PQCNC SIVB LS 1 Bucket List

8/7/2019 PQCNC SIVB LS 1 Bucket List

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Primary focus of PQCNC SIVB initiative


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7804 NSTV

40% Induction rate

40.7% had cervical ripening**

Indications for induction Fetal indications 13.6% Fetal macrosomia 3.3% Maternal indications 24.9% Post term but less than 41weeks 14.3% Post term 41 weeks 18.3% Elective 25.6% Elective with cervical ripening 37% **BISHOP SCORE < 6


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Indications for cesarean section

Labor dystocia 75.1%

Fetal distress 28.2%

Maternal medical indication1.6%

Other 2.9%

Labor dystocia 79.0% for induced, 68.9% forspontaneous labor (p


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FACTOR aORBlack Race 1.44

35 years 1.71

BMI

< 18.518.5-24.9

25-29.930-39.940

Referent1.36

1.963.244.51

Weight gain 18.14 kg 1.37

Gestational diabetes 1.38

Gestational hypertension 1.38

EGA 41 weeks 1.58

Induced labor 1.93

April 2010 Green Jl, 3)


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Black Race aOR 1.35

Age 35 or older aOR 1.83

Wt gain >18.14kg aOR 1.28 Induced labor aOR 2.03

Multivariate Analysis


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29.9% induced overall

CS in 13.6% not induced, 25.5% induced

CONCLUSION: 20% of all CSamong low risk women and allNSTV women could be attributedto labor induction!!!!

Restriction to NTSV with noco-morbidities


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Almost 2/3 of overall CS attributed to 3 groupswith potentially modifiable risk factors:

NTSV with induced labor Review indications/processes for induction

Previous CS and singleton cephalic term pregnancy

Provide VBAC

Breech presentation

Offer ECV if appropriate

Contribution of select maternal groups to temporal trends in rates of caesarean

section. VM Allan. J Ob Gyn Can July 2010


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PATIENT EDUCATION

Establish practiceagreements about

elective inductions,indicated inductions.

Communicate early on inprenatal care the policyof preferring

spontaneous labor,essential ban on electiveinductions prior to 39weeks.

38 weeks is too late to

have that conversationand to expect to havethe patient on your team


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ALL LABORS

What sort of analgesiais available and how/when is it administeredin labor?

What sort of labor supportis available?

Do your units MD, CNM

and nursing staff allshare a commitment topromoting safe vaginalbirth for patients forwhom it is not contra-

indicated?

What labor curve do youuse in your unit and howdo you functionally define

Failure to progress?


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SPONTANEOUS LABOR

What is the functional definitionof LABOR in your unit?

What is active labor?

What do you dowith prodromal

labor?Discharge to home?Therapeutic rest?Induce?

When, how do youaugment labor?


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INDUCED LABORS

Who gets induced?Do you have a policy in your

practice, labor unit

regarding electiveinductions?

When do youInduce?

What method(s) ofcervical ripening doyou use?

Who gets cervicalripening?

What are you pitocin protocols?


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Look at your data to determine the vaginal delivery rate inyour NSTV population.

What are the key drivers of your IOL rates?

What are the key drives of your success rates in the

population of NSTV?

What changes in these drivers are possible to design, vetand test in 1-2 months?

Identify 2-4 changes in these drivers that your team will

consider for further exploration during this project.

If there are issues in spontaneously laboring patients thatare important drives of the C/S rate at your hospital,consider those as well.

Ideas for Quality Projects Around Inductionof Labor for NTSV: The Bucket List


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IOL POLICIESNo electives before 39 weeksNo electives with unripe cvxUse of cervical ripening for indicated, unripe cvx

What kind of documentation required pre-inductionFunctional definitions: Labor, prodrome, failure toprogress, failed induction

IOL PROCEDURESCervical ripening orders, methodsPitocoin protocolsLabor supportUse of analgesia, anesthesiaAROM use

LABOR and DELIVERY CULTURE

Is there a will to improve this at your unit?Are all doctors, CNMs, and nurses committed?Do you have a communication issue on your unit?Are patients educated in general about expectations,

processes?

Documents

PQCNC SIVB LS 1 Bucket List