Carol Burke

Outcomes associated with introduction of a shoulder dystocia protocol

The objective of this study was to assess outcomes that are associated with the implementation of a shoulder dystocia protocol that is focused on team response. We identified women who had a shoulder dystocia during 3 time periods: 6 months before (period A), 6 months during (period B), and 6 months after (period C) the institution of a shoulder dystocia protocol. Documentation and health outcomes were compared among the time periods. During the study period, 254 women (77, 100, and 77 in periods A, B, and C, respectively) had a shoulder dystocia. There were no differences among study periods in patient characteristics. However, complete and consistent documentation increased (14% to 50% to 92%; P < .001), and brachial plexus palsy that was diagnosed at delivery (10.1% to 4.0% to 2.6%; P = .03) and at neonatal discharge (7.6% to 3.0% to 1.3%; P = .04) declined.

The effect of live and web-based education on the accuracy of blood-loss estimation in simulated obstetric scenarios

OBJECTIVE Visual estimation of blood loss has been shown to be inaccurate. The objective of this study was to evaluate the impact of a didactic training program on the accuracy of the estimation of blood loss and to compare the effectiveness of training provided by a web-based vs live session. STUDY DESIGN Multidisciplinary labor and delivery unit personnel participated in live or web-based training. Both sessions comprised a 5-station pretest and posttest. The primary outcome was the accuracy of estimated blood loss in the pretest compared with the posttest with the use of the Mann-Whitney U test. RESULTS Among 372 providers, the median improvement between pre- and posttest results was 34% (95% confidence interval, 10-57%; P < .001). This improvement did not differ significantly between the live sessions and web-based sessions (4%; 95% confidence interval, -10% to 12%). CONCLUSION Our study supports the use of live or web-based training to improve blood loss estimation accuracy.

Development and Implementation of a Team-centered Shoulder Dystocia Protocol

Objective: To develop and evaluate a team-centered shoulder dystocia protocol. Methods: This project was undertaken in two phases. The first phase consisted of protocol development, during which a basic protocol was initially developed on the basis of targeted interviews with obstetric care providers and then refined through iterative performances of the protocol. The second phase consisted of dissemination of the final protocol to obstetric providers using low-fidelity simulation. Quantitative analysis was performed regarding the frequency with which key protocol components were undertaken during the unit-wide simulation drills. Results: Qualitative data analysis revealed several potential impediments to optimal team function during a shoulder dystocia, including lack of understanding that a shoulder dystocia was occurring, difficulty with efficient summoning of additional staff, lack of role clarity, reduced situational awareness, and variable documentation. A protocol that seeks to overcome these impediments can be successfully introduced to obstetric personnel through simulated shoulder dystocia drills, during which providers become increasingly more likely to incorporate different actions of the protocol during a simulated shoulder dystocia. Conclusions: Low-fidelity simulations can be used to introduce and improve the aspects of teamwork that may be useful for the management of shoulder dystocia.

Interdisciplinary collaboration to maintain a culture of safety in a labor and delivery setting

A culture of safety is a growing movement in obstetrical healthcare quality and management. Patient-centered and safe care is a primary priority for all healthcare workers, with communication and teamwork central to achieving optimal maternal health outcomes. A mandatory educational program was developed and implemented by physicians and nurses to sustain awareness and compliance to current protocols within a large university-based hospital. A didactic portion reviewing shoulder dystocia, operative vaginal delivery, obstetric hemorrhage, and fetal monitoring escalation was combined with a simulation session. The simulation was a fetal bradycardia activating the decision to perform an operative vaginal delivery complicated by a shoulder dystocia. More than 370 members of the healthcare team participated including obstetricians, midwives, the anesthesia team, and nurses. Success of the program was measured by an evaluation tool and comparing results from a prior safety questionnaire. Ninety-seven percent rated the program as excellent, and the response to a question on perception of overall grade on patient safety measured by the Agency for Healthcare Research and Quality safety survey demonstrated a significant improvement in the score (P = .003) following the program.

Active versus expectant management of the third stage of labor and implementation of a protocol.

Although the focus at delivery may naturally shift to infant transition, continued maternal vigilance during stage 3 is imperative to accomplish a safe outcome for the mother and her newborn. The third stage of labor is a normal physiological progression of birth that may be compounded by serious complications. The most common complication is postpartum hemorrhage due to uterine atony. Clinicians choose either active management or expectant management for stage 3 to prevent excessive maternal blood loss. Rapid identification and response to a postpartum hemorrhage are critical. A multidisciplinary perinatal team at a large Midwest tertiary center led the transition from an expectant to an active-management protocol within the obstetric service. Outcomes included a decrease in the postpartum hemorrhage rate and decreased usage of additional uterotonic medications during the immediate recovery period.

Changes in care associated with the introduction of a postpartum hemorrhage patient safety program.

OBJECTIVE To determine whether the introduction of a postpartum hemorrhage (PPH) patient safety program was associated with changes in patient care or outcomes. STUDY DESIGN A multipronged patient safety program regarding PPH was instituted at a tertiary care maternity hospital. Patient care and outcomes were assessed for 6 months prior to (period A) and 6 months after (period B) program institution. RESULTS In all, 278 and 341 women were diagnosed with PPH during periods A and B, respectively. Women who had a PPH after the program were more likely to receive more than one dose of prostaglandin F2 α (24% versus 9%, p = 0.01) and more than one type of uterotonic (34% versus 25%, p = 0.02) and to have a B-lynch suture placed (9.4% versus 4.7%, p = 0.03). The frequency of blood transfusion, hysterectomy, and intensive care unit admission were similar between periods. CONCLUSION Introduction of a PPH safety program resulted in several indications of a more quickly escalated response.

Chorioamnionitis at Term: Definition, Diagnosis, and Implications for Practice.

Chorioamnionitis is a serious complication during labor at term and is associated with adverse neonatal outcome affecting approximately 10% of pregnancies. It is diagnosed clinically or microbiologically or by histopathologic examination of the placenta and umbilical cord. The clinical criteria for chorioamnionitis found in preterm or term women include maternal fever combined with 2 or more findings of maternal tachycardia, fetal tachycardia, leukocytosis, uterine tenderness, and/or malodorous amniotic fluid. These subjective findings are neither sensitive nor specific. However, clinical chorioamnionitis requires a high index of suspicion, timely diagnosis, prompt antibiotic treatment, and delivery, which may help reduce the potentially devastating outcome of maternal and neonatal infections. This article focuses on clinical chorioamnionitis and presents the physiologic immune response during pregnancy, the definition of chorioamnionitis, clinical diagnostic criteria, and implications for practice.

Save the Perineum! A Protocol to Reduce Perineal Trauma

Paper Presentation Purpose for the Program Perineal trauma, including a third‐degree or fourth‐degree laceration, is a serious adverse outcome of a vaginal delivery, which can lead to chronic pain, urinary or bowel disturbances, and sexual dysfunction. The third‐degree and fourth‐degree laceration rate at this large university hospital was noted to be in the high range based on the University Health System Consortium database. The Obstetric Quality and Safety Committee identified the rate of third‐degree and fourth‐degree lacerations and charged a multidisciplinary team composed of physicians, nurses, and nurse–midwives to investigate potential causes that could be addressed to make positive improvements on the issue. Proposed Change To implement a perineal safety bundle for management of the second stage of labor. There are practices with some evidence thought to decrease perineal trauma; however, the team was not confident that one particular change alone would affect the rate of third‐degree and fourth‐degree lacerations. Therefore, a bundle was created composed of the following: (a) “Labor down” for at least 1 hour or until the urge to push is felt (but no longer than 2 hours); (b) use of warm packs to the perineum applied every 30 minutes during the second stage of labor; (c) change position every 15 to 20 minutes to help facilitate fetal descent and rotation; (d) foot position should rest on the bed or in foot rests instead of being held by the nurse or support person (avoidance of McRobert position except for the shoulder dystocia maneuver); and (e) avoidance of manual perineal stretching during the second stage of labor. Implementation, Outcomes, and Evaluation Nurses, physicians, and residents were educated about the bundle protocol. Physicians were given the option to opt‐in or opt‐out of the bundle. The protocol used during this 6‐month time frame concluded in January 2013. Data on differences between use of the bundle versus nonuse will be compared with third‐degree and fourth‐degree laceration rates. Implications for Nursing Practice The implementation of evidence‐based practice related to the second stage of labor is a process. Varied techniques of leg holding positions, perineal massage and manipulation, and passive management of the “labor down” phase have been thought to add to the perineal trauma and use of operative vaginal delivery techniques. Introduction of the bundle has provided direction to the nursing and medical staff in use of evidence‐based practice.