Carlson Nicole S, Corwin Elizabeth J, Hernandez Teri L, Holt Elizabeth, Lowe Nancy K, Hurt K Joseph
Emory University Nell Hodgson Woodruff School of Nursing, Atlanta, GA, USA.
Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA.
Birth. 2018 Jun;45(2):159-168. doi: 10.1111/birt.12334. Epub 2018 Jan 31.
Term nulliparous women have the greatest variation across hospitals and providers in cesarean rates and therefore present an opportunity to improve quality through optimal care. We evaluated associations between provider type and mode of birth, including examination of intrapartum management in healthy, laboring nulliparous women.
Retrospective cohort study using prospectively collected perinatal data from a United States academic medical center (2005-2012). The sample included healthy nulliparous women with spontaneous labor onset and term, singleton, vertex fetus managed by either obstetricians or certified nurse-midwives. Univariate and multivariate logistic regression was used to compare labor interventions and mode of birth by provider type.
A total of 1339 women received care by an obstetrician (n = 749) or nurse-midwife (n = 590). The cesarean rate was 13.4% (179/1339). Adjusting for maternal and pregnancy characteristics, care by obstetricians was associated with an increased risk of unplanned cesarean birth (adjusted odds ratio [aOR] 1.48 [95% confidence interval {CI} 1.04-2.12]) compared with care by midwives. Obstetricians more frequently used oxytocin augmentation (aOR 1.41 [95% CI 1.10-1.80]), neuraxial anesthesia (aOR 1.69 [95% CI 1.29-2.23]), and operative vaginal delivery with forceps or vacuum (aOR 2.79 [95% CI 1.75-4.44]). Adverse maternal or neonatal outcomes were not different by provider type across all modes of birth, but were more frequent in women with cesarean than vaginal births.
In low-risk nulliparous laboring women, care by obstetricians compared with nurse-midwives was associated with increased risk of labor interventions and operative birth. Changes in labor management or increased use of nurse-midwives could decrease the rate of a first cesarean in low-risk laboring women.
足月未产妇的剖宫产率在不同医院和医疗服务提供者之间差异最大，因此存在通过优化护理来提高质量的机会。我们评估了医疗服务提供者类型与分娩方式之间的关联，包括对健康的、正在分娩的未产妇的产时管理进行检查。
采用回顾性队列研究，使用来自美国一家学术医疗中心（2005 - 2012年）前瞻性收集的围产期数据。样本包括健康的未产妇，她们自然发动分娩，孕周足月，单胎，头位胎儿，由产科医生或认证护士助产士管理。使用单因素和多因素逻辑回归按医疗服务提供者类型比较分娩干预措施和分娩方式。
共有1339名妇女接受了产科医生（n = 749）或护士助产士（n = 590）的护理。剖宫产率为13.4%（179/1339）。在调整了产妇和妊娠特征后，与助产士护理相比，产科医生护理与计划外剖宫产分娩风险增加相关（调整后的优势比[aOR]为1.48[95%置信区间{CI}为1.04 - 2.12]）。产科医生更频繁地使用缩宫素加强宫缩（aOR为1.41[95%CI为1.10 - 1.80]）、椎管内麻醉（aOR为1.69[95%CI为1.29 - 2.23]）以及使用产钳或真空吸引进行阴道助产（aOR为2.79[95%CI为1.75 - 4.44]）。在所有分娩方式中，不同医疗服务提供者类型的产妇或新生儿不良结局并无差异，但剖宫产产妇的不良结局比阴道分娩产妇更常见。
在低风险的未产妇分娩中，与护士助产士相比，产科医生护理与分娩干预和手术分娩风险增加相关。改变分娩管理或增加护士助产士的使用可能会降低低风险分娩妇女的首次剖宫产率。
