Restricted episiotomy use and maternal and neonatal injuries: a retrospective cohort study.

PURPOSE: There is relatively little information on episiotomies in the context of restricted episiotomy use. This study sought to examine maternal and neonatal injuries with restricted episiotomy use. METHODS: We performed a retrospective database analysis of vaginal deliveries at a tertiary care maternity hospital from June 2010 to June 2015. Maternal injuries (third- or fourth-degree lacerations) and neonatal injuries (birth trauma) were identified through the International Classification of Diseases, Ninth Revision, codes. Vaginal deliveries were classified as spontaneous, vacuum-assisted, or forceps-assisted. The associations between episiotomy and maternal and neonatal injuries were examined with stratification by parity, type of vaginal delivery, and type of episiotomy (midline or mediolateral). Adjusted-odds' ratios were calculated for maternal and neonatal injuries using a multiple logistic regression model to adjust for potential confounders. RESULTS: 22,800 deliveries occurred during the study interval involving 23,016 neonates. The episiotomy rate was 6.7 % overall and 22.9 % in operative vaginal deliveries. Episiotomies, both midline and mediolateral, were associated with increased risks of maternal and neonatal injuries regardless of parity (p < 0.0001). Upon stratification by the type of delivery, the association with maternal injury remained only for spontaneous vaginal deliveries (p < 0.0001). Adjusted-odds' ratios demonstrated a continued association between episiotomy and maternal [aOR 1.67 (1.39-2.05)] and neonatal injuries [aOR 1.43 (1.17-1.73)]. CONCLUSION: Episiotomy continues to be associated with increased third- and fourth-degree lacerations with restricted use, particularly in spontaneous vaginal deliveries.

Induction rates and delivery outcomes after a policy limiting elective inductions.

The purpose of this study was to assess induction rates, maternal, and neonatal outcomes following adoption of a policy prohibiting elective inductions at less than 39 weeks gestation and inductions between 39 and 41 weeks with an unfavorable cervix. A retrospective cohort study of all deliveries greater than or equal to 37 weeks gestation was conducted 1 year prior to through 1 year after implementation of the induction policy. Induction rates before and after the policy were calculated as the primary outcome while maternal and neonatal conditions were assessed as secondary outcomes. Elective inductions (p = 0.016), elective inductions less than 39 weeks gestation (p = 0.020), and elective inductions 39-40 weeks and 6 days gestation with an unfavorable cervix (p = 0.031) decreased significantly following adoption of the policy. Maternal and neonatal outcomes, including rates of cesarean deliveries, postpartum hemorrhage, chorioamnionitis, and neonatal intensive care unit admissions remained unchanged, though this study was not adequately powered to detect differences in these outcomes. An institutional induction policy was associated with a reduction in elective inductions prior to 39 weeks and up to 40 weeks and 6 days with an unfavorable cervix. These reductions were not accompanied by change in maternal or neonatal outcomes at our institution.

Discrepancy Between Identification of Early-Term Elective Deliveries by Manual Chart Review and Data Vendor.

Elective delivery from 37 to 39 weeks gestation (early-term deliveries) is a Joint Commission National Quality Measure, and hospitals report on early-term elective delivery rates through Outcome Research Yields Excellence (ORYX) vendors. The objective of this study was to compare early-term elective deliveries, identified through ORYX vendors with those identified through manual chart review, the traditional method of medical record review. We reviewed early-term labor inductions and cesarean deliveries at a single hospital from June 1, 2010 to May 31, 2012. Rates of early-term elective deliveries identified by the data vendor were compared to physician chart review. Overall, the rate of elective deliveries by ORYX was 3% compared to 2% by physician chart review (RR 1.51 [95% CI 1.12-2.03], P < .001). Of the 116 elective early-term deliveries identified by vendor and/or chart review, vendors classified significantly more inductions and cesareans as elective (P < .001) and missed nine elective deliveries. Of the 107 deliveries identified as elective by ORYX, 62 (57.9%) were verified by chart review, including 69.0% of cesareans and 36.1% of inductions. Findings from this study suggest substantial discrepancy between identification of early-term elective deliveries by data vendors and physician chart review, and indicate that vendor-derived data may overestimate the number of electively delivered patients.