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CABELL HUNTINGTON HOSPITAL OBSTETRICAL PATIENT INITIATIVE. Isn’t all medicine evidence based? well;… sort of. EVIDENCE BASED MEDICINE. EVIDENCE BASED MEDICINE. Confounders: Volume of information Rapidity of change in technology

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CABELL HUNTINGTON HOSPITAL OBSTETRICAL PATIENT INITIATIVE

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Cabell huntington hospital obstetrical patient initiative

CABELL

HUNTINGTON

HOSPITAL OBSTETRICAL PATIENT

INITIATIVE


Isn t all medicine evidence based well sort of

Isn’t all medicine evidence based?

well;… sort of

EVIDENCE BASED MEDICINE


Evidence based medicine

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


Evidence based medicine1

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.


Evidence based medicine2

EVIDENCE BASED MEDICINE

When is term not really term?

In fact, what is term?


Evidence based medicine3

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?


Evidence based medicine4

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.


Evidence based medicine5

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


Evidence based medicine6

EVIDENCE BASED MEDICINE


Evidence based medicine7

EVIDENCE BASED MEDICINE

Sometime in the late 1980’s early 1990’s, “term”

pregnancy became a commonly used

description for 36 completed weeks gestation.


The transitional period the first few hours of life

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”


Neonatal cardiopulmonary transition after elective cesarean delivery

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


Neonatal respiratory morbidity following elective c section at term

NEONATAL RESPIRATORY MORBIDITY FOLLOWING ELECTIVE C-SECTION AT TERM

1994-1998, Univ. Hosp. Vrije, Amsterdam, The Netherlands

Gestational Age (wks)TotalsRespiratory 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


Neonatal respiratory morbidity after elective cesarean delivery does labor make a difference

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


Evidence based medicine8

EVIDENCE BASED MEDICINE

HCA (225,000 deliveries)

Elective Ind/CS% admitted to special care nursery

37 – 38 11%

38 – 39 8%

39+ 4%


Elective cesarean delivery and neonatal mortality united states cdc 1998 2001

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)

VaginalCesarean

(Rates per 1000 l.b.)

Total neonatal0.621.77

Early 0.331.07

Late0.290.69

Ref: McDorman, Birth 2006; 33 (3): 175-182. (Sep).


Elective delivery project at chh

ELECTIVE DELIVERY PROJECT AT CHH


Issues

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


Issues1

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


Issues2

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?


Goals

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


Objectives

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


Method

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


Audit

AUDIT

  • Audit compliance monthly, provide report to attendings, nursing quarterly

  • Establish compliance goals


The end

THE END


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