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 1^st 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:

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

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.
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.
ACOG Practice Bulletin. Dystocia and Augmentation of Labor. Number 49. December 2003.
ACOG Practice Bulletin. Fetal Lung Maturity. Number 97. September 2007.
ACOG Practice Bulletin. Induction of Labor. Number 107, August 2009.
ACOG Practice Bulletin. Intrapartum Fetal Heart Rate Monitoring. Number 106, July 2009.
ACOG Practice Bulletin. Operative Vaginal Delivery, Number 17. June. 2000.
ACOG Practice Bulletin. Postpartum Hemorrhage. Number 76. October 2006.
ACOG Practice Bulletin. Shoulder Dystocia. Number 40. November 2002.
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 1^st or 2^nd 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□

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 1^st Stage, review oxytocin deep dive process questions.

1^st 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 2^nd Stage)

If yes, indication _______________________________________

Proceed to outcomes box.

SECOND STAGE RECOGNITION SYSTEM

Time complete: _____________ Station at start of 2^nd 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 2^nd 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 2^nd 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 2^nd stage due to tachysystole					__________#times
8.Oxytocin dose decreased or discontinued during 2^nd 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 2^nd or 3^rd 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 2^nd 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) 3^rd or 4^th 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:

Directory: extranetng -> content -> fdb3913c-db0f-481f-9553-1ee7ed523088
fdb3913c-db0f-481f-9553-1ee7ed523088 -> Perinatal Bundle- advanced Augmentation Bundle Compliance
fdb3913c-db0f-481f-9553-1ee7ed523088 -> Oxytocin Bundle- elective Induction Bundle Compliance
fdb3913c-db0f-481f-9553-1ee7ed523088 -> Oxytocin Summary Data Team Name

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