The objective of this study was to evaluate the impact of quality improvement (QI) and patient safety initiatives and data disaggregation on racial disparities in severe maternal morbidity from hemorrhage (SMM-H).Our hospital began monitoring and reporting on SMM-overall and SMM-H rates in 2018 using administrative data. In March 2019, we began stratifying data by race and ethnicity and noted a disparity in rates, with non-Hispanic Black women having the highest SMM rates. The data was presented as run charts at monthly department meetings. During this time, our hospital implemented several QI and patient safety initiatives around obstetric hemorrhage and used the stratified data to inform guideline development to reduce racial disparity. The initiatives included implementation of a hemorrhage patient safety bundle and in-depth case reviews of adverse patient outcomes with a health equity focus. We then retrospectively analyzed our data. Our outcome of interest was SMM-H prior to data stratification (pre-intervention: June 2018-February 2019) as compared to after data stratification (post-intervention: March 2019-June 2020).During our study time period, there were 13,659 deliveries: 37% Hispanic, 35% White, 20% Black, 7% Asian and 1% Other. Pre-intervention, there was a statistically significant difference between Black and White women for SMM-H rates (p<0.001). This disparity was no longer significant post-intervention (p=0.138). The rate of SMM-H in Black women decreased from 45.5% to 31.6% (p=0.011).Our findings suggest that QI and patient safety efforts that incorporate race and ethnicity data stratification to identify disparities and use the information to target interventions have the potential to reduce disparities in SMM.
OBJECTIVE: To evaluate the relationship between umbilical artery cord gas values and fetal tolerance of labor, as reflected by Apgar score. We hypothesized the existence of wide biological variability in fetal tolerance of metabolic acidemia, which, if present, would weaken one fundamental assumption underlying the use of electronic fetal heart rate (FHR) monitoring. METHODS: We conducted a retrospective cohort study of term, singleton, nonanomalous fetuses delivered in our institution between March 2012 and July 2020. Universally obtained umbilical cord gas values and Apgar scores were extracted. We calculated Spearman correlation coefficients and receiver operating characteristic curves for various levels of umbilical artery pH, base excess, and Apgar scores. RESULTS: We analyzed data from 29,787 deliveries. The statistical correlation between umbilical artery pH and base excess and both 1- and 5-minute Apgar scores was weak or nonexistent in all pH range subgroups (range 0.064–0.213). Receiver operating characteristic curve analysis suggested umbilical artery pH value of 7.22 yields the best discrimination for prediction of a severely depressed newborn (5-minute Apgar score less than 4), but sensitivity and specificity for this predictive value remains poor to moderate. CONCLUSION: The use of electronic FHR monitoring is predicated on a documented relationship between FHR patterns and umbilical artery pH, and an assumed correlation between pH and fetal outcomes, reflecting fetal tolerance of labor and delivery. Our data demonstrate a weak-to-absent correlation between metabolic acidemia and even short-term fetal condition, thus significantly weakening this latter assumption. No amount of future modification of FHR pattern interpretation to better predict newborn pH is likely to lead to improved newborn outcomes, given this weakness in a fundamental assumption on which FHR monitoring is based.
Summary Serious neurological lesions such as vertebral canal haematoma are rare after obstetric regional analgesia/anaesthesia, but early detection may be crucial to avoid permanent damage. This may be hampered by the variable and sometimes prolonged recovery following ‘normal’ neuraxial block, such that an underlying lesion may easily be missed. These guidelines make recommendations for the monitoring of recovery from obstetric neuraxial block, and escalation should recovery be delayed or new symptoms develop, with the aim of preventing serious neurological morbidity.
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(Anaesthesia. 2020;75:913–919) Early detection of neurological complications following a neuraxial procedure is essential to minimizing harm. Previous guidelines for management of neuraxial anesthesia lack guidance on neurological monitoring or are not specific to obstetric patients. The recommendations in this paper were produced by representatives from the Association of Anesthetists and Obstetric Anesthetists’ Association with the goal to guide monitoring and management of neurologic recovery in obstetric patients following neuraxial block.
Education, performance feedback, and the Hawthorne effect were associated with a reduction in the episiotomy rate in a large academic institution without a reduction in the rate of operative vaginal delivery or an increase in the rate of third- and fourth-degree lacerations.
INTRODUCTION: To identify risk factors of patients who are readmitted in the immediate postpartum period for management of hypertensive disorders. METHODS: Retrospective cohort study from 2012-2019 at a tertiary care academic center of all women with a diagnosis of hypertensive disorders during the delivery admission. Maternal characteristics for women readmitted within 30 days postpartum were compared to those not readmitted. RESULTS: Of 40,124 deliveries, 8361 were identified as having a hypertensive disorder (20.8%). 85 were subsequently readmitted for management of hypertension in the postpartum period (1%). Maternal age was significantly correlated with a higher rate of readmission (P<.001). No differences were noted among BMI, gestational age, race/ethnicity, chronic hypertension diagnosis, nulliparity, or multiple gestations. Readmitted patients showed a significantly higher rate of antihypertensive use during the delivery admission (1.33% vs 0.95%, P=.049) and those discharged on labetalol had a higher rate of readmission when compared to those discharged on nifedipine (1.51% vs 0.63%, P=.058). Patients with private insurance were more likely to be readmitted versus those with Medicaid insurance (1.25% vs 0.59%, P=.012). CONCLUSION: Women with hypertensive disorders discharged home on antihypertensive medication are more likely to be readmitted during the postpartum period and may benefit from increased vigilance during this time period. Further investigation is needed to determine the effect of insurance on readmission rate and if social determinants of health impact postpartum hypertension follow up visits. The use of nifedipine versus labetalol also warrants further investigation as there appears to be a trend towards improved blood pressure control with nifedipine.
INTRODUCTION: Provider bias plagues behavioral health screening in pregnancy. One in three pregnant women will utilize illicit substances, experience depression/anxiety, or be a victim of violence. Following our Phase I results presented in 2019, we aimed to develop a standardized algorithm for providers to guide response to positive behavioral health screens. METHODS: Through an IRB approved protocol, we screened 260 patients at three intervals during pregnancy between January and June 2019. Patients in a Maternal Fetal Medicine clinic voluntarily completed the Integrated Screening Tool at three separate encounters. A novel, evidence-based algorithm was developed and utilized to guide provider response to a positive screen. RESULTS: During the study period, 479 eligible screening visits occurred among 260 patients. Compared to Phase I, indicated urine drug screen (UDS) completion increased from 13% to 80% (P<.001), of which 11% were positive. Across the screening intervals, 65% of patients with an initial positive screen, subsequently answered negative. Of the patients who initially screened negative, 25% had a positive screen later in pregnancy, of which 33% UDS were positive. Referral to mental health services for patients with a positive emotional health screen increased by 100% following implementation of the algorithm (P<.002). CONCLUSION: Utilizing a standardized algorithm guiding provider response to behavioral health screening in pregnancy significantly increased provider action yet did not identify a significant increase in detecting patients using illicit substances. Longitudinal screening is important as patients are likely to change their response. Additional study is indicated to further establish validity of this novel algorithm.
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