@article {7752, title = {Risk-adjusted operative delivery rates and maternal-neonatal outcomes as measures of quality assessment in obstetric care: a multicenter prospective study.}, journal = {BMC Pregnancy Childbirth}, volume = {15}, year = {2015}, month = {2015}, pages = {20}, abstract = {

BACKGROUND: Although the evaluation of caesarean delivery rates has been suggested as one of the most important indicators of quality in obstetrics, it has been criticized because of its controversial ability to capture maternal and neonatal outcomes. In an "ideal" process of labor and delivery auditing, both caesarean (CD) and assisted vaginal delivery (AVD) rates should be considered because both of them may be associated with an increased risk of complications. The aim of our study was to evaluate maternal and neonatal outcomes according to the outlier status for case-mix adjusted CD and AVD rates in the same obstetric population.

METHODS: Standardized data on 15,189 deliveries from 11 centers were prospectively collected. Multiple logistic regression was used to estimate the risk-adjusted probability of a woman in each center having an AVD or a CD. Centers were classified as "above", "below", or "within" the expected rates by considering the observed-to-expected rates and the 95\% confidence interval around the ratio. Adjusted maternal and neonatal outcomes were compared among the three groupings.

RESULTS: Centers classified as "above" or "below" the expected CD rates had, in both cases, higher adjusted incidence of composite maternal (2.97\%, 4.69\%, 3.90\% for "within", "above" and "below", respectively; p = 0.000) and neonatal complications (3.85\%, 9.66\%, 6.29\% for "within", "above" and "below", respectively; p = 0.000) than centers "within" CD expected rates. Centers with AVD rates above and below the expected showed poorer and better composite maternal (3.96\%, 4.61\%, 2.97\% for "within", "above" and "below", respectively; p = 0.000) and neonatal (6.52\%, 9.77\%, 3.52\% for "within", "above" and "below", respectively; p = 0.000) outcomes respectively than centers with "within" AVD rates.

CONCLUSIONS: Both risk-adjusted CD and AVD delivery rates should be considered to assess the level of obstetric care. In this context, both higher and lower-than-expected rates of CD and "above" AVD rates are significantly associated with increased risk of complications, whereas the "below" status for AVD showed a "protective" effect on maternal and neonatal outcomes.

}, issn = {1471-2393}, doi = {10.1186/s12884-015-0450-2}, author = {Maso, Gianpaolo and Monasta, Lorenzo and Piccoli, Monica and Ronfani, Luca and Montico, Marcella and De Seta, Francesco and Parolin, Sara and Businelli, Caterina and Travan, Laura and Alberico, Salvatore} } @article {3525, title = {Diabetes in pregnancy: timing and mode of delivery.}, journal = {Curr Diab Rep}, volume = {14}, year = {2014}, month = {2014 Jul}, pages = {506}, abstract = {

Diabetes in pregnancy represents a risk condition for adverse maternal and feto-neonatal outcomes and many of these complications might occur during labor and delivery. In this context, the obstetrician managing women with pre-existing and gestational diabetes should consider (1) how these conditions might affect labor and delivery outcomes; (2) what are the current recommendations on management; and (3) which other factors should be considered to decide about the timing and mode of delivery. The analysis of the studies considered in this review leads to the conclusion that the decision to deliver should be primarily intended to reduce the risk of stillbirth, macrosomia, and shoulder dystocia. In this context, this review provides useful information for managing specific subgroups of diabetic women that may present overlapping risk factors, such as women with insulin-requiring diabetes and/or obesity and/or prenatal suspicion of macrosomic fetus. To date, the lack of definitive evidences and the complexity of the problem suggest that the "appropriate" clinical management should be customized according with the clinical condition, the type and mode of intervention, its consequences on outcomes, and considering the woman{\textquoteright}s consent and informed decisions.

}, keywords = {Delivery, Obstetric, Diabetes Mellitus, Diabetes, Gestational, Female, Humans, Pregnancy, Pregnancy Complications}, issn = {1539-0829}, doi = {10.1007/s11892-014-0506-0}, author = {Maso, Gianpaolo and Piccoli, Monica and Parolin, Sara and Restaino, Stefano and Alberico, Salvatore} }