and Impact of Maternal Health Services Research Perinatal - - PowerPoint PPT Presentation

Aaron B. Caughey MD, PhD Professor and Chair Department of Obstetrics and Gynecology Oregon Health & Science University caughey@ohsu.edu

Advancing the Translation and Impact of Maternal Health Services Research – Perinatal Collaboratives

Aaron B. Caughey MD, PhD Professor and Chair Department of Obstetrics and Gynecology Oregon Health & Science University caughey@ohsu.edu

Financial Relationships

• No financial disclosures related to this talk
• Medical Advisor to Celmatix, Mindchild
• Bob’s Red Mill

Overview

• OPC – Why a collaborative?
• Early elective delivery
• Optimal delivery
• The future

Why a collaborative?

• Big state geographically
• Moderate sized population
• >45,000 births per year
• Improve outcomes

Early Elective Delivery

• Burning platform
• EED – Perhaps worse outcomes
• EED – push as a quality metric
• Supported by March of Dimes, etc.

Elective CDs: NICU by GA

Tita A et al. NEJM, 2009

Neonatal Morbidity by GA

37 weeks 38 weeks 39 weeks 40 weeks 41 weeks 5-minute Apgar <7 1.01 % 0.69 % 0.61 % 0.70 % 0.93 % 5-minute Apgar <4 0.19 % 0.13 % 0.11 % 0.12 % 0.14 % Meconium stained amniotic fluid 2.27 % 3.24 % 5.20 % 7.39 % 10.33 % Meconium aspiration 0.07 % 0.08 % 0.12 % 0.19 % 0.27 % Hyaline membrane dz 0.45 % 0.19 % 0.14 % 0.14 % 0.18 % Mech vent >30min 0.57 % 0.32 % 0.28 % 0.29 % 0.38 %

Neonatal Outcomes

Cheng YW, et al. AJOG, 2008

Timing of Term Delivery

• Definitions
• Early Term (37 / 38 weeks)
• Full Term (39 / 40 weeks)
• Late Term (41 weeks)
• Postterm (42 weeks and beyond)

Elective IOL – early term

Pro

↑ maternal prefs ↑ md prefs

Con

↑ neonatal comps ? cesareans ↑ maternal comps ↑ costs

Elective IOL prior to 39 weeks of gestation is not consistent with the standard of care or ACOG and should only be offered in experimental protocols with written informed consent

How to translate?

Early Elective Delivery

• June, 2011
• Legacy – Duncan Nielson
• Providence – Mark Tomlinson
• Kaiser – Suzanne Lubarsky
• Tuality / Adventist
• OHSU – abc
• March of Dimes – Joanne Rogovoy

Elective IOL – Hard Stop

Hospitals take 'hard stop' on early elective C-sections, inductions Oregon is the latest state where some hospitals are refusing to do the procedures before 39 weeks

• f pregnancy

Elective IOL – Hard Stop

• Why?
• Right thing to do medically.
• IOL costly
• Need to do geographically
• Facilitates providers to “just say no”

Prevention of Early Term Births

• HCA - Clark S, et al. – 2010
• Three approaches
• Hard stop – not allowed
• Soft Stop – MDs agreed not to do
• Education

Prevention of <39 weeks

Clark et al, Am J Obstet Gynecol, 2010

Overall Before (2008–10) After (2012–13) P-val Elective deliveries (IOL or CD)

a

34.0 32.3 <0.001 Elective inductions 27.1 26.3 <0.001 <39 weeks

b

4.4 2.8 <0.001 ≥39 weeks

c

29.4 29.5 0.917 Elective cesareans 9.5 8.4 <0.001 <39 weeks

b

2.1 1.4 <0.001 ≥39 weeks

c

9.6 8.8 <0.001

OPC Hard Stop Analysis

Overall Before (2008– 10) After (2012–13) Elective deliveries b (IOL + CD) Ref. 0.92 (0.9

• 0.94)

Elective inductions Ref. 0.95 (0.93

• 0.98)

<39 weeks c Ref. 0.62 (0.59

• 0.66)

≥39 weeks d Ref. 1.00 (0.97

• 1.02)

Elective cesareans Ref. 0.87 (0.83 – 9.00) <39 weeks c Ref. 0.64 (0.59

• 0.70)

≥39 weeks d Ref. 0.90 (0.87

• 0.94)

OPC Hard Stop Analysis

Overview

• OPC – Why a collaborative?
• Early elective delivery
• Optimal delivery
• The future

Overview

• OPC – Why a collaborative?
• Early elective delivery
• Optimal delivery
• The future

Cesarean Rates

Hamilton BE, Martin JA, Ventura SJ. Births: Preliminary data for 2010. National vital statistics reports; vol 60 no 2. National Center for Health Statistics. 2011 .

Changing Practice Environment

Cesarean delivery rates vary tenfold among US hospitals; reducing variation may address quality and cost issues. Kozhimannil KB, Law MR, Virnig BA. Health Aff (Millwood). 2013 Mar;32(3):527-35

Caughey AB, Cahill AG, Guise JM, Rouse DJ. Safe Prevention of the Primary Cesarean Delivery, 2014

• Early assessment of GA
• Appropriate labor induction (cervical ripening)
• Appropriate diagnosis of failed induction
• Delayed admission until >/=4cms dilation
• Patience in first stage of labor
• Patience in second stage of labor

Caughey AB, Cahill AG, Guise JM, Rouse DJ. Safe Prevention of the Primary Cesarean Delivery, 2014

Overview

• OPC – Why a collaborative?
• Early elective delivery
• Optimal delivery
• The future

Future

• Roll out the safe deliveries approach
• Expand data center
• Collaborate w/ COIIN - prevent perinatal

mortality

• Collaborate w/ state – maternal mortality

reviews

• Collaborate with the state – opportunities to

reduce injury with out of hospital birth

• Progesterone
• Steroids
• Perinatal Summit – October 30, 2015
• Second Summit – Nov 11, 2016

Thank You

IUFD/Infant Death Rates - Compare

Rosenstein MR, et al. Am J Obstet Gynecol, In Press, 2012

Elective IOL – Hard Stop

5

Astoria Seaside St Helens Tillamook Cape Lookout Lincoln City The Dalles Condon Madras Redmond Prineville Florence Reedsport North Bend Coos Bay Roseburg Port Orford Grants Pass Ashland Bly Brookings Klamath Falls Lakeview Hermiston Pendleton La Grande Enterprise Baker City Canyon City John Day Ontario Vale Burns Jordan Valley

Portland

Eugene

Gresham Hillsboro Beaverton McMinnville Keizer Albany Corvallis Springfield Bend Medford

Salem

MILES 20 40 60 80

Satellite Regional Hub

Silverton

Labor induction: Pre-procedure

ü Consent form discussed with patient and signed for any induction; medical and non- medical (ACOG induction consent or equivalent).

Non-medically indicated

ü Not done prior to 39 0/7 weeks gestation. ü Between 39 0/7 – 40 6/7 weeks gestation must have Bishop score of 8 or greater for nulliparas or 6 or more for multiparas (no cervical ripening).

Medically indicated

ü Done for accepted medical indications within evidence-based or National Association guidelines (ACOG, SMFM, etc) for definition and most appropriate gestational age for

• delivery. For indications not on above lists,

consultation or advice is recommended. ü Cervical ripening if needed for unfavourable cervix.

Failed induction ( assuming stable mother and fetus) – parameters to use when not entering active labor (> 6 cms): If failed induction, discuss

• ptions regarding further

management: consider risks, benefits, and alternatives of all

• ptions (i.e: discharge home with

plan to return versus Cesarean Section, depending on clinical situation) Failure to achieve uterine contractions every 3 minutes with cervical change after 24 hrs of oxytocin and with AROM (if no contraindications), OR uterine contractions every 3 min x 24 hrs without entering active phase if initial Bishop score was less than 6-8

• r if cervical ripening was used.

ü Inadequate response to a needed, clinically appropriate, second cervical ripening agent defined as membranes have been ruptured with inadequate progress (assuming feasible and no contraindications to AROM) and oxytocin has been given per hospital protocol if inadequate frequency and/or intensity of contractions occurring after cervical ripening alone. ü If ROM, oxytocin given x 12 hrs without regular contractions resulting in cervical change.

Consider delay in admission to labor unit (all conditions to be met for discharge) ü Cervix 0-3 cm. ü Membranes intact. ü Reactive NST/ FHR category 1 (Confirmed by 2 practitioners - RN, MD, DO, CNM) ü Pain control adequate with appropriate

• utpatient interventions as needed.

Consider Cesarean delivery (all three present) ü Cervix 6 cm or greater. ü Membranes ruptured (if feasible). ü Uterine activity: >200 Montivideo units x 4 hours, or every 3 minute palpably strong contractions x 4 hours when not feasible to rupture membranes OR <200 Montivideo units or < 3/10 minute contractions x 6 hours despite Oxytocin administration per protocol.

Assessment of descent (and position) of presenting part ü Ideally every 1 hour. Consider Operative Vaginal Delivery or Cesarean delivery (if presenting part not on perineal floor: +2 or lower) Pushing time from complete dilation*: ü Nulliparous with epidural anesthesia – 4 hours. ü Nulliparous without epidural anesthesia – 3 hours. ü Multiparous with epidural – 3 hours. ü Multiparous without epidural – 2 hours. OR ü Total time from complete dilation 5 hours or greater. * Each may need an additional hour if occiput posterior position and rotation of greater than 45 degrees toward anterior has been previously achieved.

What Have Intervention Studies Observed for the Risk of Stillbirth?

Intervention Study Total Population Studied Stillbirth Rate Findings

Oshiro (2009)1 (large health system) 160,394 Decline during intervention period Clark (2010)2 (large health system) 433,551 No change during the intervention period Ehrenthal (2011)3 (single hospital) 24,028 (>37 wk only) Increase noted at 37 and 38 wks Benedetti (2012)4 (state of Washington) 505,445 (>37wk only) No change during the intervention period

1Obstet Gynecol 2009;113:804–11 2Am J ObstetGynecol 2010;203:449.e1-6 3Obstet Gynecol 2011;118:1047–55 4Obstet Gynecol 2012;119:656-7

Caughey AB, Cahill AG, Guise JM, Rouse DJ. Safe Prevention of the Primary Cesarean Delivery, 2014

Caughey AB, Cahill AG, Guise JM, Rouse DJ. Safe Prevention of the Primary Cesarean Delivery, 2014

OPC - future

• Let’s make Oregon the best

place in the U.S. to have a baby.

Elective IOL – Hard Stop

Ehrenthal et al, Obstet Gynecol, 2011 Term births at 37 or 38 weeks’ gestation

Elective IOL – Hard Stop

Ehrenthal et al, Obstet Gynecol, 2011

Elective IOL – Hard Stop

Ehrenthal et al, Obstet Gynecol, 2011

Elective IOL – Hard Stop

Ehrenthal et al, Obstet Gynecol, 2011