OBJECTIVE: The national primary cesarean delivery rate increased until 2004, but after 2004, this rate cannot be tracked using Vital Statistics data. Additionally, it is unknown whether changes in the primary cesarean delivery rate reflect changes in the rate of labor attempts, labor success, or both. Here, using hospital discharge data, we examined national trends in primary cesarean deliveries, labor attempts, and labor success among women without prior cesarean delivery between 1990 and 2010. STUDY DESIGN: This analysis of serial cross-sectional data from the National Hospital Discharge Survey used Joinpoint regression to assess trends over time and logistic regression with marginal effects to identify rates of change over time and adjust for demographic and clinical factors. RESULTS: The primary cesarean delivery rate declined 0.2 percentage points per year (95% confidence interval [CI], 0.1-0.3) between 1990 and 1999, increased 1.0 percentage point per year (95% CI, 0.8-1.2) between 1999 and 2004, and increased 0.3 percentage points (95% CI, 0.1-0.6) per year from 2004 until 2010. Between 1998 and 2005, the rate of labor attempts declined 0.4 percentage points (95% CI, 0.3-0.5) per year. No changes in the labor attempt rate occurred between 2005 and 2010. Labor success rates increased 0.2 percentage points (95% CI, 0.1-0.3) per year between 1990 and 1998 but then declined 0.5 (95% CI, 0.5-0.8) percentage points per year from 1998 to 2010. Adjusted results were similar. CONCLUSION: The primary cesarean delivery rate continued to increase after 2004. Increases in the primary cesarean delivery rate after 2005 were driven by declines in labor success rates.

The Johns Hopkins Oxytocin Protocol (JHOP) Survey was distributed to clinical labor and delivery staff to compare obstetrical providers' attitudes toward clinical protocols and the JHOP. Agreement by registered nurses (RNs), physicians in training (PIT), and attending physicians (APs) and certified nurse midwives (CNMs) was assessed with each of 4 attitudinal statements regarding whether clinical protocol and JHOP use result in better practice and are important to ensure patient safety. Odds of agreement with positive statements regarding clinical protocols did not differ significantly among groups. Odds of agreement with JHOP use resulting in better practice also did not differ significantly among provider groups. Odds of agreement with the JHOP being important to ensure patient safety were lower for the AP/CNM group compared with the RN group. Clinical protocol use is generally well received by obstetrical providers; however, differences exist in provider attitudes toward the use of an institutional oxytocin protocol.