1. Zero Birth Injury Initiative
Phillip N. Rauk, MD
Associate Professor, Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Women’s Health, University of Minnesota Medical School
and
Medical Director of the Birthplace at UMMC-Fairview Hospital

2. Objectives Basic safety improvement strategies
Definition of birth trauma
Brief story from Ascension Health
Bundle science and IHI obstetrics bundles
Impact of shoulder dystocia
Where are we at Fairview?

3. Why are we doing this?
Overall goal of the initiative is to reduce birth injury
UMMC birth injury rate 2007 – 0.03%
Birth injury is devastating to all involved
“Right thing to do”
Improve patient safety
Improve perinatal outcomes
Reduce medical and nursing errors

4. Preventable Perinatal Harm and Obstetrical Liability
Failure to recognize fetal distress/non-reassuring fetal status
Failure to effect a timely cesarean section
Failure to properly resuscitate a depressed baby
Inappropriate use of oxytocin/misoprostol
Inappropriate use of vacuum/forceps
Failure to manage shoulder dystocia

5. Characteristics of a Successful Safety Change Initiative
High functioning team rather than expert individuals
Shared mental models
Situational awareness
Common language
Policies and order sets support these initiative

6. Experiential learning & application, test for gaps
Strategy to create Highly Reliable Teams within a culture of organizational learning
High
Reliability
Just Culture™
Principles of risk,
Accountability,
Behavioral choices,
Drift, and use of
Coaching after errors
TeamSTEPPS™
Define the team,
Curriculum Training
& implementation of
Action Plans
“ME-YOU-US”
In Situ™
Simulation
Experiential learning
& application, test for gaps
In the “real world”
Stan Davis, MD, FACOG & Kristi K Miller RN, MS

7. Adverse Outcome Index Measure and Weighting Score
Index Measure Score
Maternal Death
Intrapartum and Neonatal Death
Uterine Rupture
Maternal Admission to ICU
Birth Trauma
Return to OR/L&D
Admission to NICU
APGAR <
Blood Transfusions
3rd and 4th degree perineal laceration

8. Birth Trauma as defined for the AOI Measure
In-born infants only and diagnosis of
767.0 Subdural and Cerebral Hemorrhage (due to trauma or to intrapartum anoxia or hypoxia)
Epicranial subaponeurotic hemorrhage (massive)
767.3 Injuries to skeleton (excludes clavicle)
767.4 Injury to spine and spinal cord
767.5 Facial nerve Injury
767.6 Injury to brachial plexus*
767.7 Other cranial and peripheral nerve injuries
* Not used in AHRQ PSI 17 measure for Birth Trauma Infant

9. AHRQ Patient Safety Indicator (PSI) 17 - Birth Trauma
• Numerator
– Discharges among cases meeting the inclusion and exclusion rules
for the denominator with ICD-9-CM code for birth trauma in any
diagnosis field
Exclude infants
With any diagnosis code of pre-term infant (denoting birth weight of
less than 2,000 grams)
With any diagnosis code of osteogenesis imperfecta (756.51)
With any diagnosis code of injury to brachial plexus (767.6)

10. Birth Trauma as defined by the AHRQ PSI 17 Birth Trauma Infant
• Subdural and Cerebral Hemorrhage (due to trauma
or to intrapartum anoxia or hypoxia)
• Epicranial subaponeurotic hemorrhage (massive)
• Injuries to skeleton (excludes clavicle)
• Injury to spine and spinal cord
• Facial Nerve Injury
• Other cranial and peripheral nerve injuries
• Other specified birth trauma*
*Not used in AOI Birth Trauma Measure

11. Story at Ascension Health
Three hospital sites were selected for implementation of:
Standardized order sets specific to augmentation and induction of labor
Complete adherence to a IHI induction, augmentation and operative delivery bundles
Best practices sharing across all disciplines
Effective communication strategies using SBAR and culture change

12. Story at Ascension Health
From February 2004 to June 2006
Bundle compliance achieved the goal of 95% compliance
Elective inductions before 39 weeks fell to zero
Operative delivery rate fell from 7.4% to 4.8%
Birth trauma rate fell from 0.2% to 0.03%
Primary cesarean rate remained unchanged at 22.5%

13. Ascension Health Birth Trauma

14. Quality Care in Obstetrics Addressing Harm Using Bundles
The Bundle Science
Individual components supported by evidence based medicine/professional guidelines
Required to be performed for every patient, every time
Bundle compliance measured by fulfilling all parts of the bundle
Focus on system

15. Bundle Science
A bundle is a group of evidence-based interventions related to a disease or care process that, when executed together, result in better outcomes than when implemented individually.
All components of the bundle must be met to achieve the desired better outcome

16. The Oxytocin Bundles Augmentation Bundle Elective Induction Bundle
Gestational Age > weeks
Reassuring Fetal Status
Pelvic Exam prior to the start of Oxytocin
Recognition and management of Hyperstimulation
Augmentation Bundle
Documentation of Estimated Fetal Weight
Reassuring Fetal Status
Pelvic Exam prior to the start of Oxytocin
Recognition and management of Hyperstimulation

17. No Elective Inductions at < 39 weeks No Elective Late-Preterm Infants
RDS
TTN
Pulmonary infection
Unspecified respiratory failure
Recurrent apnea
Temperature instability
Jaundice that delays discharge
Bilirubin induced brain injury
Hypoglycemia
Rehospitalization for any cause
Rehospitalization for neonatal dehydration
Death
Feeding difficulties
Long term behavioral problems
(Pediatrics, September :1207)

18. Vacuum Bundle Alternative labor strategies considered Prepared patient
Informed consent discussed and documented
High probability of success
EFW, fetal position and station known
Maximum application time and number of pop-offs predetermined
Exit strategy available
Cesarean and resuscitation team available

19. Vacuum Delivery Incidence of operative vaginal delivery is 10 – 15%
Compared with SVD (SVD vs Vacuum)
Rate of Death is 1/5000 vs 1/3333
Rate of IVH is 1/1900 vs 1/860
Rate of all injury is 1/216 vs 1/122
Includes nerve injury, seizure, CNS depression, mechanical ventilation
Vacuum and Forceps rate of death is 1/1666 and rate of IVH is 1/280.
ACOG 2000

20. Pop-Offs
“Pop-offs” are defined as a sudden complete detachment of the vacuum from the head with a rapid loss of pressure from the green zone to zero pressure.
The number of “pop-offs” correlates with birth trauma, ranging from abrasions to subgaleal hemorrhage
Generally > 3 increases the risk for birth injury

21. Maximum Pulls
A pull is defined as use of traction during each contraction not the number of pulls within each contraction.
There is no clear definition of the maximum pulls that should be attempted before the procedure is abandoned.
Most experts feel up to 3-4 pulls is appropriate if progression in descent is noted with each subsequent pull.
Failure to abandon the procedure when progress has not occurred is associated with an increase in birth trauma

22. Application Time There is limited data on application time
Longer application times are associated with an increased risk for failure and for neonatal morbidities
Most experts believe that consistent with other guidelines in the use of vacuum (i.e maximum pulls and progress) that 10 – 20 minutes is appropriate and that failure of any descent after 10 minutes predicts a high rate of failure

23. Other Considerations
Poor technique also effects maternal and neonatal morbidity and mortality
Improper application both with respect to placement on the head and station/position
Lack of training and credentials to perform the procedure
Use of a rocking motion or rotation
Inattention to number of “pop-offs” and pulls

24. Shoulder Dystocia Facts And Strategies
Most often unpredictable; 0.2 – 3.0% of deliveries
Most brachial plexus injuries will resolve within a year but you can’t be sure in advance which one’s will.
Standard of care is to perform correctly when it is encountered. (In Situ Simulations)
When there are risk factors, it is probably prudent to inform the parents and discuss options. It is also reasonable and acceptable to make a recommendation based on your knowledge and experience.
Get credit for meeting the standard with appropriate documentation
Shift to the “management of bad results” mode of care when injury occurs.

25. What Does ACOG Say?
November, The following recommendations are based on limited or inconsistent scientific evidence:
Shoulder Dystocia cannot be predicted or prevented because accurate methods for identifying which fetuses will experience this complication do not exist.
Elective induction of labor or elective cesarean delivery for all women suspected of carrying a fetus with macrosomia is not appropriate.

26. What Does ACOG Say?
November, The following recommendations are based primarily on consensus and expert opinion:
In patients with a history of shoulder dystocia, EFW, gestational age, maternal glucose intolerance, and the severity of the prior neonatal injury should be evaluated and the risks and benefits of cesarean delivery discussed with the patient.
Planned cesarean delivery to prevent shoulder dystocia may be considered for suspected fetal macrosomia with estimated fetal weights exceeding 5,000 grams in women without diabetes and 4,500 grams in women with diabetes.
There is no evidence that any one maneuver is superior to another in releasing an impacted shoulder or reducing the chance of injury. However, performance of the McRoberts maneuver is a reasonable initial approach.

27. Are We There Yet? Induction and Augmentation Bundles
Everyone knows about it but still not at 100%
Problems with EFW
Operative Vaginal Delivery Bundle
>70% compliance but not integrated into system practice yet.
We do have a 70% reduction in birth trauma and 30% reduction in AOI at UMMC-Riverside

28. Acknowledgements
Becky Gams, R.N., M.S., A.P.N.L., University of Minnesota Medical Center, Fairview
Phillip Rauk, M.D., University of Minnesota Medical Center, Fairview
Samantha Sommerness, R.N., M.S.N., C.N.M., A.P.N.L., Fairview Southdale Hospital
Ann Page, R.N., M.S.N., C.N.M. , University of Minnesota Medical Center, Fairview
Charlie Hirt, M.D., Fairview Southdale Hospital
Kristi Miller, R.N., M.S., Fairview Hospitals, Patient Safety
Stan Davis, M.D., Fairview Hospitals, Patient Safety
Carol Clark, R.N., M.S.N., C.N.P., Fairview Ridges Hospital
Suzin Cho, M.D., Fairview Ridges Hospital
Cass Dennison, R.N., B.S.H.A., Fairview Lakes Medical Center
Ralph Magnusson, M.D., Fairview Lakes Medical Center
Jan Gilmore, R.N.C, M.S,H.A., Fairview Red Wing Medical Center
William Saul, M.D., Fairview Red Wing Medical Center
Char Dekraker, R.N., I.B.C.L.C., Fairview Northland Medical Center
Kathy Abrahamson, M.D., Fairview Northland Medical Center
Tom George, M.D., University of Minnesota Medical Center, Fairview
Ted Thompson M.D., University of Minnesota Medical Center, Fairview
Michelle O’Brien, M.D., University of Minnesota Medical Center, Fairview