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The Cascade Effect: How Labor Management Can Impact Perinatal Mortality and Morbidity

Thursday, September 28, 2017  
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Authors: Debra Bingham, DrPH, RN, FAAN and Siena Davis, MPH

Corinne (not her real name) was 28 years old and excited to give birth to her first child, a baby girl. Corinne’s pregnancy was uneventful, she and the baby were both healthy throughout.  When she was 39 weeks pregnant, Corinne felt contractions that started to become regular, and around 4am she and her husband Derek (not his real name) decided to go to the hospital. Corinne was in early labor (1 centimeter dilated and 80% effaced) and was given the choice to go home or stay in the hospital. Corinne chose to stay, and was told to change into a gown, was put in a bed, and attached to the electronic fetal monitor in her room. She did not think she could get out of bed and move around.

The next morning, Corinne was only 2 centimeters dilated. Her physician offered her the option of breaking her water and having her labor augmented, and she agreed. As labor became more uncomfortable, she decided to get an epidural, even though she was still only 2 centimeters dilated. Her labor slowed down after the epidural and she needed more Oxytocin. Though she was making progress, Corinne still had not given birth by the next day and was starting to show signs of an infection. After a few more hours, her physician recommended she have a cesarean birth because she hadn’t made much labor progress and because Corinne’s baby’s baseline heart rate had become elevated and there were some decelerations. Corinne agreed to this plan.

During the surgery, her bladder was accidentally cut. So, after giving birth she had to have a catheter in place longer than usual, which made it difficult for her to walk around. She also needed antibiotics to treat the infection. Corinne was excited to have her little girl born, but her baby was having some trouble breathing due to fluid in her lungs and also needed to receive antibiotics to treat the infection. This meant that Corinne only got to have a quick look at her baby girl Briana before she was taken to the NICU. Since Corinne was recovering from major surgery, a cut bladder, and an infection it was difficult for her to visit her daughter in the NICU. This made breastfeeding difficult and it was not well-established before they both went home from the hospital.  Both Corinne and her daughter Briana were discharged home 4 days after birth.

At home 5 days after giving birth, Corinne was still exhausted and did not sleep well. The next morning, she started experiencing shortness of breath and obstructed breathing. She wondered if she should go back to the hospital but did not want to bother anyone, and she really didn’t want to be readmitted to the hospital. She called her doctor’s office and the receptionist agreed that she could try resting awhile to see if that made her feel better, and to call back if her symptoms did not go away. Corinne started feeling worse so her family decided to take her to the emergency room. Before they could get in the car, Corinne collapsed and died. Derek called 911 but it was too late. Corinne could not be resuscitated. She died of a pulmonary embolism.

According to a recent study published in Obstetrics & Gynecology, the management of labor and delivery patient flow in hospital settings may put women at increased risk for a variety of complications and for cesarean births.  

There is considerable variation in maternal and child health outcomes, and particularly cesarean birth rates, across hospitals in the United States. Maternal health and demographic factors do not explain this variation in maternal and child health outcomes. Compared to vaginal births, cesarean births are associated with longer hospital stays, higher costs, and more severe morbidity. The increased morbidities have both short- and long-term effects on the health of mothers and their infants. According to Debra Bingham, DrPH, RN, FAAN, Associate Professor for Healthcare Quality and Safety at the University of Maryland School of Nursing and Founder and Executive Director of the Institute for Perinatal Quality Improvement (PQI): “Ending the overuse of cesarean births is a big step forward toward ending preventable morbidity and mortality.”

The study, co-authored by Dr. Bingham, with lead researchers Avery Plough, BA (Ariadne Labs) and Neel Shah, MD, MPP (Ariande Labs and Harvard T.H. Chan School of Public Health), and other colleagues, had two primary aims:

(1) to understand the key skills required to manage labor and delivery units, and

(2) to measure the relationship between labor and delivery unit management and maternal outcomes.

The results of the study revealed that three factors ­– nursing, patient flow, and unit culture – were associated with either better or worse patient outcomes. In Corinne’s situation, there was not one single factor that led to her death, but a cascade effect of decisions that ultimately increased Corinne’s risk for a pulmonary embolism.

The findings of this recent study suggest that while some management practices may negatively impact maternal health (e.g., by increasing rates of cesarean delivery), others may positively impact maternal health (e.g., by decreasing length of hospitalization). More research is needed to determine why these differences in management approaches exist and which management practices will have the greatest effect on eliminating the overuse of cesarean births.

These study findings are also consistent with the recommendations included in the Council on Patient Safety in Women’s Health Care’s Maternal Patient Safety Bundle titled:  Safe Reduction of Primary Cesarean Births that state every hospital and unit should “Build a provider and maternity unit culture that values, promotes, and supports spontaneous onset and progress of labor and vaginal birth and understand the risks for current and future pregnancies of cesarean birth without medical indication.”  In Corinne’s case, the cesarean ultimately was needed, but there were many decisions in the management of her labor, such as offering for her to stay in the hospital and breaking her water before she was in active labor, that influenced the progress of her labor and ultimately led to her having an infection and also a cut bladder in surgery. All of which made her less mobile and thus at greater risk for a pulmonary embolism.  In addition, Corinne’s daughter Brianna had to be admitted to the NICU and breastfeeding was difficult: these circumstances lead to poorer health outcomes for newborns.

In other words, overuse of cesarean births isn’t good for moms or babies.

We at PQI congratulate the many Registered Nurses, Physicians, and Midwives who are currently working to reduce the overuse of cesarean births. However, our national statistics make it very clear that much more work is needed.

That is why the leaders of the Institute for Perinatal Quality Improvement (PQI) are working to expand the use of improvement science among Registered Nurses and other perinatal clinicians.

If you are working to eliminate the overuse of cesarean births please consider subscribing and entering your QI Project onto our Maps.  The QI Project Maps are designed to help Perinatal QI Leaders connect with others working on similar types of QI Projects.

Full Article Reference:  Plough, A. C., Galvin, G., Li, Z., Lipsitz, S. R., Alidina, S., Henrich, N. J., Hirschhorn, L.R., Berry, W.R., Gawande, A.A., Peter, D., McDonald, R., Caldwell, D.L., Muri, J.H., Bingham, D.B., Caughey, A.B., Declercq, E.R., Shah, N.T. (2017). Relationship Between Labor and Delivery Unit Management Practices and Maternal Outcomes. Obstetrics & Gynecology, 0(0), 1-8. doi: 10.1097/AOG.0000000000002128

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