SPECIAL REPORT ©2020 NPIC NPIC.ORG | 1

Special Report: Induction of Labor and Cesarean Birth

INTRODUCTION

Since 2018 and through 2019, there have been at least 8,000 papers, posters and publications published that describe Induction of Labor (IOL) through

multiple lenses—elective, medical indication, advanced maternal age, high-risk, low-risk, multiple gestation and many others. The long-awaited results of

the ARRIVE Trial (labor induction at 39 weeks + 0-4 days gestation versus expectant management in low risk nulliparous women) were published in the

New England Journal of Medicine on August 9, 20181 and created additional discussion surrounding elective induction of labor, particularly induction of

labor at 39 weeks gestation. The overarching findings within this particular study population revealed a lower frequency of cesarean delivery and

hypertensive disorders of pregnancy in elective induction at 39 weeks versus expectant management (p. 521-522). Since then, there has continued to be

considerable discussion surrounding induction of labor and cesarean delivery within NPIC’s membership, and several requests to explore this information

in more detail.

SPECIAL REPORT

For this Special Report, NPIC wanted to be responsive to recent requests for additional data related to induction of labor and cesarean delivery,

particularly trended data over time. Why both of these care measures?

1) Induction of labor continues to generate important conversations within healthcare organizations, and it is important to utilize data to assure

resource availability that can provide a successful labor and delivery outcome (skill/expertise, human and capital resources, room availability,

throughput, etc.).

2) In July 2020, The Joint Commission will begin to report cesarean section rates > 30% on their QualityCheck® site (https://www.qualitycheck.org/).

These rates are based upon a hospital’s core measure data submission for PC-02 Cesarean Birth. The first reporting will include 2018-2019 data,

and organizations will be asked about their cesarean reduction strategies during accreditation surveys effective July 2020.

You will note that NPIC uses an Estimated Rate of Inductions. To better understand this report, it is important to reference how induction of labor is

calculated for this measure (see Appendix for measure definition and associated ICD-10 coding). Induction ICD-10 procedure codes are important to

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SPECIAL REPORT ©2020 NPIC NPIC.ORG | 2

review and document. Clinical care teams responsible for coding can be a tremendous asset to an organization for tracking of induction and supporting a

more accurate estimate of induction rate. The Data Team at NPIC is eager to assist you with developing a strategy to better track both estimated induction

and cesarean delivery rates.

DESCRIPTION OF GRAPHS

The Special Report includes graphs for two measures, NPIC Estimated Rate of Inductions and AHRQ IQI 33 Primary Cesarean Delivery Rate,

Uncomplicated, a primary cesarean delivery rate for low risk multiparous women (see Appendix for additional measure information). Quarterly rates for

your hospital, peer subgroup and the NPIC Database are displayed for the period Q1 2017 – Q2 2019 (10 quarters). The vertical dashed line on each graph

represents the publication of the ARRIVE Trial study in Q3 2018.

Below the graphs for each measure there is a table which includes your hospital’s data by quarter (numerator/ denominator counts and rate), and another

table with peer subgroup and NPIC Database comparisons (average rates) by quarter. Please note, a sizeable drop appears in the Estimated Rate of

Inductions comparison rates displayed for Q4 2017. We suspect this may be related to confusion regarding the use of a new ICD-10 PCS induction code

that became effective for discharges in this quarter.

REFERENCES

1Grobman, W.A., Rice, M.M., Reddy, U.M., Tita, A.T., Silver, R.M., Mallett, G.,…& Macones, G.A. (2018). Labor induction versus expectant management in

low-risk nulliparous women. New England Journal of Medicine, 379, 513-523. Sample

|Induction of Labor and Primary Cesarean Birth, 2017 − 2019 (Q2)

NPIC ID: SA1|

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2017Q1

2017Q2

2017Q3

2017Q4

2018Q1

2018Q2

2018Q3

2018Q4

2019Q1

2019Q2

● Hospital Subgroup NPIC

Estimated Rate of Inductions

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2017Q3

2017Q4

2018Q1

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2019Q1

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● Hospital Subgroup NPIC

IQI 33 Primary Cesarean Delivery Rate, Uncomplicated

metric

numer

2017Q1

denom

2017Q2

rate

2017Q3

150

2017Q4

638

2018Q1

23.5%

2018Q2

150

2018Q3

650

2018Q4

23.1%

2019Q1

184

2019Q2

723

25.4%

73

598

12.2%

159

624

25.5%

214

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32.1%

250

707

35.4%

202

595

34.0%

203

627

32.4%

243

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37.2%

Hospital SA1

metric

numer

2017Q1

denom

2017Q2

rate

2017Q3

114

2017Q4

437

2018Q1

26.1%

2018Q2

85

2018Q3

441

2018Q4

19.3%

2019Q1

109

2019Q2

495

22.0%

81

410

19.8%

88

419

21.0%

104

466

22.3%

94

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98

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23.5%

73

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17.6%

86

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20.0%

Hospital SA1

|Subgroup: AR − Academic Regional

* ARRIVE Study publish date: AUG 9, 2018NPIC.ORG | 3

metric

Subgroup

2017Q1

NPIC

2017Q2

26.5%

2017Q3

25.4%

2017Q4

26.4%

2018Q1

24.5%

2018Q2

25.7%

2018Q3

25.0%

2018Q4

19.6%

2019Q1

18.8%

2019Q2

27.2%

25.4%

29.0%

26.0%

27.7%

26.3%

30.0%

27.4%

29.7%

27.4%

33.3%

28.2%

Comparisonsmetric

Subgroup

2017Q1

NPIC

2017Q2

17.4%

2017Q3

18.9%

2017Q4

18.2%

2018Q1

19.0%

2018Q2

18.2%

2018Q3

18.4%

2018Q4

18.1%

2019Q1

19.0%

2019Q2

18.3%

19.0%

18.1%

18.4%

17.2%

18.4%

17.8%

18.5%

17.7%

18.3%

18.2%

18.7%

Comparisons

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SPECIAL REPORT ©2020 NPIC NPIC.ORG | 4

APPENDIX

Estimated Rate of Inductions

This rate reflects all women who delivered and were coded with induction of labor

Numerator

Total cesarean deliveries with a labor of induction code

Denominator

Total deliveries with a labor induction code

Excludes deliveries coded with artificial rupture of membranes (AROM) only

ICD-10-PCS Coding:

AROM – Artificial Rupture of Membranes

10907ZC: Drainage of amniotic fluid, therapeutic from product of conception, via natural or artificial opening

Labor Induction

Cervical Dilators: 0U7C7ZZ – Dilation of cervix, via natural or artificial opening

Cervical Dilators: 0U7C7DZ – Dilation of cervix with intraluminal device, via natural or artificial opening

Oxytocin/Pitocin: 3E033VJ – Introduction of other hormone into peripheral vein, percutaneous approach

Cervical Ripening: 3E0P7GC/3E0P7VZ – Introduction of other therapeutic substance/hormone into female reproductive via natural or artificial opening

Alliance for Innovation on Maternal Health (AIM) ICD-10-PCS Coding Guidelines for Labor Inductions v7-15-2016 were used to develop the NPIC Induction

Rate. https://safehealthcareforeverywoman.org/aim-data/

AHRQ IQI 33: Primary Cesarean Delivery Rate, Uncomplicated

First-time Cesarean deliveries without a hysterotomy procedure per 1,000 deliveries. Excludes deliveries with complications (abnormal presentation,

preterm delivery, fetal death, multiple gestation diagnoses, or breech procedure)

https://www.qualityindicators.ahrq.gov/Modules/IQI_TechSpec_ICD10_v2019.aspx

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