Dale Reisner, MD - Washington State Hospital Association

Report
Algorithm & Checklist
PDSA Trials
Dale Reisner, MD
Medical Director of Obstetrics Quality
and Safety
Swedish Medical Center
WSHA Safe Table
Safe Deliveries Roadmap
November 19, 2013
Presented at Washington State Hospital Association Safe Table 11/19/2013
Induction
Draft
Fetal and Maternal Assessment Appropriate
for Induction
Medically Indicated Only
Favorable Cervix
(Bishop Score > 8)
Unfavorable Cervix
(Bishop Score < 8)
Initiate
Oxytocin
Mechanical or
Pharmacological
Cervical Ripening
No Cervical
Change
No Cervical
Change
Cervical
Change
Repeat with
Different Method
Continue Oxytocin
or AROM
Cervix > 6 cm*
*may observe for
spontaneous labor
No Response
Oxytocin Trial?
Home or
Cesarean
Cervix < 6 cm, Unable
to AROM, or no Cervical
Change with 24 Hours
Oxytocin
Assess
Cervical Change
No Change
Cervical
Change
•Adequate contractions
for > 4 hours
•Inadequate contractions
for 6 hours
Failed Induction
Second Stage
Arrest
See Spontaneous
Labor Algorithm
Proceed to Cesarean
Presented at Washington State Hospital Association Safe Table 11/19/2013
If Elective,
Consider Home
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)
Presented at Washington State Hospital Association Safe Table 11/19/2013
Maternal or Fetal
Indication
for Admission
TRIAGE
Induction Algorithm
Draft
Spontaneous Labor
> 37 wks and < 41 wks
Stable Mother and Baby
Cervix < 4 cm
Home
Cervix 4 cm or More
Walk and Reassess
Admit to L&D
Inadequate
Progress
First Stage
Adequate
Progress
First Stage
First Stage Arrest
Depending on assessment;
Home, AROM and/or Oxytocin,
or Cesarean
Adequate
Progress
Second Stage
Inadequate
Progress
Second Stage
Inadequate
Progress
Second Stage
Adequate
Progress
Second Stage
Second Stage Arrest
Operative Vaginal
or Cesarean
Presented at Washington State Hospital Association Safe Table 11/19/2013
Vaginal Delivery
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
Presented at Washington State Hospital Association Safe Table 11/19/2013
PDSA on 4 Campuses Nov 2013
Both sets of Algorithms & Respective
Checklists
• 29 Algorithms/Checklists evaluated
• 27 RNs or LIPs
Common Themes
What to do for <4cms with pain
4-5 cms but not in labor
Do we suggest the amt of walk & reassess
time?
?SROM: Induction vs Augmentation
Should 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
Indication for Induction
see Induction Algorithm
and Checklist
New
Draft
TRIAGE
Maternal or Fetal Indication
for Admission either in
Labor or Needs Induction
Spontaneous Labor > 37wks
Stable Mother and Baby
Assess Exam and Pain
New
Cervix < 4 cm
Home
Cervix 4 cm or More
in Labor
Walk and Reassess
Admit to L&D
Inadequate
Progress
First Stage
Adequate
Progress
First Stage
First Stage Arrest
Depending on assessment;
Home vs AROM and/or
Oxytocin vs Cesarean
New
Definitions
Examples:
•Adequate progress
•reVITALize
Inadequate
Progress
Second Stage
Adequate
Progress
Second Stage
Second Stage Arrest
Operative Vaginal
or Cesarean
Presented at Washington State Hospital Association Safe Table 11/19/2013
Vaginal Delivery

similar documents