Protocol - Mode of Delivery - Medical Record Abstraction
Description
Information about the womans delivery is abstracted from her medical chart.
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.
Availability
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 Category | Required |
---|---|
Major equipment | No |
Specialized training | No |
Specialized requirements for biospecimen collection | No |
Average time of greater than 15 minutes in an unaffected individual | No |
Mode of Administration
Medical record abstraction
Lifestage
Pregnancy
Participants
Woman postpartum
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
Standard | Name | ID | Source |
---|---|---|---|
Human Phenotype Ontology | Induced vaginal delivery | HP:0030369 | HPO |
Human Phenotype Ontology | Forceps delivery | HP:0011411 | HPO |
caDSR Form | PhenX PX241302 - Mode Of Delivery Medical Record Abstraction | 6912925 | caDSR Form |
Derived Variables
None
Process and Review
Not applicable.
Protocol Name from Source
A Randomized Trial of Induction Versus Expectant Management (ARRIVE), 2016
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
Export VariablesVariable Name | Variable ID | Variable Description | dbGaP Mapping | |
---|---|---|---|---|
PX241302_Mode_Delivery_Medical_Records_Date_Admission | ||||
PX241302010000 | Date of admission to Labor and Delivery | N/A | ||
PX241302_Mode_Delivery_Medical_Records_Date_Delivery | ||||
PX241302070000 | Date of delivery (mm-dd-yyyy) | N/A | ||
PX241302_Mode_Delivery_Medical_Records_Delivery_Type | ||||
PX241302090000 | Successful delivery type | N/A | ||
PX241302_Mode_Delivery_Medical_Records_Induction_Indications | ||||
PX241302060100 | Indication(s) for induction (check all that apply) | N/A | ||
PX241302_Mode_Delivery_Medical_Records_Induction_Indications_Other | ||||
PX241302060200 | Indication(s) for induction (check all that more | N/A | ||
PX241302_Mode_Delivery_Medical_Records_Initiating_Event_Delivery | ||||
PX241302130000 | Initiating event of delivery (complete for more | N/A | ||
PX241302_Mode_Delivery_Medical_Records_Labor_Type | ||||
PX241302050000 | Type of labor | N/A | ||
PX241302_Mode_Delivery_Medical_Records_Membrane_Rupture_Type | ||||
PX241302040000 | If the patient has both spontaneous ROM and more | N/A | ||
PX241302_Mode_Delivery_Medical_Records_Primary_Indication_Vaginal_Cesarean | ||||
PX241302100101 | Record the primary indication for vaginal or more | N/A | ||
PX241302_Mode_Delivery_Medical_Records_Primary_Indication_Vaginal_Cesarean_Other | ||||
PX241302100102 | Record the primary indication for vaginal or more | N/A | ||
PX241302_Mode_Delivery_Medical_Records_Reason_Admission | ||||
PX241302030000 | Indication for admission (check 1) | N/A | ||
PX241302_Mode_Delivery_Medical_Records_Secondary_Indications | ||||
PX241302100201 | List up to 3 secondary indications | N/A | ||
PX241302_Mode_Delivery_Medical_Records_Secondary_Indications_Other | ||||
PX241302100202 | List up to 3 secondary indications. If coded more | N/A | ||
PX241302_Mode_Delivery_Medical_Records_Time_Admission | ||||
PX241302020000 | Time of admission | N/A | ||
PX241302_Mode_Delivery_Medical_Records_Time_Delivery | ||||
PX241302080000 | Time of delivery | N/A | ||
PX241302_Mode_Delivery_Medical_Records_Vacuum_Vaginal_Extraction | ||||
PX241302110000 | Vaginal vacuum extraction attempted | N/A | ||
PX241302_Mode_Delivery_Medical_Records_Vaginal_Forceps | ||||
PX241302120000 | Vaginal forceps attempted | N/A |
Measure Name
Mode of Delivery
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).
Keywords
pregnancy, vaginal delivery, cesarean delivery, Pregnancy Risk Assessment Monitoring System, PRAMS, Centers for Disease Control and Prevention, CDC, Maternal Fetal Medicine Units Network, MFMU, A Randomized Trial of Induction Versus Expectant Management, ARRIVE
Measure Protocols
Protocol ID | Protocol Name |
---|---|
241301 | Mode of Delivery - Interview |
241302 | Mode of Delivery - Medical Record Abstraction |
Publications
There are no publications listed for this protocol.