß = 3.8, 95 % CI = [2.3, 5.3]; p < 0.0001). Further analysis showed significantly less blood loss (mean diff. = -78.5 ml, 95 % CI = [-116.8, -40.3]; p < 0.0001) and shorter surgery time (mean diff. = -21.9 min., 95 % CI = [-39.6, -4.2]; p = 0.016) for RTLH versus LAVH/TLH. There was no significant association between hospital stay and surgery type (p = 0.43). After adjusting for patient-level covariates, there was no statistically significant cost difference of performing robotically assisted laparoscopic hysterectomy versus standard laparoscopic hysterectomy when performed by surgeons past their initial learning curve at two community hospitals.

National Partnership for Maternal Safety: Consensus Bundle on Obstetric Hemorrhage.

Hemorrhage is the most frequent cause of severe maternal morbidity and preventable maternal mortality and therefore is an ideal topic for the initial national maternity patient safety bundle. These safety bundles outline critical clinical practices that should be implemented in every maternity unit. They are developed by multidisciplinary work groups of the National Partnership for Maternal Safety under the guidance of the Council on Patient Safety in Women's Health Care. The safety bundle is organized into four domains: Readiness, Recognition and Prevention, Response, and Reporting and System Learning. Although the bundle components may be adapted to meet the resources available in individual facilities, standardization within an institution is strongly encouraged. References contain sample resources and "Potential Best Practices" to assist with implementation.

National Partnership for Maternal Safety: consensus bundle on obstetric hemorrhage.

Hemorrhage is the most frequent cause of severe maternal morbidity and preventable maternal mortality and therefore is an ideal topic for the initial national maternity patient safety bundle. These safety bundles outline critical clinical practices that should be implemented in every maternity unit. They are developed by multidisciplinary work groups of the National Partnership for Maternal Safety under the guidance of the Council on Patient Safety in Women's Health Care. The safety bundle is organized into four domains: Readiness, Recognition and Prevention, Response, and Reporting and System Learning. Although the bundle components may be adapted to meet the resources available in individual facilities, standardization within an institution is strongly encouraged. References contain sample resources and "Potential Best Practices" to assist with implementation.

National Partnership for Maternal Safety Consensus Bundle on Obstetric Hemorrhage.

Hemorrhage is the most frequent cause of severe maternal morbidity and preventable maternal mortality and therefore is an ideal topic for the initial national maternity patient safety bundle. These safety bundles outline critical clinical practices that should be implemented in every maternity unit. They are developed by multidisciplinary work groups of the National Partnership for Maternal Safety under the guidance of the Council on Patient Safety in Women's Health Care. The safety bundle is organized into 4 domains: Readiness, Recognition and Prevention, Response, and Reporting and Systems Learning. Although the bundle components may be adapted to meet the resources available in individual facilities, standardization within an institution is strongly encouraged. References contain sample resources and "Potential Best Practices" to assist with implementation.

The future of obstetrics/gynecology in 2020: a clearer vision. Transformational forces and thriving in the new system.

Revamping the delivery of women's health care to meet future demands will require a number of changes. In the first 2 articles of this series, we introduced the reasons for change, suggested the use of the 'Triple Aim' concept to (1) improve the health of a population, (2) enhance the patient experience, and (3) control costs as a guide post for changes, and reviewed the transformational forces of payment and care system reform. In the final article, we discuss the valuable use of information technology and disruptive clinical technologies. The new health care system will require a digital transformation so that there can be increased communication, availability of information, and ongoing assessment of clinical care. This will allow for more cost-effective and individualized treatments as data are securely shared between patients and providers. Scientific advances that radically change clinical practice are coming at an accelerated pace as the underlying technologies of genetics, robotics, artificial intelligence, and molecular biology are translated into tools for diagnosis and treatment. Thriving in the new system not only will require time-honored traits such as leadership and compassion but also will require the obstetrician/gynecologist to become comfortable with technology, care redesign, and quality improvement.

Postpartum hemorrhage: state and national response.

PURPOSE OF REVIEW: The rise in maternal mortality has raised a significant concern for epidemiologists and providers. One of the most preventable and frequent causes of maternal death is hemorrhage-related events. Most providers of obstetrical care see such complications on a frequent basis, and the costs in maternal lives and blood usage have become a universal concern. As a result, a number of important responses by state and national groups have taken place to address these preventable bad outcomes. RECENT FINDINGS: A number of well designed step-by-step protocols have had success in preventing morbidity and mortality. Expert panels have applied toolkits, including risk screening, medication protocols, transfusion protocols and clinical procedures, to either abate or mitigate the effects of uterine bleeding. The usage of these 'toolkits' has allowed institutions to lower blood utilization and improve maternal outcomes in various care settings. Readiness of institutions to rapidly respond in an organized fashion prevents many of the secondary complications. SUMMARY: Postpartum hemorrhage toolkits and their application are excellent examples of system readiness improvement to address a specific obstetrical problem. Widespread adoption should lead to a reduction in maternal mortality and morbidity.

The future of obstetrics/gynecology in 2020: a clearer vision: finding true north and the forces of change.

The pressure to transform health care has been building for many years, and many frameworks have been proposed for this transformation. The 'Triple Aim' concept of improving the health of the population, improving the experience of the patient, and controlling cost can be used as a guide post for the adoption of the necessary changes to thrive in a new construct of women's health care. Following these guiding principles should lead to improved clinical outcomes at affordable costs with high patient and provider satisfaction. The actual changes will come in the form of various 'transformational forces.' One of the driving forces will be conversion of the current payment structure from a fee-for-service model to value-based payments. In addition, the methods of care must be redesigned into a 'team-based' approach in which providers and patients use best practice protocols that are individualized to specific patient needs. Redesign will continue to drive consolidation of providers into larger groups to cover the cost of the needed infrastructure.

The future of obstetrics/gynecology in 2020: a clearer vision. Why is change needed?

External and internal pressures are causing rapid changes to the delivery of health care that markedly will influence the practice of obstetrics and gynecology. These changes can be divided into broad categories: (1) Burden of the high cost of current health care on society; (2) demographic changes in women that include aging, obesity, diversity, and chronic medical conditions; and (3) workforce changes that include growing provider shortages, inexperience, and desires for improved lifestyles. The combination of these factors has brought health care to a strategic inflection point where current practice methods will lead to an inability to meet the demand for health care because of increasing volume while simultaneously controlling costs and improving quality. This necessitates providing women's health care in a redesigned fashion for it to flourish in the new world of medicine.

The relationship between previous treatment for cervical dysplasia and preterm delivery in twin gestations.

OBJECTIVE: To describe the impact of previous cervical surgery on preterm birth prior to 34 weeks in twins. METHODS: A retrospective review of twin pregnancies delivered between January 1998 and December 2005 at two institutions was performed. Women with a prior cold knife cone (CKC), loop electrosurgical excision procedure (LEEP), or ablative procedure were compared to a control group of women who had not undergone a previous treatment for cervical dysplasia. The primary outcome was delivery before 34 weeks of gestation. RESULTS: A total of 876 women met inclusion criteria. Of these, 110 (12.6%) had previous surgical procedures for cervical dysplasia, including CKC (n = 10), LEEP (n = 36), cryotherapy (n = 59) and CO2 laser treatment (n = 5). Delivery prior to 34 weeks was more common in women with a previous CKC compared to women with no prior treatment (40% versus 11.3%; odds ratio [OR], 3.6; 95% confidence interval [CI], 1.7-8.0). Delivery prior to 34 weeks was not more common in women with a previous LEEP (8.3%; OR, 0.8; 95% CI, 0.3-2.3) or ablative procedure (9.4%; OR, 0.9; 95% CI, 0.4-1.9) in comparison to the untreated group. Adjusting for the potential confounders of age, tobacco use, infertility treatments and previous preterm birth did not change the results. CONCLUSIONS: Previous CKC is associated with delivery prior to 34 weeks while LEEP and ablative procedures are not. CKC should be carefully considered and avoided when possible in reproductive age women.

Twin versus singleton pregnancies complicated by preterm premature rupture of membranes.

OBJECTIVE: To compare latency period, infectious morbidity, neonatal morbidity and neonatal mortality in twin versus singleton pregnancies complicated by preterm premature rupture of membranes (PPROM) remote from term. METHODS: A retrospective, matched cohort study comparing 41 twin and 82 singleton pregnancies complicated by PPROM between 24-0/7 and 31-6/7 weeks' gestation. The data were obtained by reviewing maternal and neonatal charts. RESULTS: The median latency periods were 3.6 days (interquartile range 1.5-13.9 days) for twins and 6.2 days (interquartile range 2.9-11.8 days) for singletons (p = 0.86). Twins were less likely to be complicated by clinical chorioamnionitis when compared with singletons (4/41 [9.8%] vs. 19/82 [23.2%], relative risk [RR] 0.42, 95% confidence interval [CI] 0.18-0.96). Histological evidence of chorioamnionitis was also lower in twins compared with singletons (14/39 [35.9%] vs. 46/68 [67.7%], RR 0.56, 95% CI, 0.34-0.92). These differences persisted after adjusting for race, insurance status, latency period and route of delivery. Neonatal morbidity and mortality rates were similar between the two groups. CONCLUSIONS: There was not a statistically significant difference in the latency periods for twin and singleton pregnancies complicated by PPROM. Clinical chorioamnionitis and histological evidence of infection were significantly less common in twins compared with singletons.

Persistent pulmonary hypertension of the newborn following elective cesarean delivery at term.

OBJECTIVE: To evaluate the frequency of persistent pulmonary hypertension of the newborn (PPHN) following elective cesarean at greater than 34 weeks' gestation in an academically affiliated community hospital. METHODS: Retrospective cohort study involving chart review of 300 newborns with PPHN between 1999 and 2006. Infants less than 34 weeks' or with congenital anomalies were excluded. Subjects were divided into two groups: (1) intended vaginal delivery and (2) elective cesarean. RESULTS: A total of 125 neonates were included. In all, 46 were delivered vaginally, 53 by cesarean after a trial of labor, and 26 by elective cesarean. No statistically significant differences were noted between groups in birth weight, gestational age, or length of stay. The crude relative risk (RR) of PPHN in cesareans prior to labor (elective cesareans) when compared to intended vaginal deliveries was 2.0 (95% CI 1.3-3.1). The RR of PPHN in elective cesareans when compared to spontaneous labor resulting in vaginal deliveries was 3.4 (95% CI 2.1-5.5). The adjusted RRs for these outcomes comparing the same delivery groups when considering gestational age at birth (less vs. equal to or more than 37 weeks') were 2.2 (95% CI 1.4-3.4) and 3.7 (95% CI 2.3-6.1), and birth weight (less vs. equal to or more than 2500 g) were 1.9 (95% 1.3-3.0) and 3.4 (95% CI 2.1-5.5), respectively. The incidence of PPHN in the elective cesarean group was 6.9 per 1000 deliveries. The number of cesareans to be avoided to prevent one case of PPHN in this cohort was 387 (number needed to harm, 95% CI 206.8-3003.1). CONCLUSIONS: Our findings include a high rate of PPHN following elective cesarean delivery, and suggest that physicians should consider this added morbidity when performing elective cesareans.

The use of ultrasound to detect small-for-gestational-age infants in patients with elevated human chorionic gonadotropin on maternal serum screening.

We evaluated serial sonography for the antenatal detection of small-for-gestational-age (SGA) infants in pregnancies with elevated human chorionic gonadotropin (hCG) levels on midtrimester triple-marker screen. A retrospective cohort study was performed at Saddleback Memorial Medical Center where serial ultrasounds from 26 weeks to delivery are generally recommended for patients with hCG levels >2.0 Multiple of the Median (MoM). From 1999 to 2007, 659 subjects were identified for analysis. The incidence of intrauterine growth restriction (IUGR) and SGA were 5.2% and 7.3%, respectively. Antenatal ultrasound identified 31.3% of SGA infants. Compared with estimated fetal weight (EFW) <10th percentile alone, abdominal circumference (AC) <10th percentile improved the detection of SGA from 31.3% (95% confidence interval [CI], 18.7 to 46.3) to 35.4% (95% CI, 22.2 to 50.5). Using either EFW or AC further increased the sensitivity to 45.8% (95% CI, 31.4 to 60.8). The sensitivity for the detection of SGA was 100% when an EFW cutoff of 75% was used. Ultrasound can be used to detect SGA infants in patients with elevated hCG levels on midtrimester serum screening. A sonographic estimated fetal weight > or = 75th percentile appears to be a safe cutoff to rule out all fetuses at risk for SGA.