Decrease In C-Sections Associated With Around-The-Clock Labor Coverage

Main Category: Pregnancy / Obstetrics
Article Date: 13 Feb 2013 - 0:00 PST


In a study to be presented on February 16 between 8 a.m., and 10 a.m. PST, at the Society for Maternal-Fetal Medicine's annual meeting, The Pregnancy Meeting ™, in San Francisco, researchers will report findings that suggest around-the-clock labor and delivery coverage decreased the odds of cesarean delivery.

The objective of the study was to determine if the implementation of "laborists" to provide around-the-clock coverage of labor and delivery would produce better outcomes. The study compared outcomes in hospitals with around-the-clock coverage versus hospitals whose coverage was based on need.

The study was a retrospective cohort study which covered live singleton births that were delivered in California between 2005-2006. There were certain variables that were taken into consideration to reduce the margin of error. Hospitals that had fewer than 1,200 deliveries were not considered for the study. The statistical analysis used included chi square and multivariable logistic regression. Hospitals were broken into two categories; one having a labor and delivery clinician "around-the-clock" while the other category was "as-needed".

The sample size was very large as 740,019 singleton births met the study criteria, and the breakdown was as follows:

• Around-the-clock 274,106 births (37 percent of births)
• As-needed 465,913 births (63 percent of births)

Data showed that around-the-clock hospitals had lower numbers of overall cesarean deliveries as well as primary cesarean delivery in both first time mothers and women who have given birth before. In addition, women who previously had a cesarean birth were more likely to attempt to achieve vaginal delivery in around-the-clock hospitals.

While the results indicate around-the-clock hospitals do have lower cesarean deliveries and better chances of a vaginal birth after a prior cesarean delivery, the overall feeling is that more research needs to be done before the laborist model can be given full credit for the rates.

Abstract 80: Labor and delivery coverage: around-the-clock or as-needed?

Objective: While the utility of hospitalists for medical units has been validated, it is unclear if the implementation of "laborists", which provides around-the-clock coverage of Labor and Delivery (L&D) unit, is associated with improved outcomes. We aimed to compare obstetric outcomes in hospitals with around-the-clock coverage to hospitals whose coverage is based on need.

Study Design: This was a retrospective cohort study of singleton, term, live births delivered in California between 2005-2006. Hospitals with fewer than 1,200 deliveries per year were excluded. Hospitals were categorized based on L&D clinician coverage as "around-the-clock" or "as-needed." Statistical analysis was performed using chi square test and multivariable logistic regression to adjust for potential confounding factors.

Results: There were 740,019 term, singleton, cephalic births that met study criteria. Of these, 274,106 (37%) delivered in hospitals with around-the-clock coverage and 465,913 (63%) delivered in hospitals with as-needed coverage. Compared to as-needed coverage, the overall cesarean delivery was lower in hospitals with around-the-clock coverage, as was primary cesarean delivery in both nulliparous and multiparous women (Table). The proportion of women who underwent a trial of labor after cesarean (TOLAC) and achieving vaginal birth after previous cesarean (VBAC) was higher with around-the-clock coverage (Table). Additionally, women were more likely to have labor induction with around-the-clock than as-needed coverage, though they remained to have lower odds of cesarean.

Conclusion: In California, around-the-clock L&D coverage is associated with decreased odds of cesarean delivery and increased likelihood of trial of labor after cesarean and achieving vaginal birth after previous cesarean but increased induction of labor. Whether the observed difference in outcome can be attributable to the implementation of a "laborist" model deserves further investigation, particularly as more hospitals are considering such staffing changes.

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