Janet A. Meyers

Maternal death in the 21st century: causes, prevention, and relationship to cesarean delivery.

OBJECTIVE We sought to examine etiology and preventability of maternal death and the causal relationship of cesarean delivery to maternal death in a series of approximately 1.5 million deliveries between 2000 and 2006. STUDY DESIGN This was a retrospective medical records extraction of data from all maternal deaths in this time period, augmented when necessary by interviews with involved health care providers. Cause of death, preventability, and causal relationship to mode of delivery were examined. RESULTS Ninety-five maternal deaths occurred in 1,461,270 pregnancies (6.5 per 100,000 pregnancies.) Leading causes of death were complications of preeclampsia, pulmonary thromboembolism, amniotic fluid embolism, obstetric hemorrhage, and cardiac disease. Only 1 death was seen from placenta accreta. Twenty-seven deaths (28%) were deemed preventable (17 by actions of health care personnel and 10 by actions of non-health care personnel). The rate of maternal death causally related to mode of delivery was 0.2 per 100,000 for vaginal birth and 2.2 per 100,0000 for cesarean delivery, suggesting that the number of annual deaths resulting causally from cesarean delivery in the United States is about 20. CONCLUSION Most maternal deaths are not preventable. Preventable deaths are equally likely to result from actions by nonmedical persons as from provider error. Given the diversity of causes of maternal death, no systematic reduction in maternal death rate in the United States can be expected unless all women undergoing cesarean delivery receive thromboembolism prophylaxis. Such a policy would be expected to eliminate any statistical difference in death rates caused by cesarean and vaginal delivery.

Improved outcomes, fewer cesarean deliveries, and reduced litigation: results of a new paradigm in patient safety

In a health care delivery system with an annual delivery rate of approximately 220,000, a comprehensive redesign of patient safety process was undertaken based on the following principles: (1) uniform processes and procedure result in an improved quality; (2) every member of the obstetric team should be required to halt any process that is deemed to be dangerous; (3) cesarean delivery is best viewed as a process alternative, not an outcome or quality endpoint; (4) malpractice loss is best avoided by reduction in adverse outcomes and the development of unambiguous practice guidelines; and (5) effective peer review is essential to quality medical practice yet may be impossible to achieve at a local level in some departments. Since the inception of this program, we have seen improvements in patient outcomes, a dramatic decline in litigation claims, and a reduction in the primary cesarean delivery rate.

Reducing Obstetric Litigation Through Alterations in Practice Patterns

OBJECTIVE: To estimate the extent to which obstetric malpractice claims might be reduced by adherence to a limited number of specific practice patterns. METHODS: We examined all 189 closed perinatal claims between 2000 and 2005 from a single, large, professional liability insurer. Each case was subjected to three separate analyses: 1) whether the adverse outcome was caused by substandard care, 2) what changes in practice likely would have avoided the adverse outcome, regardless of standard-of-care considerations, and 3) to what extent did substandard documentation lead to payment in cases in which there was no objective evidence of substandard care. RESULTS: Seventy percent of claims involving obstetric practice (accounting for 79% of all costs) involved substandard care. Payments in 85% of cases involving non–vaginal birth after cesarean (VBAC) fetal monitoring, 16% of maternal injury cases, 80% of cases involving VBAC, and 54% of shoulder dystocia cases were avoidable had four specific practice and documentation patterns been followed. CONCLUSION: Most money currently paid in conjunction with obstetric malpractice cases is a result of actual substandard care resulting in preventable injury. Well more than half of hospital litigation costs might be avoided if physician practice included: 1) delivery in a facility with 24-hour in-house obstetric coverage; 2) adherence to published high-risk medication protocols; 3) a more conservative approach to VBAC; and 4) use of a comprehensive, standardized procedure note in cases of shoulder dystocia. LEVEL OF EVIDENCE: III

Maternal mortality in the United States: predictability and the impact of protocols on fatal postcesarean pulmonary embolism and hypertension-related intracranial hemorrhage.

OBJECTIVE The purpose of this study was to examine the efficacy of specific protocols that have been developed in response to a previous analysis of maternal deaths in a large hospital system. We also analyzed the theoretic impact of an ideal system of maternal triage and transport on maternal deaths and the relative performance of cause of death determination from chart review compared with a review of discharge coding data. STUDY DESIGN We conducted a retrospective evaluation of maternal deaths from 2007-2012 after the introduction of disease-specific protocols that were based on 2000-2006 data. RESULTS Our maternal mortality rate was 6.4 of 100,000 births in just >1.2 million deliveries. A policy of universal use of pneumatic compression devices for all women who underwent cesarean delivery resulted in a decrease in postoperative pulmonary embolism deaths from 7 of 458,097 cesarean births to 1 of 465,880 births (P = .038). A policy that involved automatic and rapid antihypertensive therapy for defined blood pressure thresholds eliminated deaths from in-hospital intracranial hemorrhage and reduced overall deaths from preeclampsia from 15-3 (P = .02.) From 1-3 deaths were related causally to cesarean delivery. Only 7% of deaths were potentially preventable with an ideal system of admission triage and transport. Cause of death analysis with the use of discharge coding data was correct in 52% of cases. CONCLUSION Disease-specific protocols are beneficial in the reduction of maternal death because of hypertensive disease and postoperative pulmonary embolism. From 2-6 women die annually in the United States because of cesarean delivery itself. A reduction in deaths from postpartum hemorrhage should be the priority for maternal death prevention efforts in coming years in the United States.

Reduction of Severe Hyperbilirubinemia After Institution of Predischarge Bilirubin Screening

OBJECTIVE: The objective of this study was to demonstrate efficacy of universal predischarge neonatal bilirubin screening in reducing potentially dangerous hyperbilirubinemia in a large, diverse national population. METHODS: This was a 5-year prospective study directed at neonates who were aged ≤28 days and evaluated at facilities of the Hospital Corporation of America with a serum bilirubin level of ≥20.0 mg/dL. This time frame includes periods before, during, and after the initiation of systemwide institution of a program of universal predischarge neonatal bilirubin screening. The primary outcome measures were serum bilirubin 25.0 to 29.9 and ≥30.0 mg/dL. Neonatal phototherapy use during these years was also analyzed. RESULTS: Of the 1028817 infants who were born in 116 hospitals between May 1, 2004, and December 31, 2008, 129345 were delivered before implementation and 899472 infants were delivered after implementation of this screening program in their individual hospitals. With a program of universal screening, the incidence of infants with total bilirubin 25.0 to 29.9 mg/dL declined from 43 per 100000 to 27 per 100000, and the incidence of infants with total bilirubin of ≥30.0 mg/dL dropped from 9 per 100000 to 3 per 100000 (P = .0019 and P = .0051, respectively). This change was associated with a small but statistically significant increase in phototherapy use. CONCLUSIONS: A comprehensive program of prevention, including universal predischarge neonatal bilirubin screening, significantly reduces the subsequent development of bilirubin levels that are known to place newborns at risk for bilirubin encephalopathy.

Emergency department use during the postpartum period: implications for current management of the puerperium.

OBJECTIVE The purpose of this study was to define patterns of morbidity that are experienced by women in the postpartum period who seek care in the emergency department within 42 and 100 days of discharge. STUDY DESIGN We conducted a retrospective examination of discharge diagnosis codes and descriptions for emergency department visits and analyzed temporal patterns of both emergency department visits and hospital readmissions. RESULTS During 2007, 222,084 patients delivered in Hospital Corporation of America facilities in the United States. Among these women, there were 10,751 emergency department visits within 42 days of delivery (4.8%). Fifty-eight percent of the patients were seen for conditions that were related to pregnancy; 42% of the patients were seen for conditions unrelated to pregnancy. Fifty percent of patients in the postpartum period who were seen either in the emergency department (21,833 patients) or readmitted (5190 patients) during both 2007 and 2008 had this encounter within 10 days of discharge. CONCLUSION The scheduling and content of traditional postpartum education and clinical visits appear poorly suited to the prevention of puerperal morbidity.

The changing specter of uterine rupture

OBJECTIVE The objective of the study was to review all patient records discharged with codes for uterine rupture in 2006 in Hospital Corporation of America hospitals. STUDY DESIGN All patient charts were distributed to a committee of perinatologists and general obstetricians. Case report forms were analyzed for variables of interest to determine validity of coding and quality of care. RESULTS Of 69 cases identified, only 41 were true ruptures. Twenty patients had previous cesareans, and in 9 of these patients, concurrent use of oxytocics was documented. Among the 21 patients without previous cesareans, 7 had previous uterine surgery, and oxytocics were documented in 12 of the remaining 14 patients. Standard of care violations were identified in 10 of 41 true rupture cases. CONCLUSION Epidemiological data on uterine rupture based on hospital discharge codes without concurrent chart review may be invalid. Patients with previous cesareans represent only half of true uterine ruptures in contemporary practice.

A systematic approach to the identification and classification of near-miss events on labor and delivery in a large, national health care system

We describe a systematic approach to the identification and classification of near-miss events on labor and delivery in a large, national health care system. Voluntary reports of near-miss events were prospectively collected during 2010 in 203,708 deliveries. These reports were analyzed according to frequency and potential severity. Near-miss events were reported in 0.69% of deliveries. Medication and patient identification errors were the most common near-miss events. However, existing barriers were found to be highly effective in preventing such errors from reaching the patient. Errors with the greatest potential for causing harm involved physician response and decision making. Fewer and less effective existing barriers between these errors and potential patient harm were identified. Use of a comprehensive system for identification of near-miss events on labor and delivery units have proven useful in allowing us to focus patient safety efforts on areas of greatest need.

Association of obstetric intervention with temporal patterns of childbirth.

OBJECTIVE: To examine the gestational age at and day and time of delivery in current U.S. obstetric practice. METHODS: We examined electronic records from 72 hospitals in 16 states during a 4-month period during 2013. Day of week of delivery, time of day of delivery, and route of delivery were examined in various subpopulations delivering both with and without obstetric intervention. RESULTS: Records of 21,381 women were examined. The distribution curve for gestational age at delivery peaked at 39 weeks both for the entire group and for the subgroup entering labor spontaneously and delivering vaginally without augmentation. Statistical modeling suggests that medical intervention accounts for only a fraction of the shift in distribution peak from 40 to 39 weeks of gestation. Three temporal peaks of total and primary cesarean delivery were seen on weekdays, corresponding to immediate preclinic, lunch time, and immediate postclinic timeframes. These peaks were not seen on weekend days. The risk of nonelective primary cesarean delivery during a weekday was approximately one third higher than on a weekend (relative rate 1.36, confidence interval 1.24–1.49). CONCLUSION: The recently described shift in peak distribution of U.S. gestational age at delivery from 40 to 39 weeks of gestation may reflect an underlying physiologic change in the U.S. population and is not exclusively related to obstetric intervention. During the work week, factors other than medical necessity appear to have a marked association with both timing of delivery and rate of cesarean delivery and may affect up to one third of primary cesarean deliveries.

Validation of the joint commission exclusion criteria for elective early-term delivery.

OBJECTIVE: To evaluate whether current Joint Commission (JC) exclusion criteria for measure PC-01, “Elective Delivery” before 39 weeks of gestation, accurately identify valid, codeable indications for planned early-term delivery. METHODS: We performed a review and critical analysis of all cases recorded as noncompliant for the measure in a large health care system during the second half of 2012. RESULTS: During the study period, of 107,145 total deliveries, 205 cases were reported as noncompliant with PC-01. Ten percent of compliance fallouts (ie, cases coded as noncompliant) resulted from valid indications for delivery identifiable by International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) coding not included on the JC exclusion list; these were primarily unusual or extreme variations of these conditions. Twenty-five percent of fallouts represented valid indications not represented by an ICD-9-CM code. Eight percent of cases were reported as fallouts as a result of imprecise physician charting; only 2% represented chart abstraction errors. Fifty-five percent of cases involved stated indications for early-term delivery not generally recognized as such by the medical community. Compliance rates of 98% are achievable across a large population using the current ICD-9-CM–based metric for compliance assessment used by the JC (PC-01). The current exclusion list does not appear to be amenable to further improvement by inclusion of more or different ICD-9-CM codes. However, given the low volumes generated using the current PC-01 denominator definition, approximately 60% of facilities would have compliance rates below a 95% benchmark with even a single justified outlier if analyzed on a quarterly basis. CONCLUSION: Our data validate the current JC exclusion criteria for this measure, which identify the vast majority of valid indications for early-term delivery used by obstetrician–gynecologists and identifiable with ICD-9-CM codes. LEVEL OF EVIDENCE: III