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

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

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 Neonatal Outcomes 37 38 39 40 41 weeks weeks weeks weeks 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 2.27 % 3.24 % 5.20 % 7.39 % 10.33 % amniotic fluid Meconium aspiration 0.07 % 0.08 % 0.12 % 0.19 % 0.27 % Hyaline membrane 0.45 % 0.19 % 0.14 % 0.14 % 0.18 % dz Mech vent >30min 0.57 % 0.32 % 0.28 % 0.29 % 0.38 % 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 Con ↑ maternal prefs ↑ neonatal comps ↑ md prefs ? 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 of 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

OPC Hard Stop Analysis Overall Before After (2008 – 10) (2012 – 13) P-val a Elective deliveries (IOL or CD) 34.0 32.3 <0.001 Elective inductions 27.1 26.3 <0.001 b <39 weeks 4.4 2.8 <0.001 c ≥ 39 weeks 29.4 29.5 0.917 Elective cesareans 9.5 8.4 <0.001 b <39 weeks 2.1 1.4 <0.001 c ≥ 39 weeks 9.6 8.8 <0.001

OPC Hard Stop Analysis Overall Before (2008 – After 10) (2012 – 13) Elective deliveries b (IOL + CD) 0.94) 0.92� (0.9� -� Ref. Elective inductions 0.98) 0.95� (0.93� -� Ref. <39 weeks c 0.66) 0.62� (0.59� -� Ref. ≥ 39 weeks d 1.00� (0.97� -� 1.02) Ref. Elective cesareans 9.00) 0.87� (0.83� – � Ref. <39 weeks c 0.70) 0.64� (0.59� -� Ref. ≥ 39 weeks d 0.94) 0.90� (0.87� -� Ref.

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 Astoria Seaside St Helens Hermiston Pendleton Hillsboro The Dalles Gresham Enterprise Beaverton Tillamook Portland La Grande Cape Lookout Condon Regional Hub McMinnville Silverton Keizer Satellite Salem Baker City Lincoln City Albany Madras Corvallis John Day Canyon City Prineville 5 Redmond Eugene Ontario Springfield Bend Vale Florence Reedsport Burns North Bend Coos Bay Roseburg Jordan Valley Port Orford Grants Pass Bly Medford Ashland Klamath Falls Brookings Lakeview MILES 0 20 40 60 80

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 Failure to achieve uterine contractions every 3 stable mother and fetus) – minutes with cervical change after 24 hrs of oxytocin parameters to use when not and with AROM (if no contraindications), OR uterine entering active labor (> 6 cms): contractions every 3 min x 24 hrs without entering active phase if initial Bishop score was less than 6-8 or 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 If failed induction, discuss to AROM) and oxytocin has been given per hospital options regarding further protocol if inadequate frequency and/or intensity of management: consider risks, contractions occurring after cervical ripening alone. benefits, and alternatives of all ü If ROM, oxytocin given x 12 hrs without regular options (i.e: discharge home with contractions resulting in cervical change. plan to return versus Cesarean Section, depending on clinical situation)

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

Consider Cesarean delivery (all ü Cervix 6 cm or greater. three present) 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 ü Ideally every 1 hour. position) of presenting part Consider Operative Vaginal Pushing time from complete dilation*: Delivery or Cesarean delivery ü Nulliparous with epidural anesthesia – 4 hours. (if presenting part not on ü Nulliparous without epidural anesthesia – 3 perineal floor: +2 or lower) 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.