Zero Birth Injury Initiative

1. Zero Birth Injury Initiative Phillip N. Rauk, MD Associate Professor, Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Women’s Health, University of Minnesota Medical School and Medical Director of the Birthplace at UMMC-Fairview Hospital

2. Objectives Basic safety improvement strategies Definition of birth trauma Brief story from Ascension Health Bundle science and IHI obstetrics bundles Impact of shoulder dystocia Where are we at Fairview?

3. Why are we doing this?

4. Preventable Perinatal Harm and Obstetrical Liability Failure to recognize fetal distress/non-reassuring fetal status Failure to effect a timely cesarean section Failure to properly resuscitate a depressed baby Inappropriate use of oxytocin/misoprostol Inappropriate use of vacuum/forceps Failure to manage shoulder dystocia

5. Characteristics of a Successful Safety Change Initiative High functioning team rather than expert individuals Shared mental models Situational awareness Common language Policies and order sets support these initiative

11. Story at Ascension Health Three hospital sites were selected for implementation of: Standardized order sets specific to augmentation and induction of labor Complete adherence to a IHI induction, augmentation and operative delivery bundles Best practices sharing across all disciplines Effective communication strategies using SBAR and culture change

12. Story at Ascension Health From February 2004 to June 2006 Bundle compliance achieved the goal of 95% compliance Elective inductions before 39 weeks fell to zero Operative delivery rate fell from 7.4% to 4.8% Birth trauma rate fell from 0.2% to 0.03% Primary cesarean rate remained unchanged at 22.5%

13. Ascension Health Birth Trauma

15. Bundle Science A bundle is a group of evidence-based interventions related to a disease or care process that, when executed together, result in better outcomes than when implemented individually. All components of the bundle must be met to achieve the desired better outcome

17. No Elective Inductions at < 39 weeks No Elective Late-Preterm Infants  RDS TTN Pulmonary infection Unspecified respiratory failure Recurrent apnea Temperature instability Jaundice that delays discharge Bilirubin induced brain injury

18. Vacuum Bundle

19. Vacuum Delivery Incidence of operative vaginal delivery is 10 – 15% Compared with SVD (SVD vs Vacuum) Rate of Death is 1/5000 vs 1/3333 Rate of IVH is 1/1900 vs 1/860 Rate of all injury is 1/216 vs 1/122 Includes nerve injury, seizure, CNS depression, mechanical ventilation Vacuum and Forceps rate of death is 1/1666 and rate of IVH is 1/280.

20. Pop-Offs “Pop-offs” are defined as a sudden complete detachment of the vacuum from the head with a rapid loss of pressure from the green zone to zero pressure. The number of “pop-offs” correlates with birth trauma, ranging from abrasions to subgaleal hemorrhage Generally > 3 increases the risk for birth injury

21. Maximum Pulls A pull is defined as use of traction during each contraction not the number of pulls within each contraction. There is no clear definition of the maximum pulls that should be attempted before the procedure is abandoned. Most experts feel up to 3-4 pulls is appropriate if progression in descent is noted with each subsequent pull. Failure to abandon the procedure when progress has not occurred is associated with an increase in birth trauma

22. Application Time There is limited data on application time Longer application times are associated with an increased risk for failure and for neonatal morbidities Most experts believe that consistent with other guidelines in the use of vacuum (i.e maximum pulls and progress) that 10 – 20 minutes is appropriate and that failure of any descent after 10 minutes predicts a high rate of failure

23. Other Considerations Poor technique also effects maternal and neonatal morbidity and mortality Improper application both with respect to placement on the head and station/position Lack of training and credentials to perform the procedure Use of a rocking motion or rotation Inattention to number of “pop-offs” and pulls

27. Are We There Yet? Induction and Augmentation Bundles Everyone knows about it but still not at 100% Problems with EFW Operative Vaginal Delivery Bundle >70% compliance but not integrated into system practice yet. We do have a 70% reduction in birth trauma and 30% reduction in AOI at UMMC-Riverside

28. Acknowledgements Becky Gams, R.N., M.S., A.P.N.L., University of Minnesota Medical Center, Fairview Phillip Rauk, M.D., University of Minnesota Medical Center, Fairview Samantha Sommerness, R.N., M.S.N., C.N.M., A.P.N.L., Fairview Southdale Hospital Ann Page, R.N., M.S.N., C.N.M. , University of Minnesota Medical Center, Fairview Charlie Hirt, M.D., Fairview Southdale Hospital Kristi Miller, R.N., M.S., Fairview Hospitals, Patient Safety Stan Davis, M.D., Fairview Hospitals, Patient Safety Carol Clark, R.N., M.S.N., C.N.P., Fairview Ridges Hospital Suzin Cho, M.D., Fairview Ridges Hospital Cass Dennison, R.N., B.S.H.A., Fairview Lakes Medical Center Ralph Magnusson, M.D., Fairview Lakes Medical Center Jan Gilmore, R.N.C, M.S,H.A., Fairview Red Wing Medical Center William Saul, M.D., Fairview Red Wing Medical Center Char Dekraker, R.N., I.B.C.L.C., Fairview Northland Medical Center Kathy Abrahamson, M.D., Fairview Northland Medical Center Tom George, M.D., University of Minnesota Medical Center, Fairview Ted Thompson M.D., University of Minnesota Medical Center, Fairview Michelle O’Brien, M.D., University of Minnesota Medical Center, Fairview