Wednesday, October 14, 2015

New National Recommendations for Safe Reduction of Primary Cesarean Births

In recent years, several national partners including ACOG, AWHONN, SMFM, CDC, HRSA and others came together as the National Partnership for Maternal Safety and have worked with the Council on Patient Safety in Women’s Health to create several “bundles” of recommendations to improve the outcomes and safety of pregnant women.

A bundle is a checklist of specific changes that, if followed, will lead to improvement.

Bundles are a collection of succinct evidence-based components that when implemented together should have a positive impact on outcomes and safety for pregnant women. The bundles have four domains, Readiness, Recognition and Prevention, Response, and Reporting/Systems Learning. The bundles provide the core elements that every hospital can implement for every woman, every time. Birth facilities are encouraged to expand on the core component by developing policies, protocols and standardized practices that best meet local needs and are evidence based.

The first bundle that was released by this partnership focused on obstetric hemorrhage, one of the leading causes of maternal mortality. It has since been followed by other bundles focusing on high impact, high volume health and safety issues such as hypertension in pregnancy and safe reduction of primary cesarean births.

Below, I share with you the new national patient safety bundle recommendations for supporting intended vaginal births. You may click the image to enlarge. Lowering the primary cesarean section will increase maternal safety by decreasing morbidity from unnecessary surgeries and the consequences of prior cesarean delivery in future pregnancies.

Safe Reduction of Primary Cesarean Births: Supporting Intended Vaginal Births

Every patient, provider, and facility

  • Build a provider and maternity unit culture that values, promotes, and support spontaneous onset and progress of labor and vaginal birth and understands the risks for current and future pregnancies of cesarean birth without medical indication.
  • Optimize patient and family engagement in education, informed consent, and shared decision making about normal healthy labor and birth throughout the maternity care cycle.
  • Adopt provider education and training techniques that develop knowledge and skills on approaches which maximize the likelihood of vaginal birth, including assessment of labor, methods to promote labor progress, labor support, pain management (both pharmacologic and non-pharmacologic), and shared decision making.

Every patient

  • Implement standardized admission criteria, triage management, education, and support for women presenting in spontaneous labor.
  • Offer standardized techniques of pain management and comfort measures that promote labor progress and prevent dysfunctional labor.
  • Use standardized methods in the assessment of the fetal heart rate status, including interpretation, documentation using NICHD terminology, and encourage methods that promote freedom of movement.
  • Adopt protocols for timely identification of specific problems, such as herpes and breech presentation, for patients who can benefit from proactive intervention before labor to reduce the risk for cesarean birth.
to every labor challenge
  • Have available an in-house maternity care provider or alternative coverage which guarantees timely and effective responses to labor problems.
  • Uphold standardized induction scheduling to ensure proper selection and preparation of women undergoing induction.
  • Utilize standardized evidence-based labor algorithms, policies, and techniques, which allow for prompt recognition and treatment of dystocia.
  • Adopt policies that outline standard responses to abnormal fetal heart rate patterns and uterine activity.
  • Make available special expertise and techniques to lessen the need for abdominal delivery, such as breech version, instrumented delivery, and twin delivery protocols.
Every birth facility
  • Track and report labor and cesarean measures in sufficient detail to: 1) compare to similar institutions, 2) conduct case review and system analysis to drive care improvement, and 3) assess individual provider performance.
  • Track appropriate metrics and balancing measures, which assess maternal and newborn outcomes resulting from changes in labor management strategies to ensure safety.

I listened to the organization's conference call presentation on this new bundle. Chair of the workgroup. David Lagrew, noted:
- that 53% of disparity in cesarean section rates is related to labor induction and early admission.
- rates vary from provider to provider, so individual provider data tracking is helpful to make change
- He also emphasized creating a Culture of Supporting Intended Vaginal Delivery:
To be successful, one must achieve development of a culture in which the clinical providers, administrative support and public: 1) appreciate the true value of achieving a vaginal delivery; 2) respectfully acknowledges the desires of the patient and 3) maintains educational processes, facilities, equipment and staff expertise which can maximize the chance of successfully obtaining vaginal delivery which is safe for mother and infant(s).
Co-presenter Lisa Kane Low noted these recommendations:
- don't admit women prior to 6 cm (especially first time moms) for active labor
-in-house persons, e.g. laborists, available without other demands, are associated with an increase in spontaneous vaginal deliveries
- make doulas part of the team
- look at Bishop score to schedule inductions and reduce inductions prior to 41 weeks.
- have specialized providers available for breech version, instrumental delivery, and twin delivery

Keep an eye out on the Safety Actions Series website if you'd like the slides and recording from this call. Listen especially to the Q&A and discussion at the end!

The California Maternal Quality Care Collaborative will be coming out with a toolkit for this topic, as they have in the past for previous topics, so I will be excitedly waiting for that!

Additionally, here is the list of resources that the Council includes as part of this safety bundle:

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