title: The effect of change in a labour management protocol on caesarean section rate in nulliparous women.
abstract: OBJECTIVE
  To investigate the impact on obstetric outcome in nulliparous women of changing labour management from an expectant approach to proactive support of labour.
  
  
  METHODS
  We conducted a retrospective cohort study in a teaching hospital in the Netherlands among 858 women ≥ 37 weeks' gestation with a singleton fetus in cephalic position and spontaneous labour who planned to have a vaginal birth in the hospital under the care of an obstetrician. Exclusion criteria were gestational age < 37 weeks, induction of labour, primary Caesarean section, non-cephalic position, and non-Caucasian ethnicity. Labour outcomes in the period 1999 to 2002 (using an expectant approach) were compared with labour outcomes in the period 2008 to 2010 (using proactive support of labour). The primary outcome measure was the relationship between the CS rate and the form of labour management (expectant approach vs. proactive support). The secondary outcome measure was to identify risk factors for repeat CS.
  
  
  RESULTS
  The overall prevalence of CS in the study population was 12.2%. The CS rate increased significantly from 9.7% between 1999 and 2002, to 15.4% between 2008 and 2010 (P < 0.001). Meanwhile, the assisted vaginal delivery rate decreased from 22.7% to 16.7% (P = 0.03). Multiple logistic regression showed that epidural analgesia (OR 4.6; 95% CI 2.6 to 8.4), occiput posterior position (OR 7.4; 95% CI 4.3 to 12.8), and advanced maternal age (OR 1.91; 95% 1.31 to 2.76) were risk factors for CS.
  
  
  CONCLUSIONS
  Changing labour management from an expectant approach to proactive support of labour did not decrease the Caesarean section rate.
authors.affiliation: Department of Obstetrics and Gynaecology, Catharina Ziekenhuis, Eindhoven, the Netherlands.
authors.forename: Simone M I
authors.initials: SMI
authors.lastname: Kuppens
authors.affiliation: Department of Obstetrics and Gynaecology, Catharina Ziekenhuis, Eindhoven, the Netherlands.
authors.forename: Alice
authors.initials: A
authors.lastname: Brugman
authors.affiliation: Department of Obstetrics and Gynaecology, Catharina Ziekenhuis, Eindhoven, the Netherlands.
authors.forename: Tom H M
authors.initials: THM
authors.lastname: Hasaart
authors.affiliation: Department of Obstetrics and Gynecology, McMaster University, Hamilton ON; Midwifery Science VU Medical Center, Amsterdam, the Netherlands.
authors.forename: Eileen K
authors.initials: EK
authors.lastname: Hutton
authors.affiliation: Department of Clinical Health Psychology, University of Tilburg, Tilburg, the Netherlands.
authors.forename: Victor J M
authors.initials: VJM
authors.lastname: Pop
mesh_terms: D000328:Adult; D002585:Cesarean Section / Q000706:statistics & numerical data*; D002985:Clinical Protocols; D015331:Cohort Studies; D036861:Delivery, Obstetric / Q000592:standards; D005260:Female; D006801:Humans; D010298:Parity; D011247:Pregnancy; D012189:Retrospective Studies
keywords: Caesarean section; epidural analgesia; labour; management; nulliparous women