Background: Reliable care, understanding the process of care, and decreasing variation while being mindful of weak signals in the system allows the Perinatal teams to now learn about opportunities in the 1



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IHI Perinatal Community Labor Deep Dive Tool

Background:

Reliable care, understanding the process of care, and decreasing variation while being mindful of weak signals in the system allows the Perinatal teams to now learn about opportunities in the 1st and 2nd stage of labor.



Prerequisite: understanding of HRO concepts and proven record of execution (IHI oxytocin bundles >95%compliance). This work builds on successful execution of the oxytocin bundles, incorporates the work needed for effective vacuum bundle execution, and supports enhanced understanding of the process of labor experienced by patients in your organization.

Supporting References:

  1. Nursing Care and Management of the Second Stage of Labor, Second Edition. Association of Women’s Health, Obstetric and Neonatal Nurses. 2008.




  1. Hines S, Luna, K, Lofthus J, et al. Becoming a High Reliability Organization: Operational Advice for Hospital Leaders. (Prepared by the Lewin Group under Contract No. 290-04-0011.) AHRQ Publication No. 08-0022. Rockville, MD: Agency for Healthcare Research and Quality. April 2008.

  2. Bakker, P.C.Kurver, P.H. Kuik, ZD.J. et al. Elevated uterine activity increases the risk of fetal acidosis at birth. American Journal of Obstetrics and Gynecology.196, 313e311-e316.

  3. ACOG Practice Bulletin. Dystocia and Augmentation of Labor. Number 49. December 2003.

  4. ACOG Practice Bulletin. Fetal Lung Maturity. Number 97. September 2007.

  5. ACOG Practice Bulletin. Induction of Labor. Number 107, August 2009.

  6. ACOG Practice Bulletin. Intrapartum Fetal Heart Rate Monitoring. Number 106, July 2009.

  7. ACOG Practice Bulletin. Operative Vaginal Delivery, Number 17. June. 2000.

  8. ACOG Practice Bulletin. Postpartum Hemorrhage. Number 76. October 2006.

  9. ACOG Practice Bulletin. Shoulder Dystocia. Number 40. November 2002.

  10. Johnson J, Figueroa R, Garry D, et al. Immediate Maternal and Neonatal Effects of Forceps and Vacuum-Assisted Deliveries. Obstetrics and Gynecology. 2004; 103:513-8.

Please see Perinatal Bibliography for a complete list.



Structure

Yes

No

N/A

1. Interdisciplinary Fetal Monitoring Education










2. Documentation tools consistent with NICD terminology










3.Weekly fetal monitoring strip and case reviews (or#4)










4. Monthly fetal monitoring strip and case reviews










5. Standard mixture and policy for oxytocin administration










6. One standard administration order set










7. If provider opts out of standard order set, system in place to identify and address when standardized dosage is not followed.
Oxytocin

Deep


Dive











8. Team definition for tachysystole










9. Clinical algorithm for identification and management of tachysystole










10. Clinical algorithm for management of indeterminate/abnormal FHR patterns (NICHD 2009)










11. RN empowered to call cesarean team (not to diagnose the need for cesarean, but to activate the team)










12. RN empowered to call neonatal team










13. Consistent handoff tool {SBAR, etc} specify










14. Informed Consent for oxytocin administration










15. Individual Provider data published about induction/augmentation rates?










Labor Deep Dive Tool










16. Gestational age criteria standardized










17. Team definition for labor










18. Team definition for normal and abnormal first stage of labor.










19. Admission criteria standardized










20. Established criteria for augmentation.










21. Established team huddle at critical decision points in the patient journey. Example- (1)admission, (2)when patient is complete to review risk factors to proceed forward, (3)other examples- after 2 hours with minimal or no progress, discuss plan of care to include- forceps, vacuum, CB, continuation of pushing, etc.)










22. Second Stage Algorithm in place










23. Established policy and criteria for operative vaginal delivery ( forceps and vacuums)










24. Established team definition of normal and abnormal second stage of labor










25. Any dual mode delivery reviewed (vacuum-forceps; forceps-cesarean; etc)










26. Established neonatal hand off criteria










Worksheet

Study Population:

(TJC PC-02 Denominator) Nulliparous patients delivered of a live term singleton newborn in vertex presentation

OR:


(NQF Definition) Live births at or beyond 37.0 weeks gestation that are having their first delivery and are singleton (no twins or beyond) and vertex presentation (no breech or transverse positions). Excluded- patients with abnormal presentation, preterm, fetal death, multiple gestation diagnosis codes, or breech procedure codes.

Random sample of 20 patients who meet the definition.



Teams will then further define the segment of the population they will work on, example would be 1st or 2nd stage focus as a patient segment.
Team Worksheet (include all structural questions that request definitions)
Definition of Labor:

______________________________________________________________________________________________________________________________________

___________________________________________________________________
Team definition for normal and abnormal first stage of labor.

_________________________________________________________________________________________________________________________________________________________________________________________________________




Definition of protracted labor or arrest of descent ______________________________________________________________________________________________________________________________________

Notes:



All patient records: (TJC PC-02 Denominator) Nulliparous patients delivered of a live term singleton newborn in vertex presentation

BMI on admission _____ Gestational Age:____________

Weight gain in pregnancy___________ EFW:______________________

Diabetic Yes □ No□



  1. Reason for admission:

YES

NO

Bishops score / cervix on admit

  • Previous cervical ripening










  • Spontaneous labor










  • SROM










  • Medical induction reason










  • Elective Induction










  • AROM










  • Other










First Stage Recognition System

Time labor Diagnosed___________ Cervical status_______________

Time of arrest of labor_____________

Time of oxytocin augmentation___________ Cervical status_______________



If patient receives oxytocin in 1st Stage, review oxytocin deep dive process questions.


1st Stage Oxytocin Specific Review Process


Yes


No

Explanations to support the process questions

Careful Monitoring-

1. Appropriate level (high risk) based electronic fetal monitoring (or IA) for fetal heart rate and uterine activity while oxytocin administered.(Per Perinatal Guidelines)









High risk- every 15 minutes during the active phase of the first stage of labor. Every 5 minutes during the second stage of labor

2. Oxytocin initiated as intended – no delay in administration due to provider or nursing response.







Was there a delay in initiation or during administration due to provider unavailability, nursing staffing, provider staffing issues?

Timely Identification-

3. □Tachysystole identified and managed according to protocol /algorithm

□Tachysystole identified and managed according to team definition and standing orders








If tachysystole was not present, please make sure you note this in this column but do not collect information on yes/no unless it is present.

□ No tachysystole present



4.

□ Indeterminate/abnormal FHR identified









Note in this column if reassuring/normal status always present.

Appropriate Interventions-










5. Oxytocin dose decreased or discontinued during labor due to tachysystole?







__________#times

6. Oxytocin dose decreased or discontinued during labor due to FHR?







__________#times


7. Oxytocin resumed after a decrease or stop?







Decrease or stop related to the presence of tachysystole or non-reassuring FHR. Other?

8. Terbutaline administered?










9. Interventions needed?







Interventions may be change in position, IV fluid bolus, and emergency cesarean.

10. Once labor was progressing, was oxytocin discontinued?







Was oxytocin stopped when labor pattern was effective?

Activation of Team Response

11. Documentation of physician notification of change in dosage of oxytocin.












12. If requested, timely response by OB care provider for bedside evaluation.









13. Escalation plan in place if needed and documented.









If tachysystole or indeterminate/abnormal FHR noted, was provider supportive of decision to discontinue medication?


Delivered by cesarean yes no (if no proceed to 2nd Stage)

If yes, indication _______________________________________

Proceed to outcomes box.


SECOND STAGE RECOGNITION SYSTEM

Time complete: _____________ Station at start of 2nd stage: ____________


Time pushing started: ___________



Process

Yes

No

NA

Explanations to support the process questions

Careful Monitoring-

1. -Appropriate level (high risk) based electronic fetal monitoring (or IA) for fetal heart rate and uterine activity if oxytocin administered. (Per Perinatal Guidelines).

-With or without oxytocin, FHR and uterine activity is recorded, interpretable and consistent with risk level.














2. Supportive Care

-If AWHONN 2nd stage algorithm in place, evidence it was followed in the record.

-Evidence patient received alternative strategies for comfort care.














3.Powers: Uterine contractility adequate










Consider: adequate when entering second stage to turn off the Pit or to go up on the Pit to get the patient delivered.


4.Pitocin initiated / reinitiated in 2nd stage










Consider: starting augmentation in second stage or restarted once off for a prolonged deceleration

Timely Identification

5.FHR interpretation:

Category II or III


  • If identified, team documents plan for reassessment ____minutes and exit strategy













Consider:

-N/A if FHR remains in Category I.

-If Category III, evidence that delivery occurred by internal standards (30 minutes or less)


6. EFM tracing remains adequate for fetal assessment during second stage













Appropriate Interventions

7. Oxytocin dose decreased or discontinued during 2nd stage due to tachysystole












__________#times



8.Oxytocin dose decreased or discontinued during 2nd stage due to FHR?













9.If protracted, arrested or abnormal descent identified then team / algorithm interventions were performed?













10. Interventions needed for change in FHR? Document those applied (intrauterine resuscitation measures)













11.Pushing Interventions-

If FHR decelerations, was pushing with every 2nd or 3rd contraction initiated?












Consider: team has implemented this as a multidisciplinary strategy

Activation of Team Response

12.Documentation of physician notification of change in status















13.If requested, timely response by OB care provider for bedside evaluation.












14.Escalation plan in place if needed and documented.













15. Recognition of abnormal 2nd stage and plan documented- may include nursing interventions such as positioning/pushing techniques, proceed to delivery, expectant management, augmentation.
















Conclusion




Length of Second Stage:




Time of Delivery:




Mode of Delivery:

Single  or dual  mode of delivery

SVD




Cesarean Section

Station: Reason:

Vacuum

Station: Reason:

Forceps

Station: Reason:

NOTES: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


Outcomes (T=from Perinatal Trigger Tool)

Yes

No

N/A

Comments

Neonatal Outcomes













1. (T1) Apgar <7 at 5 min













2. (T2) Admission to NICU or higher level of care













3. (T18) Instrumented delivery, vacuum or forceps (document indication)













4. 2 or more late preterm infant (LPI Indicators)- Respiratory distress (tachypnea, retractions, nasal flaring, grunting, apnea, cyanosis, low O2 sat)

  • Thermoregulation issues (temp instability)

  • Hypoglycemia

  • Significant feeding issues (greater than 10% weight loss)

  • Hyperbilirubinemia (requiring phototherapy, prolonged hospital stay













5. (T16) Neonatal Injury (e.g. fractured

clavicle) cephalohematoma, facial drooping, documented palsy, hyperbilirubinemia















6. (T20) Cord gas < 7.20













7. (T22) Other Shoulder dystocia (document morbidity)




























Maternal Outcomes













1. (T7) 3rd or 4th degree laceration










.

2. (T9) Blood Transfusion













3. (T18) Instrumented delivery, vacuum or forceps (document indication)













4. (T15) Excessive blood loss, postpartum hemorrhage













5. (T22) Other Shoulder dystocia (document morbidity)













6. Cesarean section (indication)













NOTES:



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