INTRODUCTION

The cesarean section rate has been increasing nationwide. Over the last four years in the United States, the percentage of cesarean sections has ranged from 31.7%- 32%.1

Global epidemiological studies within the last decade have suggested that the optimal cesarean section rate falls between 15-19% in developed countries.2 With the rates in the United States nearly double that, it suggests we should question the indications leading to a cesarean section.3

Blue Cross Blue Shield of Michigan has funded an Obstetrical Initiative (OBI), a collaborative quality initiative involving 74 maternity hospitals in Michigan, including our hospital, to address the high cesarean section rate.4 A laboring checklist was implemented in order to assure that decisions were following American College of Obstetricians and Gynecologists (ACOG) evidence-based guidelines.5 Our quality improvement study evaluated the impact of this checklist on the decision making to perform a cesarean section.

METHODS

This retrospective study was approved by our hospital’s Institutional Review Board. We collected the total cesarean section rates of nulliparous, term, singleton, vertex (NTSV) at our institution’s two campuses. Two groups were evaluated- those whose cesarean sections were done prior (pre-checklist in 2021) or after (post-checklist in 2022) implementation of the ACOG checklist.4 The exclusion criteria consisted of elective primary cesarean sections, breech, and cesarean sections secondary to medical conditions (i.e., herpes simplex virus lesions, or previa).

All primary low transverse cesarean sections were reviewed by the OBI Committee and were deemed “compliant” or “noncompliant” with ACOG guidelines. Each case was tracked as a part of the OBI percentage and reported monthly, quarterly, and annually. IBM SPSS Version 25 (IBM Corp., Armonk, NY) was used to analyze the data. A Chi square test was used to compare categorical data; p<0.05 was considered statistically significant.

RESULTS

In 2021, 923 patients were NTSV upon arrival to the hospital, while in 2022 there were 1022 patients who were NTSV. A total of 595 cesarean sections were completed over the two-year study period: 292 in 2021 and 303 in 2022. The total number of NTSV deliveries was 949 in 2021 and 1062 in 2022. The cesarean section rate decreased by 2.3% from 2021 (30.8%) to 2022 (28.5%, p=0.28). Our hospital primarily ordered cesarean sections for non-reassuring fetal heart tones, although arrest of dilation was the second most called primary indication.

DISCUSSION

Based on the results of this study, implementing ACOG guidelines alongside the OBI project helped decrease the cesarean section rate, although it was not statistically significant. In 2021, the cesarean section rate for women in the state of Michigan was 33.2%. Although our institution’s rate was lower than the statewide average, there is still significant room for improvement.4 Non-reassuring fetal heart tones can potentially be improved with resuscitative measures (i.e., position changes, amnioinfusion if there are variable decelerations, fluid bolus, or discontinuing Pitocin, etc.); however, a cesarean section still may be called due to sustained fetal intolerance to labor.6

The strengths of this study were that the hospital had the same providers that practiced at affiliated training sites, so they were more willing to order the cesarean section the same way each time. One of the study’s limitations included the variation between six centimeters dilated. Cervical dilation is subjective; thus, arrest could have been called after four to six hours depending on adequacy of contractions. Given the variability in providers this can be seen as a limitation. Lastly, the study did not take into account other initiatives that were going on at the hospital during this time. Hence, we cannot solely attribute this decrease as being only due to the ACOG checklist implementation.

ACKNOWLEDGEMENTS

We would like to thank the Department of Medical Education for their support of this project.

FUNDING

The authors have no funding to report for this study.

DISCLOSURES

The authors do not have any conflicts of interest to disclose.

Author contributions

Conceptualization: Angela E Niezgoda (Lead), Alan Newman (Supporting). Methodology: Angela E Niezgoda (Lead). Investigation: Angela E Niezgoda (Lead). Writing – original draft: Angela E Niezgoda (Lead). Supervision: Alan Newman (Supporting).

CORRESPONDING AUTHOR

Alan Newman, MD
Department of Obstetrics and Gynecology
Henry Ford Providence Southfield Hospital
16001 West 9 Mile Rd
Southfield, MI 48075
Phone: 248-465-4340
Email: anewman7@hfhs.org