6/7/2014 Disclosures Decision to Incision Timing: � No financial disclosures related to this talk Is the 30-minute rule valid? � Medical Advisor to Ariosa, Cellscape, Mindchild � Bob’s Red Mill Aaron B. Caughey, MD, PhD Professor and Chair Department of Obstetrics and Gynecology Oregon Health & Science University caughey@ohsu.edu Bradycardia Overview � 30 minute rule? � History � Biology / pathophysiology � Epidemiology � Quality Improvement � Management 1
6/7/2014 How long would it take to Minimum time until injury? achieve delivery? A. 10 minutes or less A. 10 minutes or less 43% 46% B. 15 minutes B. 15 minutes C. 20 minutes C. 20 minutes 28% D. 30 minutes D. 30 minutes 22% 20% 17% E. Longer E. Longer 7% 7% 5% 5% . s s s r . s s s r . e e e e . e e e e . . r t t t g r t t t g u u u u u u o n o n n n n n n n s o s o i i i L i i i L e m m m e m m m t t u u 5 0 0 5 0 0 n 1 2 3 n 1 2 3 i i m m 0 0 1 1 Disconnect? The 30 minute rule � Established as a time threshold for � If injury occurs faster than we can cesarean delivery to occur – 1980s intervene, then why a 30-minute rule? � ACOG, RCOG, etc � Should it be shorter? � Became a more prominent rule of the land in the late 1990s ACOG Committee on Professional Standards for Obstetric-Gynecologic Services. 7th ed.; 1989. Tuffnell et al. BMJ 2001;322:1330–3 2
6/7/2014 Why 30 minutes? VBAC – 1990s � Improving outcomes? � Feasibility? � Whim? Prolonged decelerations What time threshold? The time required to extract an infant from a hostile in utero � What outcomes are we interested in? environment is a frequent issue in medical negligence cases. The American College of Obstetricians and � Mortality Gynecologists and the American Academy of Pediatrics � Short-term (neonatal) suggest a time guideline of 30 minutes from decision for Cesarean delivery to the beginning (incision) of � Long-term (infant and beyond) the procedure. This time frame is based on survey � Morbidity data from hospitals throughout the United States and is � HIE / CP not based on clinical outcomes or the pathophysiology of obstetric events . � Seizures? � Apgars? J Healthc Risk Manag. 1999 Winter;19(1):11-20. � Cord gases Is the obstetric guideline of 30 minutes from decision to incision for Cesarean delivery clinically significant? Lavery JP1, Janssen J, Hutchinson L. 3
6/7/2014 Prolonged decelerations How long? US, 1995-2005 � 238 neonates w/ UA pH <7.1 � Primary outcome – seizures from HIE � Examined all gas features � pO2; pCO2; base excess, pH � pH < 7.0 only was associated in MV model Obstet Gynecol. 2002 Sep;100(3):557-60. The correlation of seizures in newborn infants with significant acidosis at birth with umbilical artery cord gas values. Cahill AG, et al. Terminal decelerations and outcomes. Williams KP1, Singh A. Obstet Gynecol. 2013 Nov;122(5):1070-6 How long? How long? Time ≥10 min Time <10 min P value n=31 (%) n=920 (%) Acidemia ≤ 7.10 4 (12.9) 8 (0.9) <0.01 (n=12) Acidemia ≤ 7.05 2 (6.5) 2 (0.2) <0.01 (n=4) APGAR 5min < 7 2 (6.5) 2 (0.2) <0.01 (n=4) Special Care* or NICU Admission 5 (16.7) 33 (3.6) <0.01 (n=38) NICU Admission 3 (10.0) 8 (0.9) <0.01 (n=11) Cahill AG, et al. Terminal decelerations and outcomes. Obstet Gynecol. 2013 Nov;122(5):1070-6 4
6/7/2014 Only Time? How long? US, 1995-2005 � Are there other features that matter? � Leung et al – decelerations � Variability? � Etiology – uterine rupture, abruption, etc. � Heart rate? Cahill AG, et al. Terminal decelerations and outcomes. Obstet Gynecol. 2013 Nov;122(5):1070-6 Variability Heart Rate Time until P value Decreased variability before bradycardia acidemia FHR 80s 25 mins <0.01 Combined with no recovery of the bradycardia mean pH 6.83 +/- 0.16 FHR 70s 13 mins <0.01 78% incidence of significant acidosis FHR 60s 8 mins <0.01 FHR 50s 6 mins <0.01 FHR 40s 5 mins <0.01 Williams K, et al. Obstet Gynecol. 2002 Nov;100(5 Pt 1):951-4. Fetal heart rate parameters predictive of neonatal outcome in the presence of a Tranquilli A, et al. J Matern Fetal Neonatal Med. 2013 Sep;26(14):1425-9. The correlation prolonged deceleration. between fetal bradycardia area in the second stage of labor and acidemia at birth. 5
6/7/2014 What to do? What threshold? � Given the data, what approach? Is it a bradycardia? � Should there be a set time? � Should the standard time differ? � Hospital size � Local geography / population � Level What to do? What to do? Is it a bradycardia? Is it a bradycardia? Is it a bradycardia? 6
6/7/2014 What to do? What to do? Is it a bradycardia? Is it a bradycardia? Is it a bradycardia? Is it a bradycardia? What to do? What to do? � What is the Baseline status? Is it a bradycardia? Is it a bradycardia? � What is the Etiology? � What needs to be done to achieve Delivery? � BED 7
6/7/2014 What to do? What to do? � What is the Baseline status? � What is the Etiology? � Decels � Abruption � Variability � Tachysystole/Tetany � Meconium � Cord prolapse � Chorioamnionitis � Uterine rupture � Compromised mother or fetus? � Maternal � Htn disorder; fetal anomaly; preterm � Hypotension (AFE); hypoxic (PE) � Fetal � Oligo; arrhythmia; rapid descent What to do? What to do? � What needs to be done to achieve Delivery? � Individual level – BED � What is the exam? Include position � Hospital level � Parity and prior OB Hx � Establish benchmarks � Patient BMI � Environment (Geography; Populations) � EFW � Engineering (Internal and External) � Anesthesia? � Societal level � OR / staff? � Encourage collaboration � Public Health 8
6/7/2014 Can we reduce the length of time? Can we reduce the length of time? Tuffnell et al. BMJ 2001;322:1330–3 Can we reduce the length of time? Can we reduce the length of time? 9
6/7/2014 What should be done? What time goal? � Gather together leadership to discuss 40% A. 30 minutes? � OB providers (MFM, OB, CNM, FM) B. 20 minutes? 27% � Measure the outcomes – report the data C. 15 minutes? 22% D. 10 minutes? � Potentially use QI methods 11% � Institutionally based (e.g. Lean) As fast as possible!!! � Establish standards / standard behaviors ? ? ? ? s s s s e e e e t t t t u u u u n n n n i i i i m m m m 0 0 5 0 3 2 1 1 Thank You 10
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