Background Laborist practice models are associated with lower cesarean delivery rates than individual private practice models in several studies; however, this effect is not uniform. Further exploration of laborist models may help us better understand the observed reduction in cesarean delivery rates in some hospitals with implementation of a laborist model. Objective Our objective was to evaluate the degree of variation in primary cesarean delivery rates by individual laborists within a single institution employing a laborist model. In addition, we sought to evaluate whether differences in cesarean delivery rates resulted in different maternal or short-term neonatal outcomes. Study Design At this teaching institution, one laborist (either a generalist or maternal-fetal medicine attending physician) is directly responsible for labor and delivery management during each shift. No patients are followed in a private practice model nor are physicians incentivized to perform deliveries. We retrospectively identified all laborists who delivered nulliparous, term women with cephalic singletons at this institution from 2007-14. Overall and individual primary cesarean delivery rates were reported as percentages with exact Pearson 95% CI. Laborists were grouped by tertile as having low, medium or high cesarean delivery rates. Characteristics of the women delivered, indications for cesarean delivery, and short-term neonatal outcomes were compared between these groups. A binomial regression model of cesarean delivery was estimated, where the relative rates of each laborist compared to the lowest-unadjusted laborist rate were calculated; a second model was estimated to adjust for patient-level maternal characteristics. Results Twenty laborists delivered 2,224 nulliparous, term women with cephalic singletons. The overall cesarean delivery rate was 24.1% (95% CI 21.4-26.8). In an unadjusted binomial model, the overall effect of individual laborist was significant (p<0.001), and a 2.9 fold (1.5, 5.4, p=0.001) variation between the cesarean delivery rates of the highest (35.9%) and lowest (12.5%) physicians was observed. When adjusted for hypertensive disease, gestational age at delivery, race, and maternal age, the physician effect remained overall significant (p=0.0265) with the difference between physicians expanding to 3.58 (1.72-7.47, p<0.001). Between groups of laborists with low, medium, and high cesarean delivery rates, patient demographics and clinical characteristics of the population managed were clinically similar and not different statistically. The primary indication for cesarean delivery did not differ between groups. Similarly there were no differences in short-term neonatal outcomes including Apgar scores, arterial cord blood pH or incidence of neonatal encephalopathy. Conclusion The 3-fold variation in cesarean delivery rates between laborists at the same institution without observed differences in patient characteristics or short-term neonatal outcomes draws attention to the impact of individual physic...

INTRODUCTION: To evaluate if either a 1-minute Apgar 7 or greater, or umbilical artery (UA) pH 7.2 or greater can be used as a quality measure to identify unindicated cesarean deliveries (CD) for non-reassuring fetal heart rate (NRFHR). METHODS: Retrospective cohort of nulliparas with no contraindication to vaginal delivery. Individual physician CD rates were calculated. Two quality measures were investigated as indicative of normal neonatal status: (1) 1-minute Apgar 7 or greater, (2) UA pH 7.2 or greater. Pearson's correlation was calculated between individual physician CD rates and proportion of CDs performed with a primary indication of NRFHR but normal neonatal status. A random sample of 60 FHR tracings from women who had a CD for NRFHR were reviewed by 3 obstetricians blinded to Apgars and gases to determine if CD was indicated. RESULTS: 2,224 women were included. Of 537 CDs, 181 (34%) had a primary indication of NRFHR. Individual physician CD rates and rates of CD for NRFHR with normal neonatal status were moderately correlated (Apgar rho=0.53,95%CI 0.12-0.79, UA pH rho=0.53,95%CI 0.11-0.79). CDs were identified by peer review to be unindicated in 65% of cases with a UA pH of 7.2 or greater, compared to only 28% of cases with a pH less than 7.2 (p=0.04). A high proportion of CDs with 1-minute Apgar 7 or greater were also unindicated (70% vs 57%, p=0.42). CONCLUSION: Performance of a CD for NRFHR with UA pH 7.2 or greater may help identify physicians with higher CD rates and cases that may benefit from peer review.