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This ambitious undertaking involved 56 hospitals (comprising more than 119,000 annual births), divided into teams of six to eight. Each team was led by a physician and nurse mentor, who directed a broad-based educational program, which included training materials, grand rounds for physicians and nurses, webinars, and onsite assistance. Teams engaged in monthly check-in phone calls, received monthly progress reports, and were able to network with other teams through a dedicated email distribution list. The focus of the educational program was on encouraging adherence to American College of Obstetricians and Gynecologists (ACOG) and Society for Maternal-Fetal Medicine (SMFM) guidelines for labor management,2 specifically for the latent and active phases (but not the second stage), and on increasing nursing support during labor.
The collaborative activities were initiated in mid-2016, and the frequencies of various outcomes for nulliparous women at term carrying vertex, singleton fetuses were compared between calendar year 2015 and calendar year 2017-the first full year of the collaboration. The proportion of women who delivered by cesarean declined significantly, from 29.3% to 25.0%, and the frequency of severe unexpected newborn complications (a composite of hypoxic ischemic encephalopathy, seizures, ventilation, sepsis, major birth injuries, and transfer to a higher level of care) was essentially unchanged. The frequencies of other outcomes, including chorioamnionitis, blood transfusion, third- and fourth-degree perineal laceration, operative vaginal delivery, and 5-minute Apgar score less than 5, were also stable. In the tercile of hospitals with the greatest decline in the frequency of cesarean delivery, from 31.2% to 20.6%, a concomitant reduction in the frequency of unexpected newborn complications was also observed, from 3.2% to 2.2% (adjusted odds ratio 0.71, 95% CI 0.55-0.92).
This study tells us two important things: first, that a lower frequency of cesarean delivery needn't be accompanied by a higher frequency of maternal or neonatal complications and, indeed, may even be associated with fewer adverse outcomes; and, second, that the success associated with implementation of the ACOG-SMFM guidelines for labor management achieved by single centers 3,4 may, with a well-coordinated collaborative effort, be writ large.
As with all research investigations, there are limitations to the Main et al study. Before-after studies generally do not provide direct cause-and-effect evidence. Therefore, we cannot know whether the lower frequency of cesarean delivery observed after the collaborative effort was the result of the effort itself or some other factor(s), especially because adherence to the ACOG-SMFM guidelines was not assessed, nor the level of nursing support actually measured. The 1-year-after period does not provide evidence that the decline in the frequency of cesarean delivery will endure. Further, one hopes that, because a cesarean delivery frequency of 25% is not particularly low for nulliparous women at term carrying vertex, singleton fetuses, the frequency will decline even further.
Two other important contemporary studies also support realistic hopes that a lower frequency of cesarean delivery and improved neonatal outcomes are compatible. The French study by Schmitz et al 5 demonstrates that it is possible on a national level to achieve a high proportion of twin vaginal delivery and that twins delivered vaginally have better neonatal outcomes than those delivered by cesarean. More recently, Grobman et al 6 reported the results of the ARRIVE trial (A Randomized Trial of Induction Versus Expectant Management), in which more than 6,000 low-risk nulliparous women at term were randomly allocated to induction of labor at 39 weeks of gestation or to expectant management. Not only did induction result in a significantly lower frequency of cesarean delivery (18.6% vs 22.2%), but it came within a whisker of significantly lowering the composite outcome of perinatal death or severe neonatal outcomes (4.3% vs 5.4%; relative risk 0.80, 95% CI 0.64-1.00). Taken together, the three studies provide reason to believe that, just maybe, we can have our cake and eat it too.
This ambitious undertaking involved 56 hospitals (comprising more than 119,000 annual births), divided into teams of six to eight. Each team was led by a physician and nurse mentor, who directed a broad-based educational program, which included training materials, grand rounds for physicians and nurses, webinars, and onsite assistance. Teams engaged in monthly check-in phone calls, received monthly progress reports, and were able to network with ...
Néonatologie ; Césarienne ; Obstétrique
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