Date of Award

January 2018

Document Type

Thesis

Degree Name

Medical Doctor (MD)

Department

Medicine

First Advisor

Jessica Illuzzi

Abstract

Cesarean delivery for labor arrest currently makes up the largest proportion of

primary cesarean delivery in the United States. Because cesarean delivery is associated

with significant morbidity, it is important to limit its use to ensure the benefits outweigh

the risks. New diagnostic criteria to limit the diagnosis of labor arrest have the potential

to decrease the cesarean delivery rate. To investigate how cesarean delivery for arrest of

dilation or descent and failed induction contributed to the primary cesarean delivery rate,

we analyzed rates of primary cesarean for these indications among 17,864 live births at

our institution from 2010 through 2013. We used multiple logistic regression modeling to

identify predictors of meeting diagnostic criteria for these indications based on guidelines

published in 2012 by Spong et al. From 2010 through 2013 the total primary cesarean

delivery rate decreased from 23.5% to 21.1%. Over the same period, primary cesarean

delivery due specifically to arrest of dilation or descent and failed induction decreased

from 8.5% to 6.7%. Primary cesarean delivery due to arrest of dilation alone decreased

from 5.1% to 3.4%. The rate of meeting minimum criteria for arrest of dilation increased

from 18.8% to 34.9%. Primary cesarean delivery due to arrest of descent alone remained

relatively stable, however, the percent of cases meeting minimum criteria increased from

57.8% to 71.0%. The rate of primary cesarean delivery due to failed induction alone also

remained relatively stable, as did the percent of cases meeting minimum criteria with

50.00% meeting criteria in 2013. Attending type was a significant predictor of meetingiii

criteria for all three indications. Hospitalist cases were two to seven times as likely to

meet criteria compared with private cases. Dilation on admission increased, as well as the

likelihood of meeting criteria for arrest of dilation and arrest of descent. Epidural use

decreased the likelihood of meeting criteria for arrest of descent. In summary, the

decrease in primary cesarean delivery from 2010 through 2013 is significantly

attributable to a decrease in the diagnosis of labor arrest disorders and failed induction,

and specifically to a decrease in diagnosis of arrest of dilation. An increased likelihood of

meeting minimum criteria for arrest of dilation in 2012 and 2013 compared to 2010

suggests that applying new definitions of labor arrest published in 2012 can decrease the

overall primary cesarean rate. As of 2013, only 34.9% of primary cesareans performed

for arrest of dilation, 71.0% for arrest of descent, and 50.0% for failed induction, met new

respective minimum diagnostic criteria. This suggests that an even bigger decrease in the

primary cesarean rate can be achieved if a greater effort is made to meet minimum

criteria before moving to cesarean.

Comments

This thesis is restricted to Yale network users only. It will be made publicly available on 06/27/2020

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