Preventing the First Cesarean Robyn Lamar, MD, MPH Assistant - - PowerPoint PPT Presentation

10/18/2018 1

Preventing the First Cesarean

Robyn Lamar, MD, MPH Assistant Professor of OB GYN, UCSF Disclosures: none, but a debt of gratitude . . . Outline

• Why it matters
• Epidemiology
• Drivers of primary cesarean rate
• Strategies for improvement

○ Intrapartum management: NICHD paper ○ Structural change: CMQCC toolkits

• Case Studies--hospital-level interventions

○ PBGH southern California case study ○ Beth Israel experience

• Conclusions & thoughts for another couple talks

Why It Matters

• Cesareans can be lifesaving

interventions for women and neonates

• Data strongly suggest they are

currently overused in the US & many other middle & high income countries

• Maternal morbidity & mortality are

higher with cesarean delivery than vaginal delivery, and these risks diverge further with each subsequent birth

10/18/2018 2

Transforming Maternity Care

A Toolkit to Support Vaginal Birth and Reduce Primary Cesareans

Transforming Maternity Care

A Toolkit to Support Vaginal Birth and Reduce Primary Cesareans

Importance of the First Birth

If a woman has a Cesarean birth in the first labor, over 90%

• f ALL subsequent births will be Cesarean births

If a woman has a vaginal birth in the first labor,

• ver 90% of ALL subsequent births will be vaginal births

A classic example of path dependency

5

What’s the right number?

World Health Organization (WHO):

• 1985: “no justification for any region to have a rate higher than 10-15%”
• 2014: Systematic review, and ecologic (longitudinal) studies:

○ “A substantial part of the crude association between caesarean section rate and mortality appears to be explained by socioeconomic factors” ○ “However, below a caesarean section rate of 10%, maternal and neonatal mortality decreased when caesarean section rates increased.” WHO statement on caesarean section rates, April, 2015. http://www.who.int/reproductivehealth/publications/maternal_perinatal_health/cs-statement/en/

What’s the right number?

JAMA 2015:

• Cross sectional, ecologic study, 2005-2012, all 194 WHO member states
• Outcome/measures: relationship between population level cesarean rate and

maternal and neonatal mortality

• Maternal mortality: steepest drop as cesarean rate increased to 7.2%;

continued but slower drop to 19.1%; no correlation beyond this point

• Neonatal mortality: drop as cesarean rate increased to 19.4%

Molina G, et al. Relationship Between Cesarean Delivery Rate and Maternal and Neonatal Mortality.

• JAMA. 2015 Dec 1;314(21):2263-70.

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What’s the right number?

Health People 2020 Goal: “Reduce cesarean births among low-risk* women with no prior cesarean births”

• 2007 Baseline:

26.5%

• Target:

23.9% Target-Setting Method: 10% improvement

https://www.healthypeople.gov/2020/topics-objectives/topic/maternal-infant-and-child-health/objectives

What’s a low-risk primary cesarean?

Nulliparous Term Singleton Vertex

Why focus on NTSV?

• Population that is the largest contributor to the rise in cesarean rates
• Is significantly risk-stratified, facilitating comparisons between providers &

hospitals

• “NTSV is special in that it technically represents the most favorable conditions

for vaginal birth, but also the most difficult labor management”--CMQCC

• Key feature in national & regional health campaigns

○ Healthy People 2020: Goal for NTSV 23.9% https://www.healthypeople.gov/2020/leading-health-indicators/2020-lhi- topics/Maternal-Infant-and-Child-Health/data

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Accessed from http://calhospitalcompare.org/ on 10/1/2018 https://www.iha.org/our-work/insights/smart-care-california/focus-area-c-sections

"Starting in less than two years, if the hospitals haven't met certain designated targets for safety and quality, they'll risk being excluded from the "in-network" designation of health plans sold on the state's insurance exchange. "We're saying 'time's up,' " says Dr. Lance Lang, the chief medical officer for Covered California. "We've told health plans that by the end of 2019, we want networks to only include hospitals that have achieved that target.

https://www.npr.org/sections/health-shots/2018/05/23/611975420/californias-message-to- hospitals-shape-up-or-lose-in-network-status

Epidemiology: What’s the trend over time?

Osterman MJ, Martin JA. Trends in low-risk cesarean delivery in the United States, 1990-2013. Natl Vital Stat Rep. 2014 Nov 5;63(6):1-16.

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Epidemiology: International Comparisons

The US is at the upper end for high income countries

Epidemiology: US State Comparisons What Explains the Variation?

High-risk hospitals? Patient demographics? IVF-driven multiples? Non-medically indicated cesareans?

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Declercq E, MacDorman M, Osterman M, Belanoff C, Iverson R. Prepregnancy Obesity and Primary Cesareans among Otherwise Low-Risk Mothers in 38 U.S. States in 2012. Birth. 2015 Dec;42(4):309-18.

Data: https://www.cdc.gov/nchs/data/nvsr/nvsr63/nvsr63_06.pdf

What explains the variation?

• Age & BMI both clearly impact individual risk
• However, neither plays much role at all in explaining hospital variation
• Why? At least in California:

○ Hospital populations tend to either be older & thinner OR younger & heavier ○ CMQCC provides adjusted NTSV CS rate at the hospital level, showing: ■ Adjusted rates vary ≦2% points in most. ■ Only 6/251 hospitals moved >23.9% to below, and they were all <26% to start. ■ “In addition, both age and BMI effects vary greatly from hospital to hospital (and even physician to physician) suggesting that there is an important part of the risk that is provider driven rather than inherent in the patient factor” Source: https://www.cmqcc.org/VBirthToolkit

10/18/2018 7

Transforming Maternity Care

A Toolkit to Support Vaginal Birth and Reduce Primary Cesareans

Transforming Maternity Care

A Toolkit to Support Vaginal Birth and Reduce Primary Cesareans

Percent of the Increase in Primary Cesarean Rate Attributable to this Indication Cesarean Indication

Yale (2003 v. 2009) (Total: 26% to 36.5%) Focus: all primary Cesareans Kaiser SoCal (1991 v. 2008) (Primary: 12.5% to 20%) Focus: all primary singleton Cesareans

Labor progress complications (CPD/FTP) 28% ~38% Fetal Intolerance of Labor 32% ~24%

Breech/Malpresentation <1% <1% Multiple Gestation 16% Not available Various Obstetric and Medical Conditions (Placenta Abnormalities, Hypertension, Herpes, etc.) 6% 20% (Did not separate preeclampsia from other complications) Preeclampsia 10% “Elective” (variously defined) 8% (Scheduled without “medical indication”) 18% (Those “without a charted indication”)

What Indications Have Driven the RISE in CS?

26

60%!

Transforming Maternity Care

A Toolkit to Support Vaginal Birth and Reduce Primary Cesareans

Transforming Maternity Care

A Toolkit to Support Vaginal Birth and Reduce Primary Cesareans

What Indications Drive the VARIATION in CS?

27 CS Indication Proportion of Overall CS Rate Proportion of Primary CS Rate CS Rate for this Indication Repeat (prior) 30-35%

• 90+%

“Abnormal Labor” (CPD/FTP) 25-30% 35-45% Highly variable Fetal Intolerance of labor 10-15% 15-20% Highly variable

Breech/Transverse 10% 15-20% 98% Multiple Gestation 5-9% 10-15% 60-80% Other: Placenta Previa, Herpes, etc ~5% ~10% 90%

60%! Reducing Unnecessary Cesareans

• By whatever measure you use, our national cesarean rate is higher than is

useful for women or neonates

• Within the US, tremendous variation exists

○ Regionally ○ By state ○ By hospital ○ Within hospital, by provider

• Variation = opportunity

10/18/2018 8

Safe Prevention of the Primary Cesarean Delivery

Addresses most common indications for primary cesarean delivery

• 1. Labor dystocia
• 2. Abnormal or indeterminate (formerly, nonreassuring) fetal heart rate tracing
• 3. Fetal malpresentation
• 4. Multiple gestation
• 5. Suspected fetal macrosomia

Outlines a set of evidence-based guidelines for management of each issue, and creates standard criteria for diagnosis of labor dystocia

ACOG, SMFM, Caughey AB, Cahill AG, Guise JM, Rouse DJ. Safe prevention of the primary cesarean

• delivery. Am J Obstet Gynecol. 2014 Mar;210(3):179-93.

Toolkit is aligned with & draws heavily from:

• Safe Reduction of Primary Cesarean Births Bundle (published

in 2015 by the Alliance for Innovation on Maternal Health)

• Obstetric Care Consensus on Safe Prevention of the Primary

Cesarean Delivery published in 2014 by ACOG & SMFM

Safe Prevention: Labor Dystocia

1st stage

• Prolonged latent phase ≠ indication for cesarean
• Slow but progressive labor ≠ indication for cesarean
• “6 is the new 4” for active labor diagnosis
• Standard definition

ACOG, SMFM, Caughey AB, Cahill AG, Guise JM, Rouse DJ. Safe prevention of the primary cesarean

• delivery. Am J Obstet Gynecol. 2014 Mar;210(3):179-93.

10/18/2018 9

Transforming Maternity Care

A Toolkit to Support Vaginal Birth and Reduce Primary Cesareans

Transforming Maternity Care

A Toolkit to Support Vaginal Birth and Reduce Primary Cesareans

Example of ACOG/SMFM Labor Dystocia Checklist in toolkit

Response

33

Safe Prevention: Labor Dystocia

2nd stage

• “A specific absolute maximum length of time spent in the second stage of

labor beyond which all women should undergo operative delivery has not been identified.

• Operative vaginal delivery is a safe, acceptable alternative in experienced

hands--and we should work toward creating more experienced hands

• OP? Consider manual rotation

ACOG, SMFM, Caughey AB, Cahill AG, Guise JM, Rouse DJ. Safe prevention of the primary cesarean

• delivery. Am J Obstet Gynecol. 2014 Mar;210(3):179-93.

Transforming Maternity Care

A Toolkit to Support Vaginal Birth and Reduce Primary Cesareans

Transforming Maternity Care

A Toolkit to Support Vaginal Birth and Reduce Primary Cesareans

Example of ACOG/SMFM Labor Dystocia Checklist in toolkit

Response

35

Safe Prevention: Fetal Monitoring

• Amnioinfusion for repetitive variable heart rate decelerations
• Scalp stim in indeterminate situations

ACOG, SMFM, Caughey AB, Cahill AG, Guise JM, Rouse DJ. Safe prevention of the primary cesarean

• delivery. Am J Obstet Gynecol. 2014 Mar;210(3):179-93.

10/18/2018 10

Transforming Maternity Care

A Toolkit to Support Vaginal Birth and Reduce Primary Cesareans

Transforming Maternity Care

A Toolkit to Support Vaginal Birth and Reduce Primary Cesareans

Response

Clark’s Algorithm for Management of Cat II Tracings Available in Toolkit

Transforming Maternity Care

A Toolkit to Support Vaginal Birth and Reduce Primary Cesareans

Transforming Maternity Care

A Toolkit to Support Vaginal Birth and Reduce Primary Cesareans

Safe Prevention: Induction of Labor

• Before 41 weeks, IOL generally reserved for medical indications
• Ripen the cervix first!
• Allow longer duration of latent phase (24 hours or more)
• Standard definition of “failed induction”

ACOG, SMFM, Caughey AB, Cahill AG, Guise JM, Rouse DJ. Safe prevention of the primary cesarean

• delivery. Am J Obstet Gynecol. 2014 Mar;210(3):179-93.

Transforming Maternity Care

A Toolkit to Support Vaginal Birth and Reduce Primary Cesareans

10/18/2018 11

https://www.cmqcc.org/news/cmqcc-responds-induction-labor-trial

Safe Prevention: Other strategies

• Malpresentation: assess at 36 weeks, offer ECV (consider regional

anesthesia)

• Macrosomia: limit cesarean for this indication to EFW of

○ 5kg in non-diabetics ○ 4.5kg in diabetics

• Excess weight gain: counsel women about IOM guidelines & rationale
• Twin gestation: counsel to attempt vaginal delivery if Twin A is cephalic
• HSV: recommend prophylaxis in last 3-4wk of pregnancy
• Promote continuous labor support

ACOG, SMFM, Caughey AB, Cahill AG, Guise JM, Rouse DJ. Safe prevention of the primary cesarean

• delivery. Am J Obstet Gynecol. 2014 Mar;210(3):179-93.

Can this really work in the real world?

10/18/2018 12

http://www.pbgh.org/maternity

Transform Maternity Care 1. Reduce C-sections 2. Expand use of nurse-midwives 3. Spread value-based payment 4. Engage patients

So-Cal Case Study: Maternity Payment and Care Redesign Pilot

Aim: reduce NTSV C-section rates & improve maternal-neonatal health outcomes Where: 3 So-Cal maternity Hospitals Intervention:

• 1. Data & measurement support
• 2. QI support
• 3. Payment Reform

http://www.pbgh.org/storage/documents/TMC_Case_Study_Oct_2015.pdf

So-Cal Case Study: Data Support

• Enrolled in the free California Maternal Data Center (MDC)

○ links California Birth Certificate data to patient discharge diagnosis data ○ Gave insight into indications for C-sections (e.g. failed induction, FTP, FIOL) ○ Allowed analysis at physician and patient level

• Used data on perinatal quality measure to

○ identify a set of “drivers” (practices) contributing to a high C-section rate ○ link those drivers to a specific set of QI initiatives

• Goal: allow individualization of QI initiatives, targeted to areas where the

hospital is an outlier

http://www.pbgh.org/storage/documents/TMC_Case_Study_Oct_2015.pdf

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So-Cal Case Study: QI support

• CMQCC facilitated several data-driven, physician-led, meetings with hospital

leadership/staff, focused on understanding the MDC report

○ compared performance to that of nearby or similar sized hospitals ○ examined variation in provider C-section rates within the hospital ○ Root causes of unnecessary c-sections identified

• Departments committed to publishing department and physician-level MDC

data on a monthly basis

• CMQCC offered an array of tools and ideas that the department could

assemble into a customized intervention

http://www.pbgh.org/storage/documents/TMC_Case_Study_Oct_2015.pdf

Introduction to the Toolkit to Support Vaginal Birth and Reduce Primary Cesareans

Funding for the development of this toolkit was provided by the California Health Care Foundation Holly Smith MPH, MSN, CNM David Lagrew Jr. MD Elliott Main, MD Nancy Peterson, MSN, PNNP Toolkit Co-authors/Lead Editors:

10/18/2018 14

So-Cal Case Study: Payment Reform

• Required to negotiate a blended case rate for deliveries--one flat rate

regardless of delivery method (cesarean or vaginal)

• Involved two insurance plans, accounting for 10-20% of births
• Ended up being time and resource intensive, lasting anywhere from 4-18mo

http://www.pbgh.org/storage/documents/TMC_Case_Study_Oct_2015.pdf

So-Cal Case Study: Results

http://www.pbgh.org/storage/documents/TMC_Case_Study_Oct_2015.pdf

So-Cal Case Study: Results

• Average drop in NTSV cesareans ~20%; sustained now over 18mo
• Unintended but welcome rise in VBAC rates (40% rise) in the two hospitals

with low baseline rates

• No increase in “balancing measure,” unexpected neonatal harm

Takeaways: significant change is possible in a short amount of time with a motivated group, and effective, individualized intervention!

http://www.pbgh.org/storage/documents/TMC_Case_Study_Oct_2015.pdf

Beth Israel Case Study

• Tertiary care academic medical center in Boston, MA with ~4,700

deliveries/year

• Sparked by NTSV and total cesarean rates higher than state & national

averages

• Multi-pronged intervention from 2008-2015, focused on NTSV cesareans

Vadnais MA et al. Quality Improvement Initiatives Lead to Reduction in Nulliparous Term Singleton Vertex Cesarean Delivery Rate. Jt Comm J Qual Patient Saf. 2017 Feb;43(2):53-61.

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Beth Israel Case Study: factors

Identified 5 factors (by internal QI data) felt to be contributing to high rates:

• 1. Fetal heart tracing interpretation
• 2. Tolerance of labor
• 3. Induction of labor
• 4. Environmental stress
• 5. Provider awareness

Vadnais MA et al. Quality Improvement Initiatives Lead to Reduction in Nulliparous Term Singleton Vertex Cesarean Delivery Rate. Jt Comm J Qual Patient Saf. 2017 Feb;43(2):53-61.

Beth Israel Case Study: interventions

• 1. Fetal heart tracing interpretation

a. Adoption of standard FHT category system, and chart audits to ensure use b. Removed “failure to perform cesarean for NRFHT” as a quality measure for peer review

• 2. Tolerance of labor

a. Education on modern labor curve b. Mandatory annual drills for shoulder dystocia, operative vaginal delivery c. Adoption of NIH consensus statement on VBAC Vadnais MA et al. Quality Improvement Initiatives Lead to Reduction in Nulliparous Term Singleton Vertex Cesarean Delivery Rate. Jt Comm J Qual Patient Saf. 2017 Feb;43(2):53-61.

Beth Israel Case Study: interventions

• 3. Induction of labor

a. Hard stop on elective IOL prior to 39wk, then b. Limits on IOL prior to 41wk, then c. Prohibition of non-medically indicated IOL prior to 41wk d. Guidelines on cervical ripening

• 4. Environmental stress

a. Improved scheduling of repeat cesareans b. STAT cesarean drills c. Guidelines on patient support in labor

• 5. Provider awareness

a. Audits & feedback on NTSV cesarean rates Vadnais MA et al. Quality Improvement Initiatives Lead to Reduction in Nulliparous Term Singleton Vertex Cesarean Delivery Rate. Jt Comm J Qual Patient Saf. 2017 Feb;43(2):53-61.

Beth Israel Case Study: Results

Vadnais MA et al. Quality Improvement Initiatives Lead to Reduction in Nulliparous Term Singleton Vertex Cesarean Delivery Rate. Jt Comm J Qual Patient Saf. 2017 Feb;43(2):53-61.

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Beth Israel Case Study: Results

Vadnais MA et al. Quality Improvement Initiatives Lead to Reduction in Nulliparous Term Singleton Vertex Cesarean Delivery Rate. Jt Comm J Qual Patient Saf. 2017 Feb;43(2):53-61.

• Decline in

○ NTSV cesarean rate--steady & impressive over 7 years ○ Total cesarean rate (40% to 29%) ○ Episiotomy rate ○ 3rd degree lacerations

• No change in

○ 5 minute APGAR score < 5 ○ NICU admission > 24h ○ Shoulder dystocia ○ 4th degree lacerations

• Increase in

○ Maternal transfusion (1.4% at its highest in 2015--but no trend over the study time) ○ Meconium aspiration (to 0.9 in 2015; still lower than national average)

So much else to talk about . . . Conclusions

• Incredible variation in US hospital

c-section rates is alarming & reassuring

• Reduction in primary cesareans is

safe & feasible

• Excellent national & state

resources exist for those hoping to reduce the rate of unnecessary cesareans and improve quality & value of maternity care

Links to key resources

Safe Prevention of the Primary Cesarean Delivery: https://www.acog.org/Clinical-Guidance-and-Publications/Obstetric- Care-Consensus-Series/Safe-Prevention-of-the-Primary-Cesarean-Delivery CMQCC QI Initiative: Promoting Vaginal Birth https://www.cmqcc.org/qi-initiatives/promoting-vaginal-birth Pacific Health Business Group: Transform maternity care: http://www.pbgh.org/maternity Smart Care California: C-sections https://www.iha.org/our-work/insights/smart-care-california/focus-area-c-sections Comparison of California hospital cesarean rates: http://calhospitalcompare.org/ Consumer Reports: https://www.consumerreports.org/c-section/cut-your-odds-of-having-an-unnecessary-c-section/ WHO Statement C-Section: http://www.who.int/reproductivehealth/publications/maternal_perinatal_health/cs-statement/en/