Mandatory second opinion to reduce rates of unnecessary caesarean sections in Latin America: a cluster randomised controlled trial. Effect of peer review and trial of labor on lowering cesarean section rates. The impact of legislatively imposed practice guidelines on cesarean section rates: the Florida experience. Opinion leaders vs audit and feedback to implement practice guidelines. Delivery after previous cesarean section. A randomised controlled trial and meta-analysis of active management of labour. Financial incentives do not always work: an example of cesarean sections in Taiwan. Management of prelabour rupture of the membranes in term primigravidae: report of a randomized prospective trial. [The benefit of external version in full-term breech presentation]. Active management of labour in a district hospital setting. Randomized controlled trial of a prenatal vaginal birth after cesarean section education and support program. Childbirth Alternatives Post-Cesarean Study Group. Two decision aids for mode of delivery among women with previous caesarean section: randomised controlled trial. Randomised trial of educational visits to enhance use of systematic reviews in 25 obstetric units. Collaboration in maternity care: a randomised controlled trial comparing community-based continuity of care with standard hospital care. A randomized trial of one-to-one nurse support of women in labor. Prelabour rupture of the membranes at term--no advantage of delaying induction for 24 hours. A randomised trial of two expectant managements of prelabour rupture of the membranes at 34 to 42 weeks.
Latin America has a high rate of caesarean sections. We tested the hypothesis that a hospital policy of mandatory second opinion, based on the best existing scientific evidence, reduces the hospital caesarean section rate by 25%, without increasing maternal and perinatal morbidity and mortality.
                36 hospitals in Argentina (18), Brazil (eight), Cuba (four), Guatemala (two), and Mexico (four), were randomly assigned to intervention or control in a matched pair design. All physicians in the intervention hospitals deciding a non-emergency caesarean section had to follow a policy of mandatory second opinion. The primary outcome was the overall caesarean section rate in the hospitals after a 6-month implementation period. We also assessed women's satisfaction with labour and delivery care and physicians'acceptance of the second opinion policy.
                A total of 34 hospitals attending 149?276 deliveries were randomised and completed the protocol. The mandatory second opinion policy was associated with a small but significant reduction in rates of caesarean section (relative rate reduction 7.3%; 95% CI 0.2-14.5), mostly in intrapartum sections (12.6%; 0.6-24.7). Other maternal and neonatal outcomes and women's perceptions and satisfaction with the process of care were similarly distributed between the groups.
                In hospitals applying this policy of second opinion, 22 intrapartum caesarean sections could be prevented per 1000 deliveries, without affecting maternal or perinatal morbidity, and without affecting mothers' satisfaction with the care process. In an attempt to lower cesarean section rates, a cesarean surveillance system and a selective trial of labor were introduced in a tertiary hospital in Taiwan.
                From 1997 to 2000, 2 physicians were appointed as consultants for the pre-cesarean surveillance, and a trial of labor after a cesarean section was employed concurrently. We organized a weekly departmental Cesarean Indication Conference on Mondays. Comparisons of the cesarean rates between 1993-96 and 1997-2000 were made using the chi-square test. Comparisons of the proportion of overall cesarean sections contributed by each indication for both 1993 and 2000 were also made by chi-square test.
                A comparison of the 4-year periods before and after 1997 showed that the total cesarean rate had decreased from 37.0 to 30.7% (p < 0.001), primary cesarean rate from 21.3 to 17.8% (p < 0.001), and repeat cesarean rate from 15.7 to 12.9% (p < 0.001). No uterine rupture occurred. Among the 54 indications for primary cesareans, compared between 1993 and 2000, the proportion rates for dystocia, fetal distress, preeclampsia, induction failure, gestational diabetes, and elderly primigravidahad decreased substantially.
                The efficient way to lower the repeat cesarean rate is trial of labor, and the way to reduce the number of primary cesareans is in practicing of the guidelines for various indications. The cesarean surveillance system can solidify these guidelines, leading to a lower cesarean rate and an avoidance of inappropriate indications. Florida legislation implemented in the fall of 1992, unique in the nation, mandated that practice guidelines regarding cesarean section deliveries be disseminated to obstetric physicians. The law also required that peer review boards at hospitals be established to review cesarean deliveries and that the exact dates of implementation of the guidelines be reported to a state agency. To determine the impact of the legislation, we conducted a retrospective analysis of 366,246 total live births occurring in Florida hospitals during 1992 and 1993, before and after formal hospital certification of the implementation of the guidelines. Changes in primary and repeat cesarean rates were analyzed for 108 independent groups of births, controlling for the mother's age, race, payment source, and the timing of the implementation of the guidelines at hospitals. The guideline certification program did not accelerate the consistent but gradual downward trend in cesarean births which had already been evident in the three prior years. The data do suggest that the guideline program may have affected repeat cesareans more than primary cesareans, especially in the first quarter of 1993, immediately after the hospital certification period. Reductions in repeat cesareans involved both Medicaid and commercially insured births, whereas reductions in primary cesareans were found almost exclusively within commercially insured mothers, where the existing rates are highest. Although births with a prior cesarean represent only 12.5% of all births, significant decreases in repeat cesareans were found in groups representing 72.6% of this population. By comparison, significant decreases in primary cesareans were found in groups representing only 36.5% of the births without a prior cesarean. The date of guideline implementation reported by hospitals was not related to any systematic change in observed cesarean section rates. We concluded that the mere dissemination of practice guidelines by a state agency may not achieve either the magnitude or the specificity of the results desired without an explicit and thorough guideline implementation program. Blunt legislative mandates may be ineffective when multiple initiatives are already achieving desired outcomes. A randomized controlled trial with 76 physicians in 16 community hospitals evaluated audit and feedback and local opinion leader education as methods of encouraging compliance with a guideline for the management of women with a previous cesarean section. The guideline recommended clinical actions to increase trial of labor and vaginal birth rates. Charts for all 3552 cases in the study groups were audited. After 24 months the trial of labor and vaginal birth rates in the audit and feedback group were no different from those in the control group, but rates were 46% and 85% higher, respectively, among physicians educated by an opinion leader. Duration of hospital stay was lower in the opinion leader education group than in the other two groups. The overall cesarean section rate was reduced only in the opinion leader education group. There were no adverse clinical outcomes attributable to the interventions. The use of opinion leaders improved the quality of care. To test whether a policy of active management of nulliparous labour would reduce the rate of caesarean section and prolonged labour without influencing maternal satisfaction.
                Randomised controlled trial.
                Tertiary referral obstetric unit, Auckland, New Zealand.
                Nulliparous women in spontaneous labour at term with singleton pregnancy and cephalic presentation and without fetal distress.
                After the onset of active labour, previously consented women were randomly assigned to active management (n = 320) or to routine care (n = 331). Active labour was defined as regular painful contractions, occurring at least once in five minutes, lasting at least 40 seconds, accompanied by either spontaneous rupture of the membranes, or full cervical effacement and dilatation of at least two centimetres. Active management included early amniotomy, two-hourly vaginal assessments, and early use of high dose oxytocin for slow progress in labour. Routine care was not prespecified. Prolonged labour was > 12 hours duration. Maternal satisfaction with labour care was assessed by postal questionnaire at six weeks postpartum.
                Mode of delivery, duration of labour, and maternal satisfaction.
                Active management of labour did not reduce the rate of caesarean section 30/320 (9.4%), compared with 32/331 (9.7%) for routine care, but did shorten the length of first stage of labour (median 240 min vs 290 min; P = 0.02), and reduce the relative risk of prolonged labour (RR 0.39; 95% CI 0.22, 0.71). There were no differences between groups in the rates of newborn nursery admission, neonatal acidosis, low Apgar scores, or postpartum haemorrhage. Satisfaction with labour care was high (77%) and did not differ between groups.
                Active management of labour reduced the duration of the first stage of labour without affecting the rate of caesarean section, maternal satisfaction, or other maternal or newborn morbidity. To test the hypothesis that cesarean sections are less likely to be performed after equalizing the fees for vaginal births and cesarean sections.
                Population-based National Health Insurance inpatient claims in Taiwan are used. Pre-periods and post-periods are identified to investigate the impact of the policy changes. Logistic regressions are employed.
                The cesarean section rates for the first, second and higher-order births are 29, 37.4 and 39.3%, while the primary cesarean section rates are 29, 11.8 and 12.1%, respectively. After taking into consideration the case-mix and birth order, the second and higher-order births were approximately 60% less likely to be cesarean deliveries compared to the first births and the increase in the VBAC fee had an additional negative effect on them. A fee equalization policy was not found to influence the cesarean delivery. The total cesarean section rate was primarily determined by the cesarean section rate for the first birth.
                Cesarean section rates are greater for the higher-order births because of the practice "once a cesarean section, always a cesarean section". Against the background of a rapidly declining fertility rate, females play a more important role in the mode of delivery than ever before. As such, financial incentives designed specifically for obstetricians do not have the desired impact. Policies that are aimed at altering behavior should be designed within the social context. To compare a conservative and an active policy (immediate oxytocin infusion) of management of prelabour rupture of the membranes in term primigravidae.
                Randomized trial involving 444 women.
                District maternity hospital.
                Caesarean section rate in each group; also the rate of forceps deliveries, spontaneous deliveries, length of labour, number of vaginal examinations, type of analgesia, pyrexia in labour or the puerperium and antibiotic use in the mother and the infant in each group. The caesarean section rate for the whole trial where the latent period was greater than 12 h was compared to that where the latent period was less than or equal to 12 h.
                There were fewer caesarean sections in the conservative group (odds ratio (OR) 0.60, 95% confidence interval (CI) 0.35 to 1.02; P = 0.06). There was a similar number of forceps deliveries (OR 0.79; 95% CI 0.52 to 1.19; P = 0.26) but more spontaneous deliveries (OR 1.57; 95% CI 1.08 to 2.29; P = 0.02) in the conservative group. More women managed conservatively required inhalational analgesia only for pain relief in labour (OR 2.88; 95% CI 1.46 to 5.68; P = 0.003), a similar number required pethidine (OR 1.29; 95% CI 0.85 to 1.94; P = 0.23), and fewer required epidural analgesia (OR 0.57; 95% CI 0.39 to 0.84; P = 0.005). The number of vaginal examinations was less in the conservative group (difference between mean 0.53; 95% CI 0.25 to 0.80; P less than 0.001). Fewer women managed conservatively experienced four or more vaginal examinations in labour (OR 0.58; 95% CI 0.39 to 0.86; P = 0.007). There were no differences in the lengths of labour, the proportions of women who developed pyrexia in labour or the puerperium or who required antibiotics or in the proportions of infants who required antibiotics.
                These results argue in favour of a conservative policy in managing primigravidae at term with prelabour rupture of the membranes. We report a randomised controlled trial of external version in 52 women with breech presentation after 36 weeks' gestation; 83% gave informed consent to undergo the management to which they had been randomized. Only 5% of initial attempts without tocolysis succeeded, but 31% of the failures subsequently had a successful version under tocolysis. External version resulted in a small decrease in the frequency of breech presentation at birth (64% vs. 74%), and in an unexpected increase in the caesarean section rate (28% vs. 11%). The increase in caesarean section rate could be attributed to failed versions, which apparently greatly influenced the choice between abdominal and vaginal delivery. Our findings and data from similar research suggest that benefits of external version at term may not apply to populations with a low caesarean rate, unless versions are carried out with maximal efficiency (which, on the basis of available data, would imply tocolysis) or so indifferently that failed attempts do not influence the choice between abdominal and vaginal delivery. The aim of this randomised trial was to determine the effect of the policy of active management of labour in all its components on the rate of caesarean section in a Nigerian district hospital setting. Two hundred and twenty-one nulliparous women fulfilling selected inclusion criteria were randomised to receive active management of labour, and 227 control women received routine labour management. Labour was significantly shortened by over 2 hours with active management of labour, and caesarean section reduced (9% vs. 16%, RR 0.57, 95% CI 0.34-0.95). There were no significant differences in maternal infectious morbidity, uterine hyperstimulation syndromes, ruptured uterus or neonatal Apgar scores between the two groups. We conclude that active management of labour shortens primigravid labour and reduces caesarean risk. Our objective was to assess whether, for women with previous cesarean section, a prenatal education and support program promoting vaginal birth after cesarean delivery increases the probability of vaginal delivery.
                Women with a single previous cesarean were recruited before 28 weeks' gestation. Women's self-assessed motivation to attempt vaginal birth after a previous cesarean delivery was measured on a 10 cm visual analog scale: stratum I, low motivation; stratum II, high motivation. Women were randomized by stratum to one of two groups. Those in the "Verbal" group participated in an individualized education program. Those in the "Document" group were provided with a pamphlet detailing the benefits of planned vaginal birth after cesarean delivery.
                Rates of vaginal birth after cesarean section were similar in the verbal and document groups: verbal, 339 of 641 (53%); document, 310 of 634 (49%); relative risk 1.1, 95% confidence interval 1.0 to 1.2. There was no evidence of heterogeneity across motivational strata. Regardless of treatment group, women with low motivation for vaginal birth after cesarean section were more than three times as likely to undergo elective repeat cesarean than were women with high motivation (47% vs 13%).
                There was no evidence that an individualized prenatal education and support program, when offered to all women with previous cesarean delivery, results in a clinically significant increase in the rate of vaginal birth after cesarean section. To determine the effects of two computer based decision aids on decisional conflict and mode of delivery among pregnant women with a previous caesarean section.
                Randomised trial, conducted from May 2004 to August 2006.
                Four maternity units in south west England, and Scotland.
                742 pregnant women with one previous lower segment caesarean section and delivery expected at >or=37 weeks. Non-English speakers were excluded.
                Usual care: standard care given by obstetric and midwifery staff. Information programme: women navigated through descriptions and probabilities of clinical outcomes for mother and baby associated with planned vaginal birth, elective caesarean section, and emergency caesarean section. Decision analysis: mode of delivery was recommended based on utility assessments performed by the woman combined with probabilities of clinical outcomes within a concealed decision tree. Both interventions were delivered via a laptop computer after brief instructions from a researcher.
                Total score on decisional conflict scale, and mode of delivery.
                Women in the information programme (adjusted difference -6.2, 95% confidence interval -8.7 to -3.7) and the decision analysis (-4.0, -6.5 to -1.5) groups had reduced decisional conflict compared with women in the usual care group. The rate of vaginal birth was higher for women in the decision analysis group compared with the usual care group (37% v 30%, adjusted odds ratio 1.42, 0.94 to 2.14), but the rates were similar in the information programme and usual care groups.
                Decision aids can help women who have had a previous caesarean section to decide on mode of delivery in a subsequent pregnancy. The decision analysis approach might substantially affect national rates of caesarean section. Trial Registration Current Controlled Trials ISRCTN84367722. To evaluate the effectiveness of an educational visit to help obstetricians and midwives select and use evidence from a Cochrane database containing 600 systematic reviews.
                Randomised single blind controlled trial with obstetric units allocated to an educational visit or control group.
                25 of the 26 district general obstetric units in two former NHS regions.
                The senior obstetrician and midwife from each intervention unit participated in educational visits. Clinical practices of all staff were assessed in 4508 pregnancies.
                Single informal educational visit by a respected obstetrician including discussion of evidence based obstetrics, guidance on implementation, and donation of Cochrane database and other materials.
                Rates of perineal suturing with polyglycolic acid, ventouse delivery, prophylactic antibiotics in caesarean section, and steroids in preterm delivery, before and 9 months after visits, and concordance of guidelines with review evidence for same marker practices before and after visits.
                Rates varied greatly, but the overall baseline mean of 43% (986/2312) increased to 54% (1189/2196) 9 months later. Rates of ventouse delivery increased significantly in intervention units but not in control units; there was no difference between the two types of units in uptake of other practices. Pooling rates from all 25 units, use of antibiotics in caesarean section and use of polyglycolic acid sutures increased significantly over the period, but use of steroids in preterm delivery was unchanged. Labour ward guidelines seldom agreed with evidence at baseline; this hardly improved after visits. Educational visits cost pound860 each (at 1995 prices).
                There was considerable uptake of evidence into practice in both control and intervention units between 1994 and 1995. Our educational visits added little to this, despite the informal setting, targeting of senior staff from two disciplines, and donation of educational materials. Further work is needed to define cost effective methods to enhance the uptake of evidence from systematic reviews and to clarify leadership and roles of senior obstetric staff in implementing the evidence. To test whether a new community-based model of continuity of care provided by midwives and obstetricians improved maternal clinical outcomes, in particular a reduced caesarean section rate.
                Randomised controlled trial.
                A public teaching hospital in metropolitan Sydney, Australia. Sample 1089 women randomised to either the community-based model (n = 550) or standard hospital-based care (n = 539) prior to their first antenatal booking visit at an Australian metropolitan public hospital.
                Data were collected on onset and outcomes of labour, antenatal, intrapartum and postnatal complications, antenatal admissions to hospital and neonatal mortality and morbidity.
                There was a significant difference in the caesarean section rate between the groups, 13.3% (73/550) in the community-based group and 17.8% in the control group (96/539). This difference was maintained after controlling for known contributing factors to caesarean section (OR = 0.6, 95% CI 0.4-0.9, P = 0.02). There were no other significant differences in the events during labour and birth. Eighty babies (14.5%) from the community-based group and 102 (18.9%) from the control group were admitted to the special care nursery, but this difference was not significant (OR 0.75, 95% CI 0.5-1.1, P = 0.12). Eight infants died during the perinatal period (four from each group), for an overall perinatal mortality rate of 7.3 per 1000 births.
                Community-based continuity of maternity care provided by midwives and obstetricians resulted in a significantly reduced caesarean section rate. There were no other differences in clinical outcomes. Health researchers and provider groups have recommended that women in labor should receive continuous professional support. The objective of our study was to compare the risks and benefits of one-to-one nurse labor support with usual intrapartum nursing care.
                A randomized, controlled trial was conducted in a 637-bed university hospital in Montreal, Quebec, with 413 nulliparous women who were at more than 37 weeks' gestation, carrying singletons, and in labor. Women with scheduled cesarean section, scheduled induction, breech presentation, presence of paid labor support, or cervical dilatation over 4 cm were excluded. One-to-one care consisted of the presence of a nurse during labor and birth who provided emotional support, physical comfort, and instruction for relaxation and coping techniques. Usual care consisted of care for two or three laboring women with various types of supportive activities.
                A beneficial trend due to one-to-one nurse support was found with a 17 percent reduction in risk of oxytocin stimulation (relative risk of experimental vs control = 0.83; 95% confidence interval = 0.67, 1.04). No significant differences were found in overall labor durations and overall rates of total cesarean section, cesarean section for cephalopelvic disproportion, epidural analgesia, admission to the neonatal intensive care unit, instrumental vaginal delivery, and perineal trauma.
                The beneficial trend attributed to one-to-one nursing in reduction of oxytocin stimulation suggests that implementation of recommendations for continuous professional support by intrapartum nursing staff may be appropriate in North America. We performed a prospective randomized study to compare maternal and fetal outcomes in pregnancies with prelabour rupture of the membranes (PROM) at term with early induction of labour or expectant management, 126 women with singleton pregnancy, cephalic presentation and gestational duration > or = 37 weeks, were randomized either to immediate induction of labour with oxytocin (Group 1) (n=52), or conservative management (Group 2) (n=74). Women who constituted Group 2 were divided into 2 groups. The first group (Group 2A) (n=25) included women in whom spontaneous labour did not begin after a waiting period of 24 hours, in which case labour was induced with oxytocin i.e. expectant management. The second group consisted of women (Group 2B) (n=49) in whom labour began spontaneously within 24 hours. The base Caesarean section rate was significantly higher in Group 2 (28.4%) (p<0.05). The rates of Caesarean section in the Groups 1-2A-2B were 19.2%, 60%, and 12.2%, respectively for nulliparous and parous women together. The rate of fetal distress was significantly higher in Group 2 (p<0.05). For determining maternal outcomes, the other parameters such as clinical chorioamnionitis, fever before or during labour, receiving antibiotics before or during labour, postpartum fever, analgesia, anaesthesia did not differ in Groups 1 and 2. Women in Group 1 went into active labour sooner, had fewer digital vaginal examinations, had a shorter interval between membrane rupture and delivery, and spent less time in the hospital before delivery than those in Group 2 (p<0.05). Babies in Group 2 were more likely to receive antibiotics, and more likely to stay in an intensive care nursery for more than 24 hours, and more likely to receive ventilation after initial resuscitation than those babies in Group 1. For developing apnoea and hypotonia, there was no significant difference between Groups 1 and 2. However, for babies in Group 2A there was a significant difference. We conclude that immediate induction of labour with oxytocin does not increase the risk of Caesarean section, compared with a practice of expectant management. Women at term with prelabour rupture of the membranes should therefore be reassured that immediate induction with oxytocin currently appears to be the best policy with respect to maternal and neonatal morbidity. To compare obstetric and perinatal outcome between two different expectant managements in women with prelabour rupture of the membranes (PROM).
                A randomised study.
                One thousand three hundred and eighty-five women with rupture of the membranes at 34 to 42 weeks without contractions.
                Women without contractions 2 h after admission were randomised to early induction the following morning after PROM (early induction group) or induction two days later (late induction group). Women with contractions starting within 2 h after admission were included in the calculations as a short latency group. Digital examinations of the cervix were avoided until onset of active labour. Labour was induced with oxytocin in both groups if no spontaneous contractions occurred or if chorioamnionitis or fetal distress was detected.
                The frequency of spontaneous deliveries, operative deliveries, maternal and neonatal infections.
                In nulliparous women, a higher rate of spontaneous deliveries was found in the late induction group (89%) compared with the early induction group (81%) (P < 0.05). The ventouse extraction rate was 7% and 14% respectively (P < 0.05). A low (2-4%) caesarean section rate was recorded and did not differ between the groups. Endometritis was detected in six women after delivery. Sixty-one children were treated with antibiotics, and no difference could be detected between the groups.
                A higher rate of spontaneous deliveries was found among nulliparous women with prolonged latency as compared with brief latency prior to induction. A protocol of no digital examination before labour was associated with infrequent maternal and fetal morbidity, regardless of latency.
Implementation of guidelines with mandatory second opinion can lead to a small reduction in caesarean section rates, predominately in intrapartum sections. Peer review, including pre-caesarean consultation, mandatory secondary opinion and postcaesarean surveillance can lead to a reduction in repeat caesarean section rates. Guidelines disseminated with endorsement and support from local opinion leaders may increase the proportion of women with previous caesarean sections being offered a trial of labour in certain settings. Nurse-led relaxation classes and birth preparation classes may reduce caesarean section rates in low-risk pregnancies.