1. 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

2. Fetal and Maternal Assessment Appropriate Medically Indicated Only
Draft
Induction
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
DRAFT
No Cervical
Change
Cervical
Change
No Cervical
Change
Repeat with
Different Method
Continue Oxytocin
or AROM
Cervix > 6 cm*
*may observe for
spontaneous labor
No Response
Oxytocin Trial?
Cervix < 6 cm, Unable
to AROM, or no Cervical
Change with 24 Hours
Oxytocin
Home or
Cesarean
Assess
Cervical Change
Cervical Change
No Change
Adequate contractions
for > 4 hours
Inadequate contractions
for 6 hours
Failed Induction
Second Stage
Arrest
See Spontaneous Labor Algorithm
Proceed to Cesarean
If Elective, Consider Home
Presented at Washington State Hospital Association Safe Table 11/19/2013

3. 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
Presented at Washington State Hospital Association Safe Table 11/19/2013

4. DRAFT Draft TRIAGE Spontaneous Labor > 37 wks and < 41 wks
Maternal or Fetal Indication
for Admission
Induction Algorithm
Draft
Spontaneous Labor
> 37 wks and < 41 wks
Stable Mother and Baby
Cervix < 4 cm
Cervix 4 cm or More
DRAFT
Home
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
Vaginal Delivery
Presented at Washington State Hospital Association Safe Table 11/19/2013

5. 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:
90 – 100% effacement
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 hrs
Multiparous with epidural - 3 hrs
Multiparous without epidural – 2 hrs
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
Presented at Washington State Hospital Association Safe Table 11/19/2013

6. 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

7. DRAFT Draft TRIAGE New New New Definitions Examples: Adequate progress
Indication for Induction see Induction Algorithm and Checklist
TRIAGE
Maternal or Fetal Indication
for Admission either in Labor or Needs Induction
New
Spontaneous Labor > 37wks
Stable Mother and Baby
Assess Exam and Pain
New
Draft
Cervix < 4 cm
Cervix 4 cm or More
in Labor
DRAFT
Home
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
Inadequate Progress Second Stage
Adequate Progress Second Stage
Definitions
Examples:
Adequate progress
reVITALize
Second Stage Arrest
Operative Vaginal
or Cesarean
Vaginal Delivery
Presented at Washington State Hospital Association Safe Table 11/19/2013