Implementation of a calculator to predict cesarean during labor induction: a qualitative evaluation of the patient perspective.
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ABSTRACT:
SUBMITTER: Hamm RF
PROVIDER: S-EPMC10205674 | biostudies-literature | 2023 Jun
REPOSITORIES: biostudies-literature
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Implementation of a calculator to predict cesarean during labor induction: a qualitative evaluation of the patient perspective.
Hamm Rebecca F RF Wang Eileen E Szymczak Julia E JE Levine Lisa D LD
American journal of obstetrics & gynecology MFM 20230414 6
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Project description:Background. Because failed trial of labor after cesarean (TOLAC) is associated with greater morbidity than planned cesarean, it is important to distinguish women with a high likelihood of successful vaginal birth after cesarean (VBAC) from those likely to fail. The VBAC Calculator may help make this distinction but little is known about how often providers use it; nor whether use improves risk estimation and/or influences TOLAC counseling. Methods. In a cross-sectional survey, a convenience sample of obstetrical providers reported their likelihood (4-point Likert-type scale) to "Recommend,""Offer," or "Agree to" TOLAC for patients presented first through five clinical vignettes; then, in different order, by corresponding VBAC calculator estimates. Results. Of the 85 (of 101, 84% response rate) participants, 88% routinely performed TOLAC, but only 21% used the Calculator. The majority (67.1% to 89.3%) overestimated the likelihood of success for all but one vignette (which had the highest estimate of success). Most providers (42% to 89%) recommended TOLAC for all five vignettes. Given calculated estimates, the majority of providers (67% to 95%) recommended TOLAC for success estimates exceeding 40%. For estimates between 20% and 40%, most providers offered (58%) or agreed (68%) to TOLAC; and even below 20%, over half still agreed to TOLAC. The vignette with the lowest estimate of success (18.7%) had the weakest intraprovider agreement (kappa = 0.116; confidence interval [CI] = 0.045-0.187), whereas the strongest agreement was found in the two vignettes with highest success estimates: 77.9% (kappa = 0.549; CI = 0.382-0.716) and 96.6% (kappa = 0.527; CI = 0.284-0.770). Limitations. Survey responses may not reflect actual practice patterns. Conclusion. Providers are overly optimistic in their clinical estimation of VBAC success. Wider use of decision support could aid in risk stratification and TOLAC counseling to reduce patient morbidity.
| S-EPMC6540508 | biostudies-literature
Project description:BackgroundFor most women who have had a previous cesarean section, vaginal birth after cesarean section (VBAC) is a reasonable and safe choice, but which will increase the risk of adverse outcomes such as uterine rupture. In order to reduce the risk, we evaluated the factors that may affect VBAC and and established a model for predicting the success rate of trial of the labor after cesarean section (TOLAC).MethodsAll patients who gave birth at Northwest Women's and Children's Hospital from January 2016 to December 2018, had a history of cesarean section and voluntarily chose the TOLAC were recruited. Among them, 80% of the population was randomly assigned to the training set, while the remaining 20% were assigned to the external validation set. In the training set, univariate and multivariate logistic regression models were used to identify indicators related to successful TOLAC. A nomogram was constructed based on the results of multiple logistic regression analysis, and the selected variables included in the nomogram were used to predict the probability of successfully obtaining TOLAC. The area under the receiver operating characteristic curve was used to judge the predictive ability of the model.ResultsA total of 778 pregnant women were included in this study. Among them, 595 (76.48%) successfully underwent TOLAC, whereas 183 (23.52%) failed and switched to cesarean section. In multi-factor logistic regression, parity = 1, pre-pregnancy BMI < 24 kg/m2, cervical score ≥ 5, a history of previous vaginal delivery and neonatal birthweight < 3300 g were associated with the success of TOLAC. The area under the receiver operating characteristic curve in the prediction and validation models was 0.815 (95% CI: 0.762-0.854) and 0.730 (95% CI: 0.652-0.808), respectively, indicating that the nomogram prediction model had medium discriminative power.ConclusionThe TOLAC was useful to reducing the cesarean section rate. Being primiparous, not overweight or obese, having a cervical score ≥ 5, a history of previous vaginal delivery or neonatal birthweight < 3300 g were protective indicators. In this study, the validated model had an approving predictive ability.
| S-EPMC8305496 | biostudies-literature
Project description:ObjectiveTo determine whether patient-perceived pressure from clinicians for labor induction or cesarean delivery is significantly associated with having these procedures.Data sources/study settingListening to Mothers III, a nationally representative survey of women 18-45 years who delivered a singleton infant in a U.S. hospital July 2011-June 2012 (N = 2,400).Study designMultivariate logistic regression analysis of factors associated with perceived pressure and estimation of odds of induction and cesarean given perceived pressure.Principal findingsOverall, 14.8 percent of respondents perceived pressure from a clinician for labor induction and 13.3 percent for cesarean delivery. Women who perceived pressure for labor induction had higher odds of induction overall (adjusted odds ratio [aOR]: 3.51; 95 percent confidence interval [CI]: 2.5-5.0) and without medical reason (aOR: 2.13; 95 percent CI: 1.3-3.4) compared with women who did not perceive pressure. Those perceiving pressure for cesarean delivery had higher odds of cesarean overall (aOR: 5.17; 95 percent CI: 3.2-8.4), without medical reason (aOR: 6.13; 95 percent CI: 3.4-11.1), and unplanned cesarean (aOR: 6.70; 95 percent CI: 4.0-11.3).ConclusionsPatient-perceived pressure from clinicians significantly predicts labor induction and cesarean delivery. Efforts to reduce provider-patient miscommunication and minimize potentially unnecessary procedures may be warranted.
| S-EPMC4545342 | biostudies-literature
Project description:ObjectiveTo evaluate whether cervical ripening with oral misoprostol increases cesarean delivery risk and prolongs time to vaginal delivery compared with vaginal misoprostol in a predominantly overweight population.MethodsThis single center, retrospective cohort study was performed at a tertiary care academic medical center and compared labor induction outcomes with vaginal misoprostol to outcomes with oral misoprostol after a complete institutional shift to oral misoprostol. Labor induction using 25 micrograms vaginal misoprostol in 2013-2014 was compared with 50 micrograms oral misoprostol in 2014-2015. The primary outcome was cesarean delivery. Secondary outcomes included time to vaginal delivery, uterine tachysystole, maternal hemorrhage, and composite adverse neonatal outcomes. Demographics and outcomes were analyzed using standard statistical tests. Multivariable regression models accounting for potential confounders were created for the primary and secondary outcomes with adjusted odds ratios (aOR) as the measures of effect.ResultsThere were 138 women in the oral and 138 women in the vaginal misoprostol groups. In the overall cohort, the median (interquartile range) body mass index was 31.7 (28.2-36.8) and most women (72%) were of either black or Hispanic race or ethnicity. The frequency of cesarean delivery was higher in the oral than the vaginal misoprostol group (32% vs 21%; P=.04). The adjusted odds of cesarean was higher with oral misoprostol (aOR 2.01; 95% CI 1.07-3.76). Among nulliparous women, the frequency of cesarean delivery was 41% in the oral and 28% in the vaginal misoprostol groups (aOR 2.79; 95% CI 1.26-6.19). Women had a longer time to vaginal delivery in the oral compared with vaginal misoprostol group (41 vs 31 hours respectively, P=.01). Tachysystole occurred more frequently with vaginal misoprostol (20% vs 11%; P=.04).ConclusionCompared with vaginal misoprostol, oral misoprostol may be associated with increased risk of cesarean delivery and longer time to vaginal delivery.
| S-EPMC9234943 | biostudies-literature
Project description:BackgroundIn the Twin Birth Study, women at 320/7-386/7 weeks of gestation, in whom the first twin was in cephalic presentation, were randomized to planned vaginal delivery or cesarean section. The study found no significant differences in neonatal or maternal outcomes in the two planned mode of delivery groups. We aimed to compare neonatal and maternal outcomes of twin gestations without spontaneous onset of labor, who underwent induction of labor or pre-labor cesarean section as the intervention of induction may affect outcomes.MethodsIn this secondary analysis of the Twin Birth Study we compared those who had an induction of labor with those who had a pre-labor cesarean section. The primary outcome was a composite of fetal or neonatal death or serious neonatal morbidity. Secondary outcome was a composite of maternal morbidity and mortality.Trial registrationNCT00187369.ResultsOf the 2804 women included in the Twin Birth Study, a total of 1347 (48%) women required a delivery before a spontaneous onset of labor occurred: 568 (42%) in the planned vaginal delivery arm and 779 (58%) in the planned cesarean arm. Induction of labor was attempted in 409 (30%), and 938 (70%) had a pre-labor cesarean section. The rate of intrapartum cesarean section in the induction of labor group was 41.3%. The rate of the primary outcome was comparable between the pre-labor cesarean section group and induction of labor group (1.65% vs. 1.97%; p = 0.61; OR 0.83; 95% CI 0.43-1.62). The maternal composite outcome was found to be lower with pre-labor cesarean section compared to induction of labor (7.25% vs. 11.25%; p = 0.01; OR 0.61; 95% CI 0.41-0.91).ConclusionIn women with twin gestation between 320/7-386/7 weeks of gestation, induction of labor and pre-labor cesarean section have similar neonatal outcomes. Pre-labor cesarean section is associated with favorable maternal outcomes which differs from the overall Twin Birth Study results. These data may be used to better counsel women with twin gestation who are faced with the decision of interventional delivery.
| S-EPMC7672925 | biostudies-literature
Project description:BACKGROUND:The number of patient portals is rising, and although portals can have positive effects, their implementation has major impacts on the providing health care institutions. However, little is known about the organizational factors affecting successful implementation. Knowledge of the specific barriers to and facilitators of various stakeholders is likely to be useful for future implementations. OBJECTIVE:The objective of this study was to identify the barriers to and facilitators of patient portal implementation facing various stakeholders within hospital organizations in the Netherlands. METHODS:Purposive sampling was used to select hospitals of various types. A total of 2 university medical centers, 3 teaching hospitals, and 2 general hospitals were included. For each, 3 stakeholders were interviewed: (1) medical professionals, (2) managers, and (3) information technology employees. In total, 21 semistructured interviews were conducted using the Grol and Wensing model, which describes barriers to and facilitators of change in health care practice at 6 levels: (1) innovation; (2) individual professional; (3) patient; (4) social context; (5) organizational context; and (6) economic and political context. Two researchers independently selected and coded quotes by applying this model using a (deductive) directed content approach. Additional factors related to technical and portal characteristics were added using the model of McGinn et al, developed for implementation of electronic health records. RESULTS:In total, we identified 376 quotes, 26 barriers, and 28 facilitators. Thirteen barriers and 12 facilitators were common for all stakeholder groups. The facilitators' perceived usefulness (especially less paperwork) was mentioned by all the stakeholders, followed by subjects' positive attitude. The main barriers were lack of resources (namely, lack of staff and materials), financial difficulties (especially complying with high costs, lack of reimbursements), and guaranteeing privacy and security (eg, strict regulations). Both similarities and differences were found between stakeholder groups and hospital types. For example, managers and information technology employees mainly considered guaranteeing privacy and security as a predominant barrier. Financial difficulties were particularly mentioned by medical professionals and managers. CONCLUSIONS:Patient portal implementation is a complex process and is not only a technical process but also affects the organization and its staff. Barriers and facilitators occurred at various levels and differed among hospital types (eg, lack of accessibility) and stakeholder groups (eg, sufficient resources) in terms of several factors. Our findings underscore the importance of involving multiple stakeholders in portal implementations. We identified a set of barriers and facilitators that are likely to be useful in making strategic and efficient implementation plans.
| S-EPMC5970285 | biostudies-literature
Project description:ObjectiveTo study the association between the method of induction of labor (IOL) and perinatal outcomes, among women undergoing labor after cesarean (LAC) with no prior vaginal delivery.MethodA retrospective study including all women with no prior vaginal delivery undergoing IOL for LAC between March 2011 and January 2021. Oxytocin administration following prelabor rupture of membranes (PROM), oxytocin administration only, extra-amniotic balloon, and amniotomy were compared.ResultsOverall, 363 women met the inclusion criteria: extra-amniotic balloon (157, 43.3%), oxytocin following PROM (95, 26.2%), amniotomy (72, 19.8%), and oxytocin (39, 10.7%). LAC success rate did not differ among study groups (P = 0.114), varying between 62.1% and 79.5%. There were three uterine ruptures (0.8%) in the entire cohort. The rate of uterine rupture, postpartum hemorrhage, and the composite of both were similar in all study groups. Neonatal outcomes did not differ between study groups, with composite adverse neonatal outcomes varying between 7.4% in the oxytocin following PROM to 1.9% in the extra-amniotic balloon group (P = 0.141). The following factors were independently associated with LAC success: taller maternal height, lower body mass index, earlier gestational age, and epidural analgesia.ConclusionsAll examined IOL methods with an unfavorable cervix carried similar outcomes. The clinical practice should be individualized.
| S-EPMC10084373 | biostudies-literature
Project description:BackgroundRising rates of labor induction and cesarean delivery, especially when used without a medical reason, have generated concern among clinicians, women, and policymakers. Whether employment status affects pregnant women's childbirth-related care is not known. We estimated the relationship between prenatal employment and obstetric procedures, distinguishing whether women reported that the induction or cesarean was performed for medical reasons.MethodsUsing data from a nationally representative sample of women who gave birth in U.S. hospitals (n = 1,573), we used propensity score matching to reduce potential bias from nonrandom selection into employment. Outcomes were cesarean delivery and labor induction, with and without a self-reported medical reason. Exposure was prenatal employment status (full-time employment, not employed). We conducted separate analyses for unmatched and matched cohorts using multivariable regression models.FindingsThere were no differences in labor induction based on employment status. In unmatched analyses, employed women had higher odds of cesarean delivery overall (adjusted odds ratio [AOR], 1.45; p = .046) and cesarean delivery without medical reason (AOR, 1.94; p = .024). Adding an interaction term between employment and college education revealed no effects on cesarean delivery without medical reason. There were no differences in cesarean delivery by employment status in the propensity score-matched analysis.ConclusionsFull-time prenatal employment is associated with higher odds of cesarean delivery, but this association was not explained by socioeconomic status and no longer existed after accounting for sociodemographic differences by matching women employed full time with similar women not employed during pregnancy.
| S-EPMC4163009 | biostudies-literature
Project description:BackgroundInduction of labor is common; however, the optimum clinical strategy for induction of labor is less clear. Variations in clinical practices related to induction of labor may lead to increased complications and longer induction of labor times.ObjectiveThis study aimed to analyze whether the implementation of an evidence-based standardized care pathway improves the clinical outcomes associated with induction of labor.Study designThis was an approved quality improvement project implementing a clinical care pathway for induction of labor. Moreover, this was a retrospective cohort study of inductions of labor for 5 months before (January 2018 to May 2018) and 14 months after (August 2018 to September 2019) the implementation of the care pathway. The primary outcome was time from admission to delivery. Time from admission to delivery was stratified by mode of delivery. The secondary outcomes included chorioamnionitis, endometritis, neonatal intensive care unit admissions, cesarean delivery, postpartum hemorrhage, and a composite of unanticipated outcomes (chorioamnionitis, endometritis, neonatal intensive care unit admissions, cesarean delivery, and postpartum hemorrhage). In addition, pathway adherence was analyzed. The outcomes were analyzed using 2-tailed t tests for continuous data and the Fisher exact test and chi-square tests for categorical data. Propensity score matching was used to assess for confounding by potential covariates.ResultsA total of 1471 inductions of labor were reviewed, with 392 inductions of labor before the implementation of the care pathway and 1079 inductions of labor after the implementation of the care pathway. The pathway was associated with a nonsignificant reduction in the time from admission to delivery by 1.2 hours (from 23.4 to 22.2 hours; P=.08). There was a nonsignificant increase in the time to cesarean delivery before (28.2 hours) and after (28.8 hours) protocol implementation (P=.71). There was a significant decrease in the time to delivery by 1.7 hours for vaginal deliveries (from 22.2 to 20.5 hours) after protocol implementation (P=.02). There was a significant decrease in chorioamnionitis (from 12.5% to 6.0%; odds ratio, 0.44; 95% confidence interval, 0.29-0.67), a significant decrease in endometritis (from 6.9% to 2.6%; odds ratio, 0.36; 95% confidence interval, 0.20-0.65), and a significant decrease in composite unanticipated outcomes (from 56.9% to 36.6%; odds ratio, 0.46; 95% confidence interval, 0.34-0.56) after the implementation of the care pathway. There was no significant difference in postpartum hemorrhage (from 7.9% to 6.1%; odds ratio, 0.76; 95% confidence interval, 0.48-1.22), neonatal intensive care unit admissions (from 18.1% to 14.0%; odds ratio, 0.74; 95% confidence interval, 0.54-1.02), or cesarean deliveries (from 19.6% to 20.1%; odds ratio, 1.03; 95% confidence interval, 0.76-1.40) after the implementation of the care pathway. Pathway adherence varied, ranging from 50% to 89%.ConclusionThe introduction of a standardized induction of labor pathway was associated with a nonsignificant reduction in the time from admission to delivery by 1.2 hours and improved pregnancy outcomes, including decreased infections and unanticipated outcomes. Further opportunities for improvements in clinical outcomes may be realized with increased compliance with the care pathway.
| S-EPMC10750180 | biostudies-literature
Project description:BackgroundCesarean delivery remains the most common obstetrical procedure with more than 250,000 patients in the US undergoing cesarean following labor induction annually. Here, we evaluated the impact of prospectively implementing a standardized labor induction protocol on cesarean delivery rates.MethodsThis multi-site type I hybrid effectiveness-implementation study compared 2 years before (PRE) and 2 years after (POST) implementation of a standardized labor induction protocol at two hospitals within the University of Pennsylvania Health System (2018-2022). The protocol included multiple components and recommended active management of labor induction, including frequent cervical examinations, amniotomy if cervical exam ≥4 cm, and interventions for labor dystocia. The primary effectiveness outcome was cesarean delivery. Secondary effectiveness outcomes included labor length, chorioamnionitis, and maternal and neonatal morbidity. The primary implementation outcome was fidelity, defined as adherence to ≥75% of the protocol components among 8 individual components that could be evaluated discretely. All data was collected via individual chart review.Findings8509 patients were included (PRE: n = 4214, POST: n = 4295). Our population was of median age of 31 years interquartile range (IQR) [26-35], and 44.6% identified as Black, 40.1% as white, 6.9% as Asian, and 8.4% as other or unknown; 7.4% of the population identified as Latinx. There was no significant difference in cesarean delivery rate between the two time periods overall (PRE: 21.6% vs. POST: 21.8%, p = 0.85; adjusted relative risk (aRR) 0.99 95% confidence interval (CI) [0.90-1.09]). There were no significant differences in labor length, chorioamnionitis, or composite neonatal morbidity. Maternal morbidity decreased PRE to POST (PRE: 9.3% vs. POST: 6.5%, p < 0.001; aRR 0.67 95% CI [0.58-0.79]). POST-implementation, inductions with fidelity to ≥75% of protocol components increased (PRE: 52.4% vs. POST: 59.6%, p < 0.001), evidenced by more frequent cervical examinations, earlier dilation at amniotomy, and increased labor dystocia management.InterpretationDespite increasing standardized induction management, no significant difference in cesarean delivery was found.FundingNICHD K23HD102523.
| S-EPMC11683308 | biostudies-literature