Risk of cesarean delivery in ongoing pregnancies of nulliparous women after 37 weeks of gestation: a prospective cohort study

Objective: To study the risk of CD for each gestational week among ongoing pregnancies of nulliparous women at term. Design: A retrospective, population-based cohort study from January 1, 2016, through December 31, 2017 Setting: a French perinatal network of the Yvelines district, France Population: 11 308 nulliparous women with a singleton fetus in a cephalic presentation and delivered at term (≥37-week +0 day) Methods: for each week of gestation at term, we defined ongoing pregnancies as all pregnancies undelivered at the start of each week. Regression models adjusted by maternal characteristics and hospital status were used to compare the CD risk between ongoing pregnancies and the pregnancies delivered the preceding week. The same methods were applied to subgroups defined by the mode of labor onset. Main outcome measure: The caesarean delivery rate (CD) Results: Ongoing pregnancies > 40 weeks+0 days were associated with a higher risk of CD compared with pregnancies delivered the previous week: 24.3% in ongoing pregnancies ≥ 40 weeks +0 days versus 19.9% in deliveries between 39 weeks +0 days and 39 weeks+6 days (Odd ratio adjusted of 1.28, 95%CI [1.15-1.44]; 30.4% in ongoing pregnancies ≥ 41 weeks +0 days versus 19.6% in deliveries between 40 weeks +0 days and 40 weeks+6 days (OR 1.73, 95%CI [1.51-1.96]). This was also shown for all modes of labor onset and in every maternity unit. Conclusions: CD rates increased starting at 40 weeks +0 days in ongoing pregnancies, regardless of the mode of labor onset.

Caesarean delivery rate changes after audit and feedback with the Ten Group Classification System in a French perinatal network: a retrospective pre–post study

Objective : To study changes in caesarean delivery (CD) rates between maternity wards in a perinatal network after implementation of the Ten Group Classification System (TGCS) in an audit with feedback. Design A retrospective pre–post study of all births from 1 January 2012 to 31 December 2018. Setting A French perinatal network of 10 maternity wards in the Yvelines district of France. Population All live births of gestational age ≥24 weeks in the network. Methods During the pre-period (1 January 2012 to 31 December 2014), the audit and feedback provided only overall CD rates. During the post-period (1 January 2015 to 31 December 2018), CD rates for each TGCS group were provided. Regression models, adjusted for maternal characteristics and maternity ward, were used to compare CD rates globally and for each TGCS group. Variability of CD rates between maternity wards was analysed using the coefficients of variation. Main outcome measure CD rates. Results There were 51 082 women who delivered during the pre-period and 63 964 during the post-period. The overall CD rate did not decrease (24.5% during the pre-period versus 25.1% during the post-period). There were no significant differences in CD rates for any TGCS group after adjustment for maternity, maternal age and socio-demographic characteristics. Nor did audit implementation decrease CD rate variability between maternity wards or within TGCS groups. Conclusion Implementation of an audit-and-feedback cycle using the TGCS did not decrease either CD rates or variability between maternity wards.

Variation between hospital caesarean delivery rates when Robson’s classification is considered: An observational study from a French perinatal network

Introduction WHO has recommended using Robson’s Ten Group Classification System (TGCS) to monitor and analyze CD rates. Its failure to take some maternal and organizational factors into account, however, could limit the interpretation of CD rate comparisons, because it may contribute to variations in hospital CD rates. Objective To study the contribution of maternal socioeconomic and clinical characteristics and hospital organizational factors to the variation in CD rates when using Robson’s ten-group classification system for CD rate comparisons. Methods This prospective, observational, population-based study included all deliveries at a gestational age > 24 weeks at the 10 hospitals of the French MYPA perinatal network in the Paris area. CD rates were calculated for each TGCS group in each hospital. Interhospital variations in these rates were investigated with hierarchical logistic regression models to quantify the variation explained by differences in patient and hospital characteristics when the TGCS is considered. Variations in CD rates between hospitals were estimated with median odds ratios (MOR) to express interhospital variance on the standard odds ratio scale. The percentage of variation explained by TGCS and maternal and hospital characteristics was also calculated. Results The global CD rate was 24.0% (interhospital range: 17–32%). CD rates within each TGCS group differed significantly between hospitals (P<0.001). CD was significantly associated with maternal age (>40 years), severe preeclampsia, and two organizational factors: hospital status (private maternities) and the deliveries per staff member per 24 hours. The MOR in the empty model was 1.27 and did not change after taking the TGCS into account. Adding maternal characteristics and hospital organizational factors lowered the MOR to 1.14 and reduced the variation between hospital CD rates by 70%. Conclusion Maternal characteristics and hospital factors are needed to address variation in CD rates among the TGCS groups. Therefore, comparisons of these rates that do not consider these factors should be interpreted carefully.

Disaster Medical Management of Pediatric and Perinatal Disaster Medical Liaison (PPDML) for Children and Pregnant Women in Osaka, Japan

Introduction:Children are a vulnerable population in disasters. However, there were few pediatricians, neonatologists, and obstetricians in the Japan Disaster Medical Assistance Team (DMAT), so disaster medical headquarters had limited knowledge to solve these problems. Pediatric and perinatal disaster liaison coordinators were trained to improve disaster medical management for children and pregnant women since the 2016 Kumamoto earthquake.Aim:To analyze and report the activity of PPDML during these years in Osaka, Japan.Methods:The records of PPDML in major disasters and disaster drills from 2017 to 2018 were reviewed.Results:The DMAT had disaster drills twice a year in Osaka, and PPDML participated in the drill for the first time in July 2017. In the drill, PPDML coordinated the pediatric and perinatal issues with DMAT and Japan Ground Self-Defense Force (JGSDF) in disaster headquarters. In June 20184. months after the drill, PPDML participated for the second time in February 2018 when the North Osaka Earthquake occurred. PPDML coordinated transport of 22 children and babies with congenital heart disease from the damaged National Cerebral and Cardiovascular Center Hospital. The operation was finished within 5 hours after requested transportation.Discussion:To protect children and pregnant women, cooperation between the disaster medical network and the pediatric and perinatal network is absolutely important for any phase in disaster. Because PPDML had attended in disaster drills before, the experience could make PPDML achieve good performance in a real disaster in North Osaka Earthquake. It can be concluded that cooperation between disaster medical network and PPDML is very useful to manage the disaster issues for children and pregnant women, and the most important thing is to cooperate not only in disaster but also in ordinary days.