Cesarean Birth

Nulliparous women with a term, singleton baby in a vertex position delivered by cesarean birth

Measure specifications are in the Public Domain

LOINC(R) copyright 2004-2019 Regenstrief Institute, Inc. 

This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2019 International Health Terminology Standards Development Organisation. All Rights Reserved.

These performance measures are not clinical guidelines and do not establish a standard of medical care and have not been tested for all potential applications. The measures and specifications are provided without warranty.

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The removal of any pressure to not perform a cesarean birth has led to a skyrocketing of hospital, state and national cesarean birth (CB) rates. Some hospitals now have CB rates over 50%. Hospitals with CB rates at 15-20% have infant outcomes that are just as good and better maternal outcomes (Gould et al., 2004). There are no data that higher rates improve any outcomes, yet the CB rates continue to rise. This measure seeks to focus attention on the most variable portion of the CB epidemic, the term labor CB in nulliparous women. This population segment accounts for the large majority of the variable portion of the CB rate, and is the area most affected by subjectivity. 

As compared to other CB measures, what is different about nulliparous, term singleton vertex (NTSV) CB rate (low-risk primary CB in first births) is that there are clear cut quality improvement activities that can be done to address the differences. Main et al. (2006) found that over 60% of the variation among hospitals can be attributed to first birth labor induction rates and first birth early labor admission rates. The results showed if labor was forced when the cervix was not ready the outcomes were poorer. Alfirevic et al. (2004) also showed that labor and delivery guidelines can make a difference in labor outcomes. Many authors have shown that physician factors, rather than patient characteristics or obstetric diagnoses, are the major driver for the difference in rates within a hospital (Berkowitz, et al., 1989; Goyert et al., 1989; Luthy et al., 2003). The dramatic variation in NTSV rates seen in all populations studied is striking according to Menacker (2006). Hospitals within a state (Coonrod et al., 2008; California Office of Statewide Hospital Planning and Development [OSHPD], 2007) and physicians within a hospital (Main, 1999) have rates with a 3-5 fold variation.

The American College of Obstetrics and Gynecology (ACOG) report, Evaluation of Cesarean Delivery, recognizes the importance of the Nulliparous, Term Singleton Vertex (NTSV) population as the optimal focus for measurement and quality improvement action. A reduction in the number of nulliparous patients with live term singleton newborns in vertex position delivering by cesarean birth will result in increased patient safety, a substantial decrease in maternal and neonatal morbidity and substantial savings in health care costs.

Improvement noted as a decrease in the rate

Freeman, R.K., Cohen A.W., Depp II R., et al. (2000). American College of Obstetricians and Gynecologists. Task force on cesarean delivery rates. Evaluation of cesarean delivery.

Alfirevic, Z., Edwards, G., Platt, M.J. (2004). The impact of delivery suite guidelines on intrapartum care in standard primigravida. European Journal of Obstetrics and Gynecology and Reproductive Biology, 115, 28-31.

Berkowitz, G.S., Fiarman, G.S., Mojica, M.A., et al. (1989). Effect of physician characteristics on the cesarean birth rate. American Journal of Obstetrics and Gynecology, 161, 146-149.

California Office of Statewide Hospital Planning and Development. (2017). Hospital volume and utilization indicators for California. Retrieved from https://www.oshpd.ca.gov/hid/ahrq-volume-utilization.html

Bailit, J.L., Love, T.E., Dawson, N.V. (2006). Quality of obstetric care and risk-adjusted primary cesarean delivery rates. American Journal of Obstetrics and Gynecology, 194, 402.

Coonrod, D.V., Drachman, D., Hobson, P., et al. (2008) Nulliparous term singleton vertex cesarean delivery rates: institutional and individual level predictors. American Journal of Obstetrics and Gynecology, 694-696.

Gould, J., Danielson, B., Korst, L., et al. (2004). Cesarean delivery rate and neonatal morbidity in a low-risk population. American Journal of Obstetrics and Gynecology, 104, 11-19.

Govert, G.L., Bottoms, F.S., Treadwell, M.C., et al. (1989). The physician factor in cesarean birth rates. New England Journal of Medicine, 320, 706-709.

Luthy, D.A., Malmgren, J.A., Zingheim, R.W., et al. (2003). Physician contribution to a cesarean delivery risk model. American Journal of Obstetrics and Gynecology, 188, 1579-1585.

Main, E.K. (1999). Reducing cesarean birth rates with data-driven quality improvement activities. Pediatrics, 103, 374-383.

Main, E.K., Moore, D., Farrell, B., et al. (2006). Is there a useful cesarean birth measure? Assessment of the nulliparous term singleton vertex cesarean birth rate as a tool for obstetric quality improvement. American Journal of Obstetrics and Gynecology, 194, 1644-1651.

Menacker, F. (2005) Trends in cesarean rates for first births and repeat cesarean rates for low-risk women: United States, 1990-2003. National Vital Statistics Reports, 54(4), 1-5.

U.S. Department of Health and Human Services. (2000). Healthy people 2010: Understanding and improving health. 2nd Edition. Washington, DC: U.S. Government Printing Office. Measure 16-9.

American College of Obstetricians and Gynecologists.  Revitalize:  Obstetrics Data Definitions (Version 1.0)

Caughey, A.B., Cahill, A.G., Guise, JM., Rouse, D.J. (2019). Safe prevention of the primary cesarean delivery. American College of Obstetricians and Gynecologists, 123: 693-711.  Retrieved from https://www.acog.org/Clinical-Guidance-and-Publications/Obstetric-Care-Consensus-Series/Safe-Prevention-of-the-Primary-Cesarean-Delivery.

Main, E.K, Shen-Chih, C., Cape, V., Sakowski, C., Smith, H., Vasher, J. (2019). Safety assessment scale of a large-scale improvement collaborative to reduce nulliparous cesarean delivery rates. American College of Obstetricians and Gynecologists, 133 (4): 613-623.

Parity:  The number of pregnancies reaching 20 weeks gestation regardless of the number of fetuses or outcomes
Gravidity:  The number of pregnancies, current and past, regardless of the pregnancy outcome  
Preterm Birth: The number of births  >= 20 weeks and < 37 weeks gestation, regardless of outcome 
Term Birth:  The number of births >= 37 weeks gestation, regardless of outcome

This eCQM is an episode-based measure.

This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center (https://ecqi.healthit.gov/qdm) for more information on the QDM

Vertex position is modeled implicitly, as the measure excludes deliveries with abnormal presentations.

Patients who do not receive prenatal care and have no documented gestational age or estimated due date are implicitly excluded from the measure, as gestational age is required to meet denominator criteria. 

This measure allows for 2 approaches to determine estimated gestational age (EGA) in the following order of precedence:

1.  The EGA is calculated using the American College of Obstetricians and Gynecologists ReVITALize guidelines.*
2.  The EGA is obtained from a discrete field in the electronic health record.  This option is only used when the calculated EGA is not available.

Wherever gestational age is mentioned, relative to the delivery, the intent is to capture the last estimated gestational age prior to or at the time of delivery.  
 
*ACOG ReVITALize Guidelines for Calculating Gestational Age:      
     
                                Gestational Age = (280-(EDD minus Reference Date))/7

--Estimated Due Date (EDD):  The best obstetrical Estimated Due Date is determined by last menstrual period if confirmed by early ultrasound or no ultrasound performed, or early ultrasound if no known lastmenstrual period or the ultrasound is not consistent with last menstrual period, or known date of fertilization (eg, assisted reproductive technology) 
--Reference Date is the date on which you are trying to determine gestational age. For purposes of this eCQM, Reference Date would be the Date of Delivery.   

Note however the calculation may yield a non-whole number and gestational age should be rounded off to the nearest completed week. For example, an infant born on the 5th day of the 36th week (35 weeks and 5/7 days) is at a gestational age of 35 weeks, not 36 weeks.

The timing relationship of relevantDatetime 42 weeks or less before TimeOfDelivery is applied to the data elements of parity, gravida, preterm/term live births for which prenatal records may include relevant information. 

The denominator includes logic to determine if the patient is nulliparous. The patient is considered nulliparous when one of the following is true: 

     Parity equals zero
     Gravida equals one
     Preterm and Term births both equal zero 

Parity, preterm and term live births may be updated by the electronic health record software or by clinicians during a delivery encounter. To capture the pre-delivery value, organizations may need to create a rule or calculation to capture the number prior to the delivery start time.

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Inpatient hospitalizations for patients age >= 8 years and < 65 admitted to the hospital for inpatient acute care who undergo a delivery procedure with a length of stay less than or equal to 120 days that ends during the measurement period

Inpatient hospitalizations for nulliparous patients delivered of a live term singleton newborn >= 37 weeks' gestation

Note:  The eCQM and chart-based measure slightly digress in the denominator logic.  

eCQM:
The measure description states "Nulliparous women with a term, singleton baby in a vertex position delivered by cesarean birth".  ACOG defines nulliparous as a woman with a parity of zero.  The eCQM logic concludes that a patient is nulliparous when ONE of the following is true:

1.      Parity equals zero
2.      Gravidity equals one
3.      Preterm and Term births both equal zero. 

See Definition Section for more details.

Chart Based:
The chart based measure evaluates the data element "Previous Live Births".  If the answer is "yes" the patient will be excluded from the denominator.  If a patient had a previous stillbirth or fetal demise, the abstractor is instructed to answer "no" and the patient will remain in the denominator.

Inpatient hospitalizations for patients with abnormal presentation or placenta previa during the encounter.  

Note that the chart-based measure excludes single stillbirth and patients with multiple gestations from the denominator.  These concepts are mutually exclusive of the denominator requirement of live singleton newborn and therefore the logic does not address single stillbirth nor multiple gestation.

Inpatient hospitalizations for patients who deliver by cesarean section.

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For every patient evaluated by this measure also identify payer, race, ethnicity and sex