CABELL HUNTINGTON HOSPITAL OBSTETRICAL PATIENT INITIATIVE

1. CABELL HUNTINGTON HOSPITAL OBSTETRICAL PATIENT INITIATIVE

2. Isn’t all medicine evidence based? well;… sort of EVIDENCE BASED MEDICINE

3. EVIDENCE BASED MEDICINE Confounders: • Volume of information • Rapidity of change in technology • Ongoing sensationalization by uninformed observers • Direct marketing by drug companies • Experience and its constipating effect

4. EVIDENCE BASED MEDICINE So what do we really know in obstetrics (evidence based) • Group B Strep screening & prophylaxis works. • Shoulder dystocia is unpredictable; so be ready! • Labor inhibition with MgSO4 does not work and, incidentally, is dangerous! • There is still no advantage to being born premature.

5. EVIDENCE BASED MEDICINE When is term not really term? In fact, what is term?

6. EVIDENCE BASED MEDICINE Duration of pregnancy Embryologic 266 d +/- 14 d Obstetric 280 d +/- 14 d Mean, median or mode and is the “14 d” a standard deviation?

7. EVIDENCE BASED MEDICINE 40 years ago, if you were born prior to 38 weeks gestation, whether or not you survived was for the most part determined by your lungs. If they worked, you would probably live, if not, you would likely die.

8. EVIDENCE BASED MEDICINE In the early 1970’s, Joe Gluck, working in San Diego, identified a marker for lung functional maturity. The L/S ratio could reliably predict who would probably not get RDS

9. EVIDENCE BASED MEDICINE

10. EVIDENCE BASED MEDICINE Sometime in the late 1980’s early 1990’s, “term” pregnancy became a commonly used description for 36 completed weeks gestation.

11. THE TRANSITIONAL PERIODThe First Few Hours of Life • FIRST STAGE : 0 – 30 minutes “First Period of Reactivity • SECOND STAGE : 30 minutes – 2 hours “Period of Unresponsiveness” • THIRD STAGE : 2 – 8 hours “Second Period of Reactivity”

12. NEONATAL CARDIOPULMONARY TRANSITION AFTER ELECTIVE CESAREAN DELIVERY Babies born by ECD are more likely to have: • More lung fluid at the time of birth • A more intense and prolonged First Stage (60’ – 120’) • Delayed improvement in lung compliance • Delayed establishment of FRC (6h vs 3h) • Slower decline of PVR • Less than optimal respiratory control. They exhibit more sleep apneas of longer duration during quiet sleep. - Boon - J Pediatr 98: 912-815, 1981 - Hagnevick – Early Hum Dev 27: 103-10, 1991 - Agaia – Biol Neonate 68: 404, 1995 - Bader – AciaPaediatr 93: 1216-23, 2004

14. NEONATAL RESPIRATORY MORBIDITY FOLLOWING ELECTIVE C-SECTION AT TERM 1994-1998, Univ. Hosp. Vrije, Amsterdam, The Netherlands Gestational Age (wks) Totals Respiratory Morbidity 37 – 37 6/7 505 40 (7.92) 38 – 38 6/7 1341 61 (4.54) >39 1100 13 (1.18) _______________________________________________________________ TOTAL 2946 114 (3.86) Adapted from: Table 3 in van der Berg. Eur J ObstetGynecolReprod Biol. 2001; 98: 9-13

16. NEONATAL RESPIRATORY MORBIDITY AFTER ELECTIVE CESAREAN DELIVERYDoes Labor Make a Difference? • There is strong evidence of the benefits of labor prior to an ECD • Although ECD is an independent risk factor for NRM, this risk is reduced with labor before cesarean, but still remains elevated - Curet – Int J GynecolObstet 27: 165-70, 1988 - Morrison – Br J ObstetGynecol 102: 101-6, 1995 - Hood – Pediatrics 100: 348-53, 1997 - Gerter – Am J GynecolObstet 193: 1061-4, 2005

17. EVIDENCE BASED MEDICINE HCA (225,000 deliveries) Elective Ind/CS % admitted to special care nursery 37 – 38 11% 38 – 39 8% 39+ 4%

18. ELECTIVE CESAREAN DELIVERY AND NEONATAL MORTALITY(United States, CDC: 1998-2001) Neonatal mortality rates were 2.9 times higher among infants delivered by primary elective cesarean delivery (1.77 per 1000 live births) than for those delivered vaginally (0.62 per 1000 live births) Vaginal Cesarean (Rates per 1000 l.b.) Total neonatal 0.62 1.77 Early 0.33 1.07 Late 0.29 0.69 Ref: McDorman, Birth 2006; 33 (3): 175-182. (Sep).

19. ELECTIVE DELIVERY PROJECT AT CHH

20. ISSUES • There are increasing numbers of elective deliveries (ind/RCS/1°CS) being done at CHH. • Elective inductions, especially in primagravidas are associated with an increased risk of cesarean section, 36% in WV in 2005, 50% or more at CHH. • There has been an associated drift toward earlier and earlier elective delivery which brings into play the issue of iatrogenic prematurity

21. ISSUES • The use of pitocin and cervical ripening agents are not without risk • Fifty percent of fetal birth trauma is associated with the use of pitocin • A major source of difficulty in defending “bad baby” cases is inconsistent terminology in describing FHR patterns

22. ISSUES Federal payors are initiating non-payment exclusions for certain complications of elective/preventable health care events, eg: catheter related infections, central line related infections, blood incompatibility, etc. DOES IT NOT SEEM POSSIBLE, IF NOT PROBABLE, THAT COMPLICATIONS OF ELECTIVE DELIVERIES PRIOR TO 39 WKS GESTATION MIGHT NOT SOON FOLLOW?

23. GOALS • Eliminate the incidence of iatrogenic birth trauma and prematurity • Eliminate elective inductions, repeat cesarean sections and elective cesarean sections prior to 39 weeks gestation • Optimize defense of unpreventable bad outcomes

24. OBJECTIVES • Standardize the nomenclature of FHR interpretation • Standardize the use of pitocin • Require evaluation of the maternal fetal status prior to instituting the use of pitocin utilizing information bundles

28. METHOD • Inservice physicians and nursing on the use, risks and complications of cervical ripening agents and pitocin • Establish a single pitocin protocol • Inservice and certify physicians and nursing on the use of NICHD FHR nomenclature • Phase in induction, augmentation, repeat cesarean section and elective cesarean section bundles

29. AUDIT • Audit compliance monthly, provide report to attendings, nursing quarterly • Establish compliance goals

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