6/17/2017 Disclosures Decision to Incision Timing with Terminal Bradycardia: � No financial disclosures related to this talk � Medical Advisor to Celmatix, Mindchild How Long is Too Long? � 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
6/17/2017 How long would it take to Minimum time until injury? achieve delivery? A. 10 minutes or less A. 10 minutes or less 39% 57% B. 15 minutes B. 15 minutes 31% C. 20 minutes C. 20 minutes D. 30 minutes D. 30 minutes 18% 23% E. Longer E. Longer 8% 14% 5% 5% 1% s s s r s e e e e s g e t t t u u u n l n n n o r o i i i L m m m s e r 5 0 0 s s s s t 1 2 3 e e e e u s t t t g n e l u u u n i n n n o m r o i i i L m m m 0 s 1 e 5 0 0 t 1 2 3 u n i m 0 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
6/17/2017 Why 30 minutes? VBAC – 1990s � Improving outcomes? � Feasibility? � Whim? 30 minutes in nonemergent? 30 minute rule The time required to extract an infant from a hostile in utero environment is a frequent issue in medical negligence cases. The American College of Obstetricians and Gynecologists and the American Academy of Pediatrics suggest a time guideline of 30 minutes from decision for Cesarean delivery to the beginning (incision) of the procedure. This time frame is based on survey data from hospitals throughout the United States and is not based on clinical outcomes or the pathophysiology of obstetric events . J Healthc Risk Manag. 1999 Winter;19(1):11-20. Is the obstetric guideline of 30 minutes from decision to incision for Cesarean delivery clinically significant? Lavery JP1, Janssen J, Hutchinson L. Sabol BA, Lim J, Gregory T, Caughey AB. Am J Obstet Gynecol, 2017 3
6/17/2017 What time threshold? Prolonged decelerations � What outcomes are we interested in? � 238 neonates w/ UA pH <7.1 � Mortality � Primary outcome – seizures from HIE � Short-term (neonatal) � Examined all gas features � Long-term (infant and beyond) � pO2; pCO2; base excess, pH � Morbidity � pH < 7.0 only was associated in MV model � HIE / CP � Seizures? � Apgars? Williams KP1, Singh A. The correlation of seizures in newborn � Cord gases infants with significant acidosis at birth with umbilical artery cord gas values. Obstet Gynecol. 2002 Sep;100(3):557-60. How long? How long? US, 1995-2005 Holmgren C, Scott JR, Porter TF, Esplin MS, Bardsley Cahill AG, et al. Terminal decelerations and outcomes. T. Obstet Gynecol. 2012 Apr;119(4):725-31 Obstet Gynecol. 2013 Nov;122(5):1070-6 4
6/17/2017 How long? Only Time? Time ≥10 min Time <10 min P value � Are there other features that matter? n=31 (%) n=920 (%) Acidemia ≤ 7.10 <0.01 � Leung et al – decelerations 4 (12.9) 8 (0.9) (n=12) Acidemia ≤ 7.05 � Variability? 2 (6.5) 2 (0.2) <0.01 (n=4) � Etiology – uterine rupture, abruption, etc. APGAR 5min < 7 2 (6.5) 2 (0.2) <0.01 (n=4) � Heart rate? 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 How long? Variability US, 1995-2005 Decreased variability before bradycardia Combined with no recovery of the bradycardia mean pH 6.83 +/- 0.16 78% incidence of significant acidosis 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 Cahill AG, et al. Terminal decelerations and outcomes. prolonged deceleration. Obstet Gynecol. 2013 Nov;122(5):1070-6 5
6/17/2017 Heart Rate What threshold? Time until P value � Given the data, what approach? acidemia FHR 80s 25 mins <0.01 � Should there be a set time? FHR 70s 13 mins <0.01 FHR 60s 8 mins <0.01 � Should the standard time differ? FHR 50s 6 mins <0.01 � Hospital size <0.01 FHR 40s 5 mins � Local geography / population � Level Tranquilli A, et al. J Matern Fetal Neonatal Med. 2013 Sep;26(14):1425-9. The correlation between fetal bradycardia area in the second stage of labor and acidemia at birth. What to do? What to do? Is it a bradycardia? Is it a bradycardia? 6
6/17/2017 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? Is it a bradycardia? Is it a bradycardia? Is it a bradycardia? Is it a bradycardia? 7
6/17/2017 What to do – Parer case? What to do? What to do? What to do? � What is the Baseline status? � What is the Baseline status? � Decels � Variability � What is the Etiology? � Meconium � Chorioamnionitis � What needs to be done to achieve Delivery? � Compromised mother or fetus? � Htn disorder; fetal anomaly; preterm � BED 8
6/17/2017 What to do? What to do? � What needs to be done to achieve Delivery? � What is the Etiology? � What is the exam? Include position � Abruption � Parity and prior OB Hx � Tachysystole/Tetany � Patient BMI � Cord prolapse � EFW � Uterine rupture � Anesthesia? � Maternal � OR / staff? � Hypotension (AFE); hypoxic (PE) � Fetal � Oligo; arrhythmia; rapid descent Can we reduce the length of time? What to do? � Individual level – BED � Hospital level � Establish benchmarks � Environment (Geography; Populations) � Engineering (Internal and External) � Societal level � Encourage collaboration � Public Health 9
6/17/2017 Can we reduce the length of time? Can we reduce the length of time? Can we reduce the length of time? What should be done? • Can emergent cesareans be improved? • Does it matter? � Gather together leadership to discuss � OB providers (MFM, OB, CNM, FM, RN, Anesthesia) � Measure the outcomes – report the data � Potentially use QI methods % pH < 7.2 Pre Kaizen 17.4% � Institutionally based (e.g. Lean) Post Kaizen 7.4% � Establish standards / standard behaviors Sabol BA, Lim J, Gregory T, Caughey AB. Am J Obstet Gynecol, 2017 10
6/17/2017 What time goal? Thank You A. 30 minutes? 68% B. 20 minutes? C. 15 minutes? D. 10 minutes? As fast as possible!!! 16% 10% 5% ? ? ? ? s s s s e e e e t t t t u u u u n n n n m i m i m i m i 0 0 5 0 3 2 1 1 11
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