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St. Joseph Hospital in Orange, California, like most institutions performing deliveries in 2016, started releasing metrics internally before subsequently releasing them to the public. Data for the first 9 months of 2016 were released. As I am often an outlier, I was gratified to see that I ranked 1st in the vaginal birth after cesarean delivery (VBAC) rate at 36.8% and 4th at 15.9% for my cesarean delivery (CD) rate in the low-risk nulliparous term singleton vertex (NTSV) population.
I have been an avid proponent of VBAC since 1984 when one of the fathers of modern obstetric care, Edward J. Quilligan, MD, presented the benefits and safety of VBAC at our institution.
Experiences that may alter a reported rate
I list here a few circumstances of a CD on maternal request:
- A primagravida with a 10-cm nonphysiologic, nonmalignant ovarian cyst at term elects a primary CD with ovarian cystectomy.
- A woman who is concerned about pelvic organ prolapse and urinary incontinence later in life requests a CD. After all, normal babies do not weigh 5 and 6 lb anymore.
- An elderly primagravida with an in vitro fertilization pregnancy requests a CD.
Should these experiences adversely affect a physician’s statistics? Personally, I don’t think so. Is the morbidity and mortality from a CD really all that much higher than a normal spontaneous vaginal delivery (NSVD)? Granted, the cost is more. But are we really helping all our patients by insisting on a NSVD? Thousands of people have medically indicated and elective surgery in the United States each day.
Of course, these data points depend on the denominator (the number of deliveries attributed to each ObGyn). Those with a contradictory opinion will say that this evens out over time. I dispute that claim. This might be closer to being true for the ObGyn with the highest number, say, 134 in the NTSV denominator versus someone with a low number, such as 4. For VBAC, the denominator range at our institution was 1 to 115 cases.
Rethinking my position
Two recent cases have caused me to rethink my position on using VBAC and CD rates to evaluate ObGyns.
Uterine rupture
A 31-year-old G3P1 woman at 39 6/7 weeks’ gestation was admitted in early labor for a VBAC. She had undergone a CD with her first baby because of fetal intolerance to labor. Her prenatal course was complicated by white-coat hypertension, but I monitored her blood pressure at home and it had been normal. She took aspirin 81 mg during the pregnancy. The fetus was not reactive to a nonstress test on the day of admission.
That evening, amniotomy results showed clear fluid. I placed an intrauterine pressure catheter. The patient’s labor progressed well during the night, she received an epidural anesthetic, and labor was augmented with intravenous oxytocin. She progressed to complete dilation. I was notified of severe, prolonged, variable fetal heart-rate decelerations.
The Laborist who evaluated the patient recommended an emergency CD. I came immediately to Labor and Delivery and performed a CD with delivery of a 7 lb 4 oz infant whose Apgars were 2, 5, and 8 at 1, 5, and 10 minutes, respectively. Arterial cord blood gas tests revealed: pH, 6.94; pCO2, 95 mm Hg; pO2, 19.9 mm Hg; HCO3, 19.9 mmol/L; and base excess (BE), –14.4 mmol/L. Venous cord blood gas tests revealed: pH, 7.25; pCO2, 45 mm Hg; pO2, 35 mm Hg; HCO3, 19.2 mmol/L; BE, −8.0 mmol/L. The cord blood gases revealed that the baby was becoming compromised, but was delivered in time to avoid complications.
After advocating and performing many successful VBACs for 33 years, this was my first uterine rupture.
The uterus had ruptured in the lower segment from the mid-portion extending inferolaterally on the right side and was hemorrhaging. I successfully repaired the rupture. Maternal quantitative blood loss was 1,020 mL.
The baby initially was apneic and was limp. He required continuous positive airway pressure (CPAP) and positive pressure ventilation in the operating room. The baby was transferred to the neonatal intensive care unit (NICU), recovered well, and was discharged home with the mother on the 4th day of life.
Commentary: Why should this necessary, emergency CD count against me on my core measure rate? Although I have advocated for VBACs for 33 years, perhaps they aren’t so safe. After this experience, I do not ever want to have to deal with a ruptured uterus, a compromised baby, and maternal hemorrhage again.
Read Dr. Kanofsky’s solution to using this metric.
Depressed baby
A 24-year-old G1P0 woman at 39 weeks’ gestation was admitted for induction of labor because of mild pregnancy-induced hypertension. Her prenatal course was complicated by Class A1 gestational diabetes mellitus, which was untreated due to compliance issues, Group B streptococcus, and cholelithiasis. Clinically, I suspected she was going to have a large (9 lb) baby. An ultrasound to estimate fetal weight at 37 2/7 weeks’ gestation showed the fetus at 3.937 kg. I was concerned, but, because the mother was 5 ft 5 in tall and weighed 282 lbs, I thought it was reasonable for her to attempt a NSVD.
Induction and labor progressed normally. Her labor curve decelerated at an anterior lip, but subsequently stage 2 progressed normally and lasted 2 hrs. Her temperature was elevated in stage 2 to 100.00F. The fetal heart rate tracings were reassuring.
Immediately after delivery of the fetal vertex, a turtleneck sign was seen and shoulder dystocia occurred. A Wood’s maneuver was performed in both directions, the nurse applied suprapubic pressure, and the infant was delivered. A loose nuchal cord x2 was reduced. The infant was apneic and had no tone. She was taken to the warmer, given oxygen, suctioned, and stimulated until the NICU team arrived. Her Apgar scores were 2, 5, and 9 at 1, 5, and 10 minutes, respectively. The birthweight was 9 lb 0 oz.
A depressed baby of this magnitude was certainly not expected from the FHR tracing or the shoulder dystocia. Venous cord gas evaluation revealed pH, 7.16; pCO2, 57 mm Hg; pO2, 17 mm Hg; HCO3, 20.2 mmol/L; and BE, –19.1 mmol/L.
The baby recovered quickly in the labor and delivery recovery room, went to the NICU on CPAP, subsequently transitioned to room air, and was discharged on the 4th day of life with her mother.
Commentary: Did I do the best I could for this mother and baby? In hindsight, I should have performed a CD because of my concerns for a large fetus. The “retrospectoscope” always makes cases more clear! Note that, if I had performed an elective CD for fetal macrosomia, it would have counted against me on this metric. Prior to labor, if I thought an elective CD was the right approach to this patient, and was providing the best care I could for this mother and fetus, why should it count against me?
Is there a solution?
With my newfound concerns, it is my opinion that VBAC and CD/NTSV rates may not be the correct things to use as quality metric measures without some additional qualifying information.
Better metrics of quality and safety that might be more helpful to measure include:
- Prophylactic oxytocin after delivery of the baby’s anterior shoulder
- Since “6 is the new 4,” in order to increase the NTSV rate, we could measure1:
- patients admitted before active labor
- patients receiving an epidural before active labor.
- Since NTSV is a goal, measure the number of patients in an advanced stage of labor whose labor pattern has become dysfunctional, no interventions are taken, and who subsequently deliver by primary CD.
Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.
- Committee on Obstetric Practice, American College of Obstetricians and Gynecologists. Committee Opinion No. 687: Approaches to limit intervention during labor and birth. Obstet Gynecol. 2017;129(2):e20–e28.
Dr. Kanofsky is in private ObGyn practice in Orange, California. He is a member of the Perinatal Safety Work Group and the Perinatal Collaborative Committee at St. Joseph Hospital, Orange, and is Chairman, Division of Gynecology, Department of Surgery, at CHOC Children’s Hospital of Orange County.
The author reports that he is a consultant to the St. Joseph Hospital Clinical Information Systems Project.
Dr. Kanofsky is in private ObGyn practice in Orange, California. He is a member of the Perinatal Safety Work Group and the Perinatal Collaborative Committee at St. Joseph Hospital, Orange, and is Chairman, Division of Gynecology, Department of Surgery, at CHOC Children’s Hospital of Orange County.
The author reports that he is a consultant to the St. Joseph Hospital Clinical Information Systems Project.
Dr. Kanofsky is in private ObGyn practice in Orange, California. He is a member of the Perinatal Safety Work Group and the Perinatal Collaborative Committee at St. Joseph Hospital, Orange, and is Chairman, Division of Gynecology, Department of Surgery, at CHOC Children’s Hospital of Orange County.
The author reports that he is a consultant to the St. Joseph Hospital Clinical Information Systems Project.
St. Joseph Hospital in Orange, California, like most institutions performing deliveries in 2016, started releasing metrics internally before subsequently releasing them to the public. Data for the first 9 months of 2016 were released. As I am often an outlier, I was gratified to see that I ranked 1st in the vaginal birth after cesarean delivery (VBAC) rate at 36.8% and 4th at 15.9% for my cesarean delivery (CD) rate in the low-risk nulliparous term singleton vertex (NTSV) population.
I have been an avid proponent of VBAC since 1984 when one of the fathers of modern obstetric care, Edward J. Quilligan, MD, presented the benefits and safety of VBAC at our institution.
Experiences that may alter a reported rate
I list here a few circumstances of a CD on maternal request:
- A primagravida with a 10-cm nonphysiologic, nonmalignant ovarian cyst at term elects a primary CD with ovarian cystectomy.
- A woman who is concerned about pelvic organ prolapse and urinary incontinence later in life requests a CD. After all, normal babies do not weigh 5 and 6 lb anymore.
- An elderly primagravida with an in vitro fertilization pregnancy requests a CD.
Should these experiences adversely affect a physician’s statistics? Personally, I don’t think so. Is the morbidity and mortality from a CD really all that much higher than a normal spontaneous vaginal delivery (NSVD)? Granted, the cost is more. But are we really helping all our patients by insisting on a NSVD? Thousands of people have medically indicated and elective surgery in the United States each day.
Of course, these data points depend on the denominator (the number of deliveries attributed to each ObGyn). Those with a contradictory opinion will say that this evens out over time. I dispute that claim. This might be closer to being true for the ObGyn with the highest number, say, 134 in the NTSV denominator versus someone with a low number, such as 4. For VBAC, the denominator range at our institution was 1 to 115 cases.
Rethinking my position
Two recent cases have caused me to rethink my position on using VBAC and CD rates to evaluate ObGyns.
Uterine rupture
A 31-year-old G3P1 woman at 39 6/7 weeks’ gestation was admitted in early labor for a VBAC. She had undergone a CD with her first baby because of fetal intolerance to labor. Her prenatal course was complicated by white-coat hypertension, but I monitored her blood pressure at home and it had been normal. She took aspirin 81 mg during the pregnancy. The fetus was not reactive to a nonstress test on the day of admission.
That evening, amniotomy results showed clear fluid. I placed an intrauterine pressure catheter. The patient’s labor progressed well during the night, she received an epidural anesthetic, and labor was augmented with intravenous oxytocin. She progressed to complete dilation. I was notified of severe, prolonged, variable fetal heart-rate decelerations.
The Laborist who evaluated the patient recommended an emergency CD. I came immediately to Labor and Delivery and performed a CD with delivery of a 7 lb 4 oz infant whose Apgars were 2, 5, and 8 at 1, 5, and 10 minutes, respectively. Arterial cord blood gas tests revealed: pH, 6.94; pCO2, 95 mm Hg; pO2, 19.9 mm Hg; HCO3, 19.9 mmol/L; and base excess (BE), –14.4 mmol/L. Venous cord blood gas tests revealed: pH, 7.25; pCO2, 45 mm Hg; pO2, 35 mm Hg; HCO3, 19.2 mmol/L; BE, −8.0 mmol/L. The cord blood gases revealed that the baby was becoming compromised, but was delivered in time to avoid complications.
After advocating and performing many successful VBACs for 33 years, this was my first uterine rupture.
The uterus had ruptured in the lower segment from the mid-portion extending inferolaterally on the right side and was hemorrhaging. I successfully repaired the rupture. Maternal quantitative blood loss was 1,020 mL.
The baby initially was apneic and was limp. He required continuous positive airway pressure (CPAP) and positive pressure ventilation in the operating room. The baby was transferred to the neonatal intensive care unit (NICU), recovered well, and was discharged home with the mother on the 4th day of life.
Commentary: Why should this necessary, emergency CD count against me on my core measure rate? Although I have advocated for VBACs for 33 years, perhaps they aren’t so safe. After this experience, I do not ever want to have to deal with a ruptured uterus, a compromised baby, and maternal hemorrhage again.
Read Dr. Kanofsky’s solution to using this metric.
Depressed baby
A 24-year-old G1P0 woman at 39 weeks’ gestation was admitted for induction of labor because of mild pregnancy-induced hypertension. Her prenatal course was complicated by Class A1 gestational diabetes mellitus, which was untreated due to compliance issues, Group B streptococcus, and cholelithiasis. Clinically, I suspected she was going to have a large (9 lb) baby. An ultrasound to estimate fetal weight at 37 2/7 weeks’ gestation showed the fetus at 3.937 kg. I was concerned, but, because the mother was 5 ft 5 in tall and weighed 282 lbs, I thought it was reasonable for her to attempt a NSVD.
Induction and labor progressed normally. Her labor curve decelerated at an anterior lip, but subsequently stage 2 progressed normally and lasted 2 hrs. Her temperature was elevated in stage 2 to 100.00F. The fetal heart rate tracings were reassuring.
Immediately after delivery of the fetal vertex, a turtleneck sign was seen and shoulder dystocia occurred. A Wood’s maneuver was performed in both directions, the nurse applied suprapubic pressure, and the infant was delivered. A loose nuchal cord x2 was reduced. The infant was apneic and had no tone. She was taken to the warmer, given oxygen, suctioned, and stimulated until the NICU team arrived. Her Apgar scores were 2, 5, and 9 at 1, 5, and 10 minutes, respectively. The birthweight was 9 lb 0 oz.
A depressed baby of this magnitude was certainly not expected from the FHR tracing or the shoulder dystocia. Venous cord gas evaluation revealed pH, 7.16; pCO2, 57 mm Hg; pO2, 17 mm Hg; HCO3, 20.2 mmol/L; and BE, –19.1 mmol/L.
The baby recovered quickly in the labor and delivery recovery room, went to the NICU on CPAP, subsequently transitioned to room air, and was discharged on the 4th day of life with her mother.
Commentary: Did I do the best I could for this mother and baby? In hindsight, I should have performed a CD because of my concerns for a large fetus. The “retrospectoscope” always makes cases more clear! Note that, if I had performed an elective CD for fetal macrosomia, it would have counted against me on this metric. Prior to labor, if I thought an elective CD was the right approach to this patient, and was providing the best care I could for this mother and fetus, why should it count against me?
Is there a solution?
With my newfound concerns, it is my opinion that VBAC and CD/NTSV rates may not be the correct things to use as quality metric measures without some additional qualifying information.
Better metrics of quality and safety that might be more helpful to measure include:
- Prophylactic oxytocin after delivery of the baby’s anterior shoulder
- Since “6 is the new 4,” in order to increase the NTSV rate, we could measure1:
- patients admitted before active labor
- patients receiving an epidural before active labor.
- Since NTSV is a goal, measure the number of patients in an advanced stage of labor whose labor pattern has become dysfunctional, no interventions are taken, and who subsequently deliver by primary CD.
Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.
St. Joseph Hospital in Orange, California, like most institutions performing deliveries in 2016, started releasing metrics internally before subsequently releasing them to the public. Data for the first 9 months of 2016 were released. As I am often an outlier, I was gratified to see that I ranked 1st in the vaginal birth after cesarean delivery (VBAC) rate at 36.8% and 4th at 15.9% for my cesarean delivery (CD) rate in the low-risk nulliparous term singleton vertex (NTSV) population.
I have been an avid proponent of VBAC since 1984 when one of the fathers of modern obstetric care, Edward J. Quilligan, MD, presented the benefits and safety of VBAC at our institution.
Experiences that may alter a reported rate
I list here a few circumstances of a CD on maternal request:
- A primagravida with a 10-cm nonphysiologic, nonmalignant ovarian cyst at term elects a primary CD with ovarian cystectomy.
- A woman who is concerned about pelvic organ prolapse and urinary incontinence later in life requests a CD. After all, normal babies do not weigh 5 and 6 lb anymore.
- An elderly primagravida with an in vitro fertilization pregnancy requests a CD.
Should these experiences adversely affect a physician’s statistics? Personally, I don’t think so. Is the morbidity and mortality from a CD really all that much higher than a normal spontaneous vaginal delivery (NSVD)? Granted, the cost is more. But are we really helping all our patients by insisting on a NSVD? Thousands of people have medically indicated and elective surgery in the United States each day.
Of course, these data points depend on the denominator (the number of deliveries attributed to each ObGyn). Those with a contradictory opinion will say that this evens out over time. I dispute that claim. This might be closer to being true for the ObGyn with the highest number, say, 134 in the NTSV denominator versus someone with a low number, such as 4. For VBAC, the denominator range at our institution was 1 to 115 cases.
Rethinking my position
Two recent cases have caused me to rethink my position on using VBAC and CD rates to evaluate ObGyns.
Uterine rupture
A 31-year-old G3P1 woman at 39 6/7 weeks’ gestation was admitted in early labor for a VBAC. She had undergone a CD with her first baby because of fetal intolerance to labor. Her prenatal course was complicated by white-coat hypertension, but I monitored her blood pressure at home and it had been normal. She took aspirin 81 mg during the pregnancy. The fetus was not reactive to a nonstress test on the day of admission.
That evening, amniotomy results showed clear fluid. I placed an intrauterine pressure catheter. The patient’s labor progressed well during the night, she received an epidural anesthetic, and labor was augmented with intravenous oxytocin. She progressed to complete dilation. I was notified of severe, prolonged, variable fetal heart-rate decelerations.
The Laborist who evaluated the patient recommended an emergency CD. I came immediately to Labor and Delivery and performed a CD with delivery of a 7 lb 4 oz infant whose Apgars were 2, 5, and 8 at 1, 5, and 10 minutes, respectively. Arterial cord blood gas tests revealed: pH, 6.94; pCO2, 95 mm Hg; pO2, 19.9 mm Hg; HCO3, 19.9 mmol/L; and base excess (BE), –14.4 mmol/L. Venous cord blood gas tests revealed: pH, 7.25; pCO2, 45 mm Hg; pO2, 35 mm Hg; HCO3, 19.2 mmol/L; BE, −8.0 mmol/L. The cord blood gases revealed that the baby was becoming compromised, but was delivered in time to avoid complications.
After advocating and performing many successful VBACs for 33 years, this was my first uterine rupture.
The uterus had ruptured in the lower segment from the mid-portion extending inferolaterally on the right side and was hemorrhaging. I successfully repaired the rupture. Maternal quantitative blood loss was 1,020 mL.
The baby initially was apneic and was limp. He required continuous positive airway pressure (CPAP) and positive pressure ventilation in the operating room. The baby was transferred to the neonatal intensive care unit (NICU), recovered well, and was discharged home with the mother on the 4th day of life.
Commentary: Why should this necessary, emergency CD count against me on my core measure rate? Although I have advocated for VBACs for 33 years, perhaps they aren’t so safe. After this experience, I do not ever want to have to deal with a ruptured uterus, a compromised baby, and maternal hemorrhage again.
Read Dr. Kanofsky’s solution to using this metric.
Depressed baby
A 24-year-old G1P0 woman at 39 weeks’ gestation was admitted for induction of labor because of mild pregnancy-induced hypertension. Her prenatal course was complicated by Class A1 gestational diabetes mellitus, which was untreated due to compliance issues, Group B streptococcus, and cholelithiasis. Clinically, I suspected she was going to have a large (9 lb) baby. An ultrasound to estimate fetal weight at 37 2/7 weeks’ gestation showed the fetus at 3.937 kg. I was concerned, but, because the mother was 5 ft 5 in tall and weighed 282 lbs, I thought it was reasonable for her to attempt a NSVD.
Induction and labor progressed normally. Her labor curve decelerated at an anterior lip, but subsequently stage 2 progressed normally and lasted 2 hrs. Her temperature was elevated in stage 2 to 100.00F. The fetal heart rate tracings were reassuring.
Immediately after delivery of the fetal vertex, a turtleneck sign was seen and shoulder dystocia occurred. A Wood’s maneuver was performed in both directions, the nurse applied suprapubic pressure, and the infant was delivered. A loose nuchal cord x2 was reduced. The infant was apneic and had no tone. She was taken to the warmer, given oxygen, suctioned, and stimulated until the NICU team arrived. Her Apgar scores were 2, 5, and 9 at 1, 5, and 10 minutes, respectively. The birthweight was 9 lb 0 oz.
A depressed baby of this magnitude was certainly not expected from the FHR tracing or the shoulder dystocia. Venous cord gas evaluation revealed pH, 7.16; pCO2, 57 mm Hg; pO2, 17 mm Hg; HCO3, 20.2 mmol/L; and BE, –19.1 mmol/L.
The baby recovered quickly in the labor and delivery recovery room, went to the NICU on CPAP, subsequently transitioned to room air, and was discharged on the 4th day of life with her mother.
Commentary: Did I do the best I could for this mother and baby? In hindsight, I should have performed a CD because of my concerns for a large fetus. The “retrospectoscope” always makes cases more clear! Note that, if I had performed an elective CD for fetal macrosomia, it would have counted against me on this metric. Prior to labor, if I thought an elective CD was the right approach to this patient, and was providing the best care I could for this mother and fetus, why should it count against me?
Is there a solution?
With my newfound concerns, it is my opinion that VBAC and CD/NTSV rates may not be the correct things to use as quality metric measures without some additional qualifying information.
Better metrics of quality and safety that might be more helpful to measure include:
- Prophylactic oxytocin after delivery of the baby’s anterior shoulder
- Since “6 is the new 4,” in order to increase the NTSV rate, we could measure1:
- patients admitted before active labor
- patients receiving an epidural before active labor.
- Since NTSV is a goal, measure the number of patients in an advanced stage of labor whose labor pattern has become dysfunctional, no interventions are taken, and who subsequently deliver by primary CD.
Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.
- Committee on Obstetric Practice, American College of Obstetricians and Gynecologists. Committee Opinion No. 687: Approaches to limit intervention during labor and birth. Obstet Gynecol. 2017;129(2):e20–e28.
- Committee on Obstetric Practice, American College of Obstetricians and Gynecologists. Committee Opinion No. 687: Approaches to limit intervention during labor and birth. Obstet Gynecol. 2017;129(2):e20–e28.