Updating quality indicators for low-risk labour care in Japan using current clinical practice guidelines: a modified Delphi method.

OBJECTIVES: Quality indicators are measurable elements widely used to assess the quality of care. They are often developed from the results of systematic reviews or clinical practice guidelines. These sources are regularly updated in line with new clinical evidence, but there are few articles on updating quality indicators based on clinical practice guidelines. This study aimed to update the quality indicators developed for low-risk labour care in Japan in 2012, mainly drawing on new or updated clinical practice guidelines, and making the process clearly visible and assessable. DESIGN AND SETTING: We used a modified Delphi method for the update. The procedure included four steps: (1) updating the definition of low-risk labour; (2) reviewing the literature published between June 2012 and December 2015 using five guidelines and two quality indicator databases to extract potential candidate indicators; (3) formation of a multidisciplinary panel including mothers and (4) panel ratings (two rounds between February and April 2016) on the validity of the candidate indicators, and judging the validity of the previous quality indicators drawing on the new evidence. PARTICIPANTS: A multidisciplinary panel of 13 clinicians, including obstetricians, paediatricians and midwives, plus 3 non-clinician mothers. RESULTS: The literature review identified 276 new recommendations from 27 clinical practice guidelines including 2 published in Japan and 21 quality indicators. We developed 13 new candidate indicators from these sources and panel recommendations, 12 of which were approved by the multidisciplinary panel. The panel also accepted all 23 existing quality indicators as still valid, resulting in a total of 35 quality indicators for low-risk labour. CONCLUSIONS: We successfully updated the quality indicators for low-risk labour care in Japan. The procedure developed may be useful for updating other quality indicators based on new clinical practice guidelines.

Development of quality indicators for low-risk labor care provided by midwives using a RAND-modified Delphi method.

BACKGROUND: In childbirth, most deliveries are low-risk, defined as spontaneous labor at full term without special high-risk facts or complications, especially in high-resource countries where maternal and perinatal mortality rates are very low. Indeed, the majority of mothers and infants have no serious conditions during labor. However, the quality of care provided is not assured, and performance may vary by birthing facility and provider. The overuse of technology in childbirth in some parts of the world is almost certainly based on assumptions like, "something can go wrong at any minute." There is a need to assess the quality of care provided for mothers and infants in low-risk labor. We aimed to develop specific quality indicators for low-risk labor care provided primarily by midwives in Japan. METHODS: We used a RAND-modified Delphi method, which integrates evidence review with expert consensus development. The procedure comprises five steps: (1) literature review, including clinical practice guidelines, to extract and develop quality indicator candidates; (2) formation of a multidisciplinary panel; (3) independent panel ratings (Round 1); (4) panel meeting and independent panel ratings (Round 2); and (5) independent panel ratings (Round 3). The three independent panel ratings (Rounds 1-3) were held between July and December 2012. RESULTS: The assembled multidisciplinary panel comprised eight clinicians (two pediatricians, three obstetricians, and three midwives) and three mothers who were nonclinicians. Evidentiary review extracted 166 key recommendations from 32 clinical practice guidelines, and 31 existing quality indicators were added. After excluding duplicate recommendations and quality indicators, the panel discussed 25 candidate indicators. Of these, 18 were adopted, one was modified, six were not adopted, and four were added during the meeting, respectively. CONCLUSIONS: We established 23 quality indicators for low-risk labor care provided by midwives in labor units in Japan.

Progression of cervical dilatation in normal human labor is unpredictable.

INTRODUCTION: The aim of this study was to analyze how the progression of cervical dilatation in active labor can be predicted by digital assessment in low-risk pregnant women, in spontaneous labor at term. MATERIAL AND METHODS: This prospective observational study was performed on 328 women with singleton term gestations experiencing midwife-led labor according to local protocols, progressing to full dilatation and spontaneous delivery without any medical intervention. Mixed nonlinear models were adopted to (i) model individual cervical data into centile curves and (ii) calculate the time needed to gain 1 cm in cervical dilatation (TNG1cm ) modeled as a function of current dilatation. We correlated the first and the last TNG1cm on parturients with at least four cervical data points. RESULTS: TNG1cm showed large variations, both before and after 6 cm. This variability of natural progression of cervical curves described by the 10th and 90th centiles exceeded the differences observed in published curves from cohorts homogeneous for parity, weight and ethnicity. There was no significant correlation between the first and the last TNG1cm . Neonatal base excess was not significantly different in women with TNG1cm <10th centile and >90th centile. CONCLUSIONS: The rate of cervical dilatation, traced by parsimonious nonlinear mixed models, is largely unpredictable in the case of spontaneous naturally progressing labor, even when possible larger individual variability is excluded by prudent clinical rules. Future research in labor and delivery should be focused on the diagnosis of the causes that lie behind apparently erratic cervical changes.

Cost-Effectiveness Analysis of Latent versus Active Labor Hospital Admission for Medically Low-Risk, Term Women.

OBJECTIVE: To assess the outcomes and costs of hospital admission during the latent versus active phase of labor. Latent labor hospital admission has been consistently associated with elevated maternal risk for increased interventions, including epidural anesthesia and cesarean delivery, longer hospital stay, and higher utilization of hospital resources. METHODS: A cost-effectiveness model was built to simulate a theoretic cohort of 3.2 million term, medically low-risk women either being admitted in latent labor (< 4 cm dilation) or delaying admission until active labor (≥ 4 cm dilation). Outcomes included epidural use, mode of delivery, stillbirth, maternal death, and costs of care. All probability, cost, and utility estimates were derived from the literature, and total quality-adjusted life years were calculated. Sensitivity analyses and a Monte Carlo simulation were used to investigate the robustness of model assumptions. RESULTS: Delaying admission until active labor would result in 672,000 fewer epidurals, 67,232 fewer cesarean deliveries, and 9.6 fewer maternal deaths in our theoretic cohort as compared to admission during latent labor. Additionally, delaying admission results in a cost savings of $694 million annually in the United States. Sensitivity analyses indicated the model was robust within a wide range of probabilities and costs. Monte Carlo simulation found that delayed admission was the optimal strategy in 76.79 percent of trials. CONCLUSION: Delaying admission until active labor is a dominant strategy, resulting in both better outcomes and lower costs. Issues related to clinical translation of these findings are explored.