Labor induction process improvement: a patient quality-of-care initiative.

Magee-Womens Hospital, and Department of Obstetrics, Gynecology and Reproductive Sciences, Division of Maternal-Fetal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.
Obstetrics and Gynecology (Impact Factor: 4.37). 05/2009; 113(4):797-803. DOI: 10.1097/AOG.0b013e31819c9e3d
Source: PubMed

ABSTRACT To examine the effects that medical staff education and a new process for scheduling inductions had on decreasing inappropriate inductions.
At our institution in 2004, guidelines were developed and shared with the medical staff and reinforced in 2005. The guidelines for elective induction required patients to have completed 39 weeks of gestation and to have a Bishop score of at least 8 for nulliparas and 6 for multiparas. In 2006, the induction scheduling process was changed and the guidelines were strictly enforced. All scheduled inductions during the same 3-month time period (June through August) in 2004 (n=533) and 2005 (n=454) and during a 13-month period from November 2006 to December 2007 (n=1,806) were compared. Outcomes included elective inductions less than 39 weeks, cesarean birth rate for elective inductions among nulliparas, and the overall induction rate.
From 2004-2007, the overall induction rate dropped from 24.9% to 16.6%, a 33% reduction(P<.001); the elective induction rate dropped from 9.1% to 6.4%, a 30% reduction (P<.001); the percentage of elective inductions before 39 weeks of gestation dropped from 11.8% to 4.3%, a decrease of 64% (P<.001); and the frequency of cesarean delivery among nulliparas undergoing elective induction dropped from 34.5% to 13.8%, a decrease of 60%. (P=.01).
Medical staff education and the development and enforcement of induction guidelines contributed to a decrease in inappropriate inductions, a lower cesarean birth rate for electively induced nulliparas, and a lower elective and overall induction rate.

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    ABSTRACT: Objective:Given the increasing rates of labor induction and cesarean delivery, and efforts to reduce early term births, we examined recent trends in methods and timing of delivery.Study Design:We identified delivery methods and medical indications for delivery from administrative hospital discharge data for 231 691 deliveries in 2006 and 213 710 deliveries in 2010 from 47 specialty care member hospitals of the National Perinatal Information Center/Quality Analytic Services. In a subset of 17 hospitals, we examined trends by gestational age.Result:From 2006 to 2010, there was an 11% increase in labor induction and a 6% increase in cesarean delivery, largely due to repeat cesareans. There was a 4 per 100 reduction in early term births (37 to 38 weeks), mostly due to a decline in non-medically indicated interventional deliveries.Conclusion:We report a shift in deliveries at 38 weeks, which we believe may be attributed to efforts to actively limit non-medically indicated early term deliveries.Journal of Perinatology advance online publication, 8 August 2013; doi:10.1038/jp.2013.90.
    Journal of perinatology: official journal of the California Perinatal Association 08/2013; 33(12). DOI:10.1038/jp.2013.90 · 1.59 Impact Factor
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    ABSTRACT: Introduction. Post-term delivery is associated with signifi cantly increased risks of perinatal and maternal complications. Th e aim of the study was to compare maternal and neonatal complica-tions in two groups: women who delivered at 41 completed weeks (study group) and women who delivered at 40 completed weeks (control group). Materials and methods. Th is is a retrospective case-control study which included all preg-nant women who delivered in the Vilnius City University Hospital (VCUH) from January 1, 2007 to December 31, 2007. Patients were eligible for inclusion in our study if they delivered a live birth beyond 41 weeks of gestation during the study period in the VCUH (n = 182). Using the week of gestation as the primary predictor variable, we examined its association with the follow-ing outcomes: mode of delivery, expectant management or labour induction, labour induction method, delivery time, perineal laceration, postpartum hemorrhage, meconium-stained amni-otic fl uid, oligohydramnios, umbilical artery pH, neonatal morbidity, duration of hospitalisation. From all the women who delivered from 40 completed weeks to 40 weeks + 6 days (n = 193) in the same study period, every tenth woman was selected for the control group. Results. Th e pregnancy protracts frequently for nulliparous women without reference to mother's age. Labour induction in them more frequently occurs at 41 completed weeks than in the control group (39.6% vs 14.5%, p < 0.05; OR 0.37), and the main way of induction in prolonged pregnancies is vaginal prostaglandins. Th e mother and her newborn at 41 completed weeks tend to have a higher risk of oligohydramnios (10.4% vs 5.2%, p < 0.05; OR 0.5), umbilical cord rotation around the baby's neck (57% vs 43%, p < 0.05; OR 0.7), meconium-stained amniotic fl uid (27.4% vs 16.6 %, p < 0.05; OR 0.6), vacuum extraction rate (7.7% vs 3.1%, p < 0.05; OR 0.4), newborn acidosis (45.5 % vs 33.2%, p < 0.05; OR 0.73). When meconium-stained amniotic fl uid is diagnosed at 41 completed weeks, the delivery should be monitored more intensively because of a higher risk of newborn acidosis aft er the labour. Th e mode of delivery, delivery duration, mother's injuries, postpartum hemorrhage and complications, also Apgar scores show no signifi -cant diff erences in these groups. Conclusion. When delivery occurs at 41 competed weeks, the results are worse as compared to those of the delivery at 40 completed weeks. Th erefore, it is reasonable to induce labour at 40 completed weeks and beyond of gestation. Th is suggestion requires large prospective studies and a very precise gestation time estimation for all pregnant women before recommending labour induction at 40 competed weeks.
    06/2010; 17(1). DOI:10.2478/v10140-010-0002-z
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    ABSTRACT: Non-medically indicated (NMI) deliveries prior to 39 weeks increase the risk of neonatal mortality, excess morbidity, and health care costs. The study's purpose was to identify maternal and hospital characteristics associated with NMI deliveries prior to 39 weeks. The study included 207,775 births to women without a previous cesarean and 38,316 births to women with a previous cesarean, using data from Florida's 2006-2007 linked birth certificate and inpatient record file. Adjusted risk ratios (ARR) and 95 % confidence intervals (CI) for characteristics were calculated using generalized estimating equation for multinomial logistic regression. Among women without a previous cesarean, NMI deliveries occurred in 18,368 births (8.8 %). Non-medically indicated inductions were more likely in women who were non-Hispanic white (ARR: 1.41, 95 % CI 1.31-1.52), privately-insured (ARR: 1.42, 95 % CI 1.26-1.59), and delivered in hospitals with <500 births per year. Non-medically indicated primary cesareans were more likely in women who were older than 35 years (ARR: 2.96, 95 % CI 2.51-3.50), non-Hispanic white (ARR: 1.44, 95 % CI 1.30-1.59), and privately-insured (ARR: 1.43, 95 % CI 1.17-1.73). Non-medically indicated primary cesareans were also more likely to occur in hospitals with <30 % nurse-midwife births, <500 births per year, and in large metro areas. Among women with previous cesarean, NMI repeat cesareans occurred in 16,746 births (43.7 %). Only weak risk factors were identified for NMI repeat cesareans. The risk factors identified varied by NMI outcome. This information can be used to inform educational campaigns and identify hospitals that may benefit from quality improvement efforts.
    Maternal and Child Health Journal 01/2014; 18(8). DOI:10.1007/s10995-014-1433-z · 2.24 Impact Factor

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