Variation in hospital caesarean section rates and obstetric outcomes among nulliparae at term: a population-based cohort study.

OBJECTIVE: To explore the variation in hospital caesarean section (CS) rates for nulliparous women, to determine whether different case-mix, labour and delivery, and hospital factors can explain this variation and to examine the association between hospital CS rates and outcomes. DESIGN: Population-based cohort study. SETTING: New South Wales, 2009-2010. POPULATION: Nulliparous women with singleton cephalic live births at term. METHODS: Random effect multilevel logistic regression models using linked hospital discharge and birth data. MAIN OUTCOME MEASURES: Prelabour and intrapartum CS rates following spontaneous labour or labour induction; maternal and neonatal severe morbidity rates. RESULTS: Of 67 239 nulliparous women, 4902 (7.3%) had a prelabour CS, 39 049 (58.1%) laboured spontaneously, and 23 288 (34.6%) had labour induced. Overall, there were 18 875 (28.1%) CSs, with labour inductions twice as likely to result in an intrapartum CS compared with women with a spontaneous onset of labour (34.0% versus 15.5%). After adjusting for differences in case-mix, labour and delivery, and hospital factors, the overall variation in CS rates decreased by 78% for prelabour CSs, 52% for intrapartum CSs following spontaneous labour and 9% following labour induction. Adjusting for labour and delivery practices increased the unexplained variation in intrapartum CSs. The adjusted rates of severe maternal and neonatal morbidity were not significantly different across CS rate quintile groups, except for women in spontaneous labour, where the hospitals in the lowest CS quintile had the lowest neonatal morbidity rate. CONCLUSIONS: Differences in clinical practice were substantial contributors to variation in intrapartum CS rates. Our findings suggest that CS rates in some hospitals could be lowered without adversely affect pregnancy outcomes.

What factors contribute to hospital variation in obstetric transfusion rates?

BACKGROUND AND OBJECTIVES: To explore variation in red blood cell transfusion rates between hospitals, and the extent to which this can be explained. A secondary objective was to assess whether hospital transfusion rates are associated with maternal morbidity. MATERIALS AND METHODS: Linked hospital discharge and birth data were used to identify births (n = 279 145) in hospitals with at least 10 deliveries per annum between 2008 and 2010 in New South Wales, Australia. To investigate transfusion rates, a series of random-effects multilevel logistic regression models were fitted, progressively adjusting for maternal, obstetric and hospital factors. Correlations between hospital transfusion and maternal, neonatal morbidity and readmission rates were assessed. RESULTS: Overall, the transfusion rate was 1.4% (hospital range 0.6-2.9) across 89 hospitals. Adjusting for maternal casemix reduced the variation between hospitals by 26%. Adjustment for obstetric interventions further reduced variation by 8% and a further 39% after adjustment for hospital type (range 1.1-2.0%). At a hospital level, high transfusion rates were moderately correlated with maternal morbidity (0.59, P = 0.01), but not with low Apgar scores (0.39, P = 0.08), or readmission rates (0.18, P = 0.29). CONCLUSION: Both casemix and practice differences contributed to the variation in transfusion rates between hospitals. The relationship between outcomes and transfusion rates was variable; however, low transfusion rates were not associated with worse outcomes.

Successful obstetric outcome after simultaneous pancreas and kidney transplantation.

A 34-year-old woman became pregnant two years after having a simultaneous pancreas and kidney (SPK) transplantation, necessitated by type 1 diabetes and end-stage renal disease. The pregnancy was uneventful until 30 weeks' gestation, when she developed pancreatitis and a worsening of mild hypertension. A healthy 1700 g boy was delivered by caesarean section at 34 weeks' gestation. This is the first report of a successful pregnancy after SPK transplantation in Australia.

Stomas and pregnancy.

Few obstetricians have much experience of the pregnant patient with a stoma. This paper was prompted by the management of 3 such patients in as many months and reviews the limited literature on stomas and pregnancy.

The short-term outcome of singleton infants delivered before 28 weeks' gestation.

The short-term outcome of 271 singleton infants born at Westmead Hospital between 20 and 28 weeks' gestation, during a 5-year period are reported. The earliest gestation at which there was a survivor was 23 weeks. Survival rates from 23-23+6 weeks to 27-27+6 weeks, excluding congenital abnormalities, were 8.3% to 77.5% respectively. Overall 21.9% of deaths occurred in the delivery suite, 63.4% in the neonatal period, 3.7% in the postneonatal period in hospital and a further 11% after discharge from hospital. Of survivors at 12 months, 18.8% were judged to have a major impairment.

The short-term outcome of infants of multiple pregnancies delivered before 28 weeks' gestation.

The short-term outcomes of 29 multiple pregnancies delivered at Westmead Hospital between 20 and 28 weeks' gestation, during a 5-year period are reported. The earliest gestation at which there was a survivor was 24 weeks. The overall survival rate was 25%. Of deaths, 11.1% occurred in the delivery suite, 85.2% in the neonatal period with a further 3.7% in the postneonatal period in hospital. The outcomes for second twins were generally poor. Of survivors at 12 months, 44% were judged to have a major impairment. Extremely preterm multiple pregnancies have a high mortality and morbidity rate.