algorithm & checklist pdsa trials dale reisner, md medical director of obstetrics quality and...

Algorithm & Checklist PDSA Trials

Dale Reisner, MDMedical Director of Obstetrics Quality

and SafetySwedish Medical Center

WSHA Safe TableSafe Deliveries Roadmap

November 19, 2013

Presented at Washington State Hospital Association Safe Table 11/19/2013

InductionFetal and Maternal Assessment Appropriate

for Induction

Unfavorable Cervix(Bishop Score < 8)

Medically Indicated Only

Mechanical or Pharmacological Cervical Ripening

Favorable Cervix (Bishop Score > 8)

Initiate Oxytocin

Cervical Change

Cervical Change

Cervix > 6 cm**may observe for spontaneous labor

Repeat with Different Method

Home or Cesarean

No ResponseOxytocin Trial?

Continue Oxytocin or AROM

Assess Cervical Change

Cervix < 6 cm, Unable to AROM, or no Cervical Change with 24 Hours

Oxytocin

Proceed to Cesarean

No Change• Adequate contractions

for > 4 hours•Inadequate contractions

for 6 hours

Second Stage Arrest

Failed Induction

No Cervical Change

No Cervical Change

If Elective, Consider Home

See Spontaneous Labor Algorithm

Draft


DRAFT

Labor Induction Checklist - DRAFT

Type of Induction:

Medical ___________________________ Non-medical/Elective

Pre-procedure:

Consent form discussed with patient and signed, and on chart (medical and non-medical)

Non-medical Induction:

Not done prior to 39 weeks gestation. Gestational age: wks_________ days__________ Between 39 – 40 6/7 weeks gestation, Bishop score is 8 or greater confirmed by 2 examiners (no

cervical ripening)

Medical Induction:

Done for accepted medical inductions w/i evidenced-based or National association guidelines (ACOG, SMFM, etc) for definition and most appropriate gestational age for delivery.

Consultation for indication not on above lists Cervical ripening for unfavorable cervix

Failed Induction (assuming stable mother and fetus) – parameters to use when not entering active labor (> 6 cms):

Either: failure to achieve uterine contractions every 3 minutes with cervical change after 24 hrs of Pitocin 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 8 or if cervical ripening was used.

Inadequate response to a needed, clinically appropriate, second cervical ripening agent Membranes have ben ruptured with inadequate progress (assuming feasible and no contraindications

to AROM) Pitocin has been given per hospital protocol if inadequate frequency and/or intensity of contractions

occur after cervical ripening alone If ROM, Pitocin given x 12 hrs without regular contractions resulting in cervical change If Failed Induction:

Options discussed regarding further management: consideration of risks, benefits, and alternatives of all options (i.e. discharge home with plan to return versus Caesarean Section, depending on clinical situation)


DRAFT

TRIAGE

Cervix < 4 cm Cervix 4 cm or More

Maternal or Fetal Indication

for Admission

Admit to L&D

Vaginal Delivery

Induction Algorithm

Spontaneous Labor > 37 wks and < 41 wks

Stable Mother and Baby

Operative Vaginal or Cesarean

Depending on assessment; Home, AROM and/or Oxytocin,

or Cesarean

Inadequate Progress

First Stage Adequate Progress

First Stage First Stage Arrest

Inadequate Progress

Second Stage

Adequate Progress

Second Stage

Second Stage Arrest

Inadequate Progress

Second Stage

Adequate Progress Second

Stage

Home Walk and Reassess

Draft


DRAFT

Spontaneous Labor Checklist - DRAFT

First Stage: Admission delayed for (all conditions met for discharge):

Cervix less than 4 cm Membranes intact Reactive NST/FHR category I (if uterine contractions present). Confirmed by 2 practitioners (RN,

MD, DO, CNM) Pain control adequate with appropriate outpatient interventions as needed

Admitted to Labor and delivery (delay admission criteria not met) Discharged home for:

Cervix 4-5 cm without change x 2-4 hrs < 80% effacement Reactive NST/FHR category I (if uterine contractions present) Contractions less than 3/10 minutes

Further observation for: Cervix 4-5 cm without change x 2-4 hrs 90 – 100% effacement Membranes intact Reactive NST/FHR category I (if uterine contractions present) Contractions less than 3/10 minutes

Cesarean delivery for (all criteria present) Cervix 6 cm or greater Membranes ruptured (if feasible) Uterine activity

>200 Montivideo untis x 4 hrs, or every 3 minutes palpabley strong contractions x 4 hrs when not feasible to rupture membranes

OR<200 Montivideo units or <3/10 minute contractions x 6 hrs despite Oxytocin administration per protocol

Second Stage: Assessment of decent and position of presenting part at least every 1-2 hrs Operative vaginal delivery or Cesarean delivery for (if presenting part not on perineal floor: +4 or lower) Time from complete dilation*/**

Nulliparous with epidural - 4 hrs Nulliparous without epidural - 3 hrs Multiparous with epidural - 3 hrs Multiparous without epidural – 2 hrs

OR Total time from complete dilation 5 hours or greater > 2 hrs, adequate pattern, no descent

*Passive decent (laboring down) is included in these time periods**Each may need an additional hour if occiput posterior position and rotation of greater than 45 degrees toward anterior has been previously achieved


DRAFT

PDSA on 4 Campuses Nov 2013Both sets of Algorithms & Respective

Checklists

• 29 Algorithms/Checklists evaluated • 27 RNs or LIPs

Common ThemesWhat to do for <4cms with pain4-5 cms but not in laborDo we suggest the amt of walk & reassess time??SROM: Induction vs AugmentationShould we note effacement, station?Are there separate considerations based on parity?Can a little more guidance be put into algorithms but still keep them easy to follow?Presented at Washington State Hospital Association Safe Table 11/19/2013

TRIAGE

Cervix < 4 cm Cervix 4 cm or More in Labor

Maternal or Fetal Indication for Admission either in

Labor or Needs Induction

Admit to L&D

Vaginal Delivery

Indication for Induction see Induction Algorithm

and Checklist

Spontaneous Labor > 37wksStable Mother and Baby

Assess Exam and Pain

Depending on assessment; Home vs AROM and/or Oxytocin vs Cesarean

Inadequate Progress

First Stage Adequate Progress

First Stage First Stage Arrest

Second Stage Arrest

Inadequate Progress

Second Stage

Adequate Progress Second

Stage

Home Walk and Reassess

Draft

NewNew

Operative Vaginal or Cesarean

DefinitionsExamples:•Adequate progress•reVITALize

New


DRAFT

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