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Protocol - Mode of Delivery - Medical Record Abstraction

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Protocol Name from Source:

A Randomized Trial of Induction Versus Expectant Management (ARRIVE)

Availability:

Publicly available

Description:

Information about the woman's delivery is abstracted from her medical chart.

Protocol:

1. Date of admission to Labor and Delivery _______________ (mm/dd/yyyy)

2. Time of admission _______________ (24 hour clock)

3. Indication for admission (check 1)

[ ] 0 Postpartum admission after home or in-transit delivery

[ ] 1 Spontaneous labor

[ ] 2 Spontaneous ROM (rupture of membranes)

[ ] 3 Induction

[ ] 4 Cesarean

If the patient has both spontaneous ROM and spontaneous labor she should be coded as 1 ¿ spontaneous labor. Do not use codes 3 or 4 unless she is being admitted for a planned induction or cesarean.

4. Type of membrane rupture

[ ] 1 Spontaneous

[ ] 2 Artificial

5. Type of labor

[ ] 0 No labor

[ ] 1 Spontaneous

[ ] 2 Spontaneous, augmented

[ ] 3 Induced

6. Indication(s) for induction (check all that apply)

[ ] 01 Elective

[ ] 02 Post-dates

[ ] 03 IUGR (intrauterine growth restriction)

[ ] 04 Oligohydramnios

[ ] 05 Non-reassuring fetal status

[ ] 06 Abruption

[ ] 07 Hypertension/preeclampsia

[ ] 08 Chorioamnionitis

[ ] 09 PROM (premature (or prolonged) rupture of membranes)

[ ] 10 Macrosomia

[ ] 99 Other

If coded 99, Specify ______________

7. Date of delivery _______________ (mm/dd/yyyy)

8. Time of delivery _______________ (24 hour)

9. Successful delivery type

[ ] 1 Spontaneous vaginal

[ ] 2 Forceps vaginal

[ ] 3 Vacuum vaginal

[ ] 4 Cesarean

10a. Record the primary indication for vaginal or cesarean delivery

[ ] 1 Non-reassuring fetal status

[ ] 2 Dystocia

[ ] 3 Abnormal presentation

[ ] 4 Placental abruption

[ ] 5 Umbilical cord prolapse

[ ] 6 Suspected Macrosomia

[ ] 7 Preeclampsia/hypertension

[ ] 8 Maternal exhaustion

[ ] 9 Other

If coded 9, Specify _________________

10b. List up to 3 secondary indications

[ ] 0 No other indications

[ ] 1 Non-reassuring fetal status

[ ] 2 Dystocia

[ ] 3 Abnormal presentation

[ ] 4 Placental abruption

[ ] 5 Umbilical cord prolapse

[ ] 6 Suspected Macrosomia

[ ] 7 Preeclampsia/hypertension

[ ] 8 Maternal exhaustion

[ ] 9 Other

If coded 9, Specify _________________

11. Vaginal vacuum extraction attempted (yes/no)

12. Vaginal forceps attempted (yes/no)

13. Initiating event of delivery (complete for all deliveries of 16+ weeks, regardless of gestational age)

[ ] 0 Spontaneous labor with delivery (regardless of route of delivery)

[ ] 1 PROM leading to spontaneous labor (regardless of route of delivery)

[ ] 2 PROM leading to induction of labor or C-section without labor

[ ] 3 Indicated delivery, not spontaneous labor or spontaneous PROM

[ ] 8 Not documented

[ ] 9 Records missing

Personnel and Training Required

This information should be abstracted by someone conversant in obstetric practice, such as an obstetrician, resident in obstetrics-gynecology (OB-GYN), a labor and delivery nurse or an obstetric nurse.

Equipment Needs

None

Requirements

Requirement CategoryRequired
Average time of greater than 15 minutes in an unaffected individualNo
Major equipmentNo
Specialized requirements for biospecimen collectionNo
Specialized trainingNo

Mode of Administration

Self-administered

Life Stage:

Pregnancy

Specific Instructions:

Information about the type of delivery and what initiated that type of delivery is abstracted from the obstetric medical record and this is the preferred approach. Mode of Delivery - Interview protocol should be used if the medical records are not available; it may also be used to supplement the information in the medical record.

Research Domain Information

Release Date:

March 31, 2017

Definition

Information about the initiating event of a woman’s delivery, the mode of delivery, and if it was an assisted delivery.

Purpose

The mode of delivery may influence the health of the mother. Cesarean deliveries are becoming more common in the United States, often performed without a medical reason, and put the mother at increased risk of infection, hemorrhaging, blood clots, or experiencing a reaction to the anesthesia. Mode of delivery may also impact the health of the neonate. Cesarean section in the absence of labor has been associated with an increased occurrence of difficulties in respiratory transition to newborn life; for example, an increased risk of transient tachypnea of the newborn. Instrumental vaginal deliveries (forceps and vacuum) have been associated with increased risk of birth injuries such as facial nerve damage (forceps) and subgaleal hematomas (vacuum).

Selection Rationale

This information was collected during a major clinical trial (ARRIVE) by physicians in the Maternal Fetal Medicine Units (MFMU) Network, a major network that has conducted these types of trials since 1986.

Language

English

Standards

StandardNameIDSource
Common Data Elements (CDE)Chart Abstraction Pregnancy Pregnancy Birth Mode Assessment Text5633927CDE Browser

Process and Review

The Expert Review Panel has not reviewed this measure yet.

Source

Maternal Fetal Medicine Units (MFMU) Network, A Randomized Trial of Induction Versus Expectant Management (ARRIVE), 2016 Manual of Operations, Form AR08 Labor and Delivery Form. Questions 1, 2, 4, 7, 8, 9, 16, 23, 24, 25, and 26

Ohio Perinatal Research Network, 2014 Maternal Data Abstraction Form.

General References

American Academy of Pediatrics, American College of Obstetricians and Gynecologists. (2012). Guidelines for perinatal care (7th ed). Elk Grove Village, IL; Washington, DC: Author.

Caughey, A. B., & Musci, T. J. (2004). Complications of term pregnancies beyond 37 weeks of gestation. Obstetrics and Gynecology, 103, 57-62.

Caughey, A. B., Stotland, N. E., Washington, A. E., & Escobar, G. J. (2007). Maternal and obstetric complications of pregnancy are associated with increasing gestational age at term. American Journal of Obstetrics and Gynecology, 196, 155 e1-6.

Caughey, A. B., Washington, A. E., & Laros R. K., Jr. (2005). Neonatal complications of term pregnancy: Rates by gestational age increase in a continuous, not threshold, fashion. American Journal of Obstetrics and Gynecology, 192, 185-190.

Protocol ID:

241302

Variables:

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