Labor and Delivery Unit Safety: Slide Presentation

Slide 1: AHRQ Safety Program for Perinatal Care

Labor and Delivery Unit Safety

Slide 2: Learning Objectives

Image: Three ascending steps show the learning objectives:

• Describe the rationale for the use of checklists for reducing errors.
• Identify the key safety elements for four specific situations encountered on labor and delivery (L&D) units.
• Identify ways the key safety elements can be customized for unit procedures for these four situations.

Slide 3: L&D Unit Safety Tools

• The Labor and Delivery Unit Safety bundle focuses on key safety elements for four specific L&D situations:
  • Safe cesarean section.
  • Shoulder dystocia.
  • Obstetric hemorrhage.
  • Umbilical cord prolapse.
• Training materials and tools offer key safety elements for these situations.
• Key safety elements.
  • Provide a comprehensive starting point for each unit to consider.
  • Can be adapted and applied to other perinatal situations requiring high reliability processes.

Slide 4: Rationale for Use of Checklists^1-4

• Checklists help to facilitate safety in high-complexity, high-risk, and high-reliability professions.
• Health care errors are often slips rather than mistakes.
• Checklists are cognitive aids that—
  • Reduce slips that occur due to lapses in concentration, distractions, fatigue, or lack of knowledge of evidence-based practices.
  • Decrease reliance on memory for tasks typically performed reflexively or "on auto-pilot."
  • Provide confidence that no step will be forgotten.

Slide 5: Role of Checklists

Checklist effectiveness for reducing errors can be enhanced when—

• They are created or adapted to meet unit needs.
• They are implemented within a culture that fosters teamwork and communication.
• Staff gain experience with them during in situ simulation practice.

Slide 6: L&D Unit Safety Tools

• Purpose.
• Who should use.
• How to use.
• Key safety elements.
• Sample checklists and references to externally developed checklists.

Four tools are available as part of the AHRQ Safety Program for Perinatal Care (SPPC) in support of this module.

Slide 7: SPPC Key Perinatal Safety Elements for L&D Unit Safety

• Situation specific:
  • Standardize When Possible (CUSP Science of Safety).
  • Create Independent Checks (CUSP Science of Safety).
  • Simulation (Safety Program for Perinatal Care Program Pillar).
• General:
  • Learn From Defects (CUSP Module).
  • Teamwork Training (TeamSTEPPS®).
  • Patient and Family Engagement (CUSP Module).

Slide 8: Safe Cesarean Section

Safe Cesarean Section

Slide 9: Key Safety Elements: Standardize When Possible

• Use a standard perioperative process for cesarean sections (C/S).^5,6

Image: Three rows of text boxes describe the process:

When (first row):

1. Before Anesthesia.
2. Before Skin Incision.
3. Before Patient Leaves Operating Room.

What (second row, superimposed on an arrow pointing from left to right):

1. Preoperative Briefing.
2. Timeout.
3. Signout and Debrief.

Where (third row):

1. Briefing Station.
2. In Operating Room.

Slide 10: Key Safety Elements: Standardize When Possible

• Preoperative briefing.
  • Review plan for patient care, risks, or concerns.
  • Typically led by the obstetrician/surgeon.
  • Ensure shared mental model.
  • Include reviews of—
    • Patient information.
    • C/S procedure.
    • Indications.
    • Anticipated complications.
    • Risk.
    • Medical history.
    • Fetal status.
    • Type of anesthesia.

Slide 11: Key Safety Elements: Standardize When Possible

• Timeout:
  • Initiated once all team members are present in operating room (OR).
  • Assures safety through a "huddle."
  • Team members agree with plan and maternal/fetus status.
• Signout and debrief:
  • Standard approach for wrapping up and debriefing.
  • Often a moment for process improvement.

Slide 12: Key Safety Elements: Create Independent Checks

• Checklists can facilitate the three components of a safe perioperative process^3-6 to—
  • Engage all relevant team members.
  • Introduce some redundancy into the perioperative process.
  • Ensure critical factors are considered and addressed at each step.

Slide 13: Sample Checklist: Cesarean Section

• A sample checklist for C/S, based on the World Health Organization model,⁷ is provided as an appendix to this tool.
• It provides suggested specific checklist items for each of the three perioperative safety steps: the preoperative briefing, timeout, and signout and debrief.
  • The sample is provided in two formats: an "at a glance" format or a "large print" format.
  • The specific checklist items can be customized based on unit preference.

Slide 14: Key Safety Elements: Simulation

• Team simulation can improve knowledge, practical skills, communication, and team performance in acute situations.
• Any of the sample scenarios available through the SPPC that ultimately result in team decision to proceed to OR for C/S can be used.
• Scenarios reinforce teamwork and communication related to—
  • Situational awareness.
  • Efficient use of safe surgery checklists to guide the perioperative process using a perioperative briefing, timeout, and signout.
  • Communication with rapid responders.
  • Communication with patient/family.
  • Use of briefings, huddles, and debriefings.

Slide 15: Shoulder Dystocia

Shoulder Dystocia

Slide 16: Key Safety Elements: Standardize When Possible

• Use predetermined approach to managing shoulder dystocia.
  • Care provider clearly states the concern for shoulder dystocia.
  • Communication to others for assistance to put plan for safe delivery into place.
  • Role designation of staff.
  • Clinical maneuvers and directed maternal pushing.^8,9
  • Recording time of dystocia identification, and time of maneuvers as performed.
  • Episode documentation elements.¹⁰ 
• Standardize communication of information during episode using callouts.¹¹

Slide 17: Key Safety Elements: Create Independent Checks

• Cognitive aids such as checklists, algorithms, or protocols, may improve team response and management of shoulder dystocia.^10,12-15
  • Such aids can provide clinical teams with an independent check on steps for facilitating a safe delivery by offering logic and a clear focus.
  • Such aids help teams have a shared mental model and efficient approach for management and documentation during an episode.

Slide 18: Sample Checklist: Shoulder Dystocia

• A sample checklist for shoulder dystocia management and documentation is provided as an appendix to this tool.
• It provides the suggested checklist items for safe care during a delivery complicated by shoulder dystocia.
• It can also foster accurate and comprehensive documentation, which can be critical for a medical liability defense.
• The checklist items can be customized based on unit preference. Other example checklists, algorithms, and protocols are also available.^10,12-15

Slide 19: Key Safety Elements: Simulation

• Simulation training can improve clinician skills.^13,16,17 A sample scenario is available through the SPPC to train teams on the key perinatal safety elements related to shoulder dystocia management. This scenario reinforces teamwork and communication related to—
  • Situational awareness.
  • Ability to get additional help quickly.
  • Use of cognitive aids, such as checklists.
  • Communication with rapid responders.
  • Communication with patient/family.
  • Use of briefings, huddles, and debriefings.
• Shoulder dystocia simulation training focused on clinical/technical skills may require a mannequin or high-fidelity birthing simulator.

Slide 20: Obstetric Hemorrhage

Obstetric Hemorrhage

Slide 21: Key Safety Elements: Standardize When Possible

• Use routine and standardized hemorrhage risk assessment on admission.^18-21
• Use standardized approach including obstetric hemorrhage kits and carts for responding to hemorrhage episodes.^19,20
• Use standardized approach for the active management of third stage of labor for vaginal births to prevent hemorrhage.^22-31

Slide 22: Key Safety Elements: Create Independent Checks

• Use cognitive aids, such as checklists, flow sheets, and algorithms based on best practice guidelines to guide clinical response to obstetric hemorrhage.
• Many externally developed examples are available.^{18-20,26,32-35}

Slide 23: Key Safety Elements: Create Independent Checks

• Quantify blood loss during all deliveries and during a hemorrhage episode.
  • Underestimation of blood loss is common and leads to delays in recognition and management.^19,27,36-41
  • Quantification of blood loss includes—
    • Using calibrated under-buttocks drapes.
    • Measuring blood in collection containers.
    • Weighing blood-soaked objects to estimate volume.
    • Using standardized visual estimation methods.
  • Resources for training staff to learn quantification methods are available.^19,42,43

Slide 24: Key Safety Elements: Simulation

• Two sample scenarios related to obstetric hemorrhage are available through the SPPC:
  • Antepartum hemorrhage.
  • Postpartum hemorrhage.
• These scenarios reinforce teamwork and communication related to—
  • Situational awareness.
  • Early identification of hemorrhage through quantification of blood loss.
  • Use of cognitive aids.
  • Communication with rapid responders.
  • Communication with patient/family.
  • Use of briefings, huddles, and debriefings.
• Several externally developed hemorrhage scenarios are also available.^43-45

Slide 25: Cord Prolapse

Cord Prolapse

Slide 26: Key Safety Elements: Standardize When Possible

• Use predetermined approach to management of cord prolapse:
  • Staff clearly state a prolapse has occurred.
  • Communication to others for assistance to put plan for safe delivery into place.⁴⁶
  • Role designation of staff.
  • Appropriate clinical interventions.
  • Recording time of prolapse identification and time of interventions performed.
  • Episode documentation elements.

Slide 27: Key Safety Elements: Create Independent Checks

• Increase situational awareness by using cognitive aids, such as checklists, of maternal and fetal criteria for procedures that increase risk for cord prolapse⁴⁷ such as—
  • Amniotomy.
  • Intrauterine pressure catheter or fetal scalp electrode placement.
  • Manual rotation.
  • Placement of cervical balloon catheter.
  • External cephalic version.
  • Amnioinfusion.
  • Placement of forceps or vacuum.
• Cognitive aids such as checklists, algorithms, or protocols, may improve team response to cord prolapse.^48-51

Slide 28: Sample Checklist: Cord Prolapse

• A sample checklist for Cord Prolapse Management and Documentation isprovided as an appendix to this tool.
• It provides the suggested checklist items for safe care during a delivery complicated by cord prolapse. It can also foster accurate and comprehensive documentation, which can be critical for a medical liability defense.
• The checklist items can be customized based on unit preference. Other example checklists, algorithms, and protocols are also available.^48-50

Slide 29: Key Safety Elements: Simulation

• A sample scenario is available through the SPPC to train teams on the key perinatal safety elements related to cord prolapse. This scenario reinforces teamwork and communication related to—
  • Situational awareness.
  • Ability to get additional help quickly.
  • Use of cognitive aids.
  • Communication with rapid responders.
  • Communication with patient/family.
  • Use of briefings, huddles, and debriefings.
• Cord prolapse simulation training focused on clinical/technical skills may require a mannequin or high-fidelity birthing simulator.

Slide 30: Labor and Delivery Unit Safety

Labor and Delivery Unit Safety
General Key Safety Elements

Slide 31: Key Safety Elements: Learn From Defects

• Debrief and analyze near misses and adverse events.
• Have a process in place to review severe maternal or neonatal morbidity and mortality events.
• Share outcomes or process improvements from the informal (debriefing) and formal analysis with staff to achieve transparency and organizational learning.

Slide 32: Key Safety Elements: Teamwork Training

• Have situational awareness around maternal and fetal risks and status.
• Use SBAR, callouts, huddles, and closed- loop communication techniques.
• Communicate during transitions of care.
• Have high-reliability teams.

Slide 33: Key Safety Elements: Patient and Family Engagement

• Communication with patient and family during episode.
• Unit approach includes disclosure of any unintended outcomes.

Slide 34: Customizing the Key Elements & Checklists

• Review the key perinatal safety elements with L&D leadership and relevant staff.
• Determine how the elements will be tailored for the unit.
• Consider any existing hospital procedures, policies, and processes related to these situations.
• Reformat or build customized content into unit’s existing documentation systems.

Slide 35: Unit Next Steps

• Decide whether to select components of the L&D Unit Safety bundle for implementation locally. Factors to consider:
  • Unit and malpractice claims data suggesting adverse events or near misses related to cesarean section, shoulder dystocia, postpartum hemorrhage, or cord prolapse.
  • Synergy with related or similar initiatives.
  • Interest and enthusiasm of unit staff for implementing.
• Support implementation of unit procedure.
  • Staff training/communication.
  • Simulation.
• Monitor implementation progress and impact of data.

Slide 36: Tips for Implementation Success

• Use Comprehensive Unit-based Safety Program (CUSP) principles for implementing teamwork and communication (e.g., incorporating diverse perspectives) to develop consensus on the "clinical content" of the L&D Unit Safety tools.
• Pilot test any new tools, including revisions, on a limited scale to work out any bugs or problems.
• Comprehensively review unit procedures each year to assess the need for updates to ensure content is up to date.
• Create a mechanism for identifying recurrent nonuse or deviation from the established procedure by clinicians. Seek to understand why, rather than assign blame.

Slide 37: References

1. Agency for Healthcare Quality and Research’s Patient Safety Network. Patient Safety Primer on Checklists. 2014 August. http://psnet.ahrq.gov/primer.aspx?primerID=14. Accessed May 2, 2016.
2. Hales B, Terblanche M, Fowler R, et al. Development of medical checklists for improved quality of patient care. Int J Qual Health Care 2008 Feb;20(1):22-30. PMID: 18073269.
3. Physician-Patient Alliance for Health & Safety. 5 Benefits of Adopting Patient Safety Checklists. 2013 March 19. http://ppahs.org/2013/03/19/5-benefits-of-adopting-patient-safety-checklists/. Accessed May 2, 2016.
4. Gawande AA. The Checklist Manifesto: How to Get Things Right. 1st ed., New York, NY: Metropolitan Books; 2009.
5. Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009 Jan 29;360(5):491-9. PMID: 19144931.
6. Russ S, Rout S, Sevdalis N, et al. Do safety checklists improve teamwork and communication in the operating room? A systematic review. Ann Surg 2013 Dec;258(6):856-71. PMID: 24169160.

Slide 38: References

7. World Health Organization. Patient Safety: Safe Surgery: Why Safe Surgery Is Important. 2014. http://www.who.int/patientsafety/safesurgery/en/. Accessed May 2, 2016.
8. Sokol RJ, Blackwell SC, American College of O, et al. ACOG practice bulletin: Shoulder dystocia. Number 40, November 2002. (Replaces practice pattern number 7, October 1997). Int J Gynaecol Obstet 2003 Jan;80(1):87-92. PMID: 12578001.
9. Bruner JP, Drummond SB, Meenan AL, et al. All-fours maneuver for reducing shoulder dystocia during labor. J Reprod Med 1998 May;43(5):439-43. PMID: 9610468.
10. Patient safety checklist No. 6: documenting shoulder dystocia. Obstet Gynecol 2012 Aug;120(2 Pt 1):430-1. PMID: 22825113.
11. Macones GA, Hankins GD, Spong CY, et al. The 2008 National Institute of Child Health and Human Development workshop report on electronic fetal monitoring: update on definitions, interpretation, and research guidelines. J Obstet Gynecol Neonatal Nurs 2008 Sep-Oct;37(5):510-5. PMID: 18761565.

Slide 39: References

12. Stitely ML, Gherman RB. Shoulder dystocia: management and documentation. Semin Perinatol 2014 Jun;38(4):194-200. PMID: 24863024.
13. Inglis SR, Feier N, Chetiyaar JB, et al. Effects of shoulder dystocia training on the incidence of brachial plexus injury. Am J Obstet Gynecol 2011 Apr;204(4):322 e1-6. PMID: 21349495.
14. Deering SH, Tobler K, Cypher R. Improvement in documentation using an electronic checklist for shoulder dystocia deliveries. Obstet Gynecol 2010 Jul;116(1):63-6. PMID: 20567169.
15. Kwek K, Yeo GS. Shoulder dystocia and injuries: prevention and management. Curr Opin Obstet Gynecol 2006 Apr;18(2):123-8. PMID: 16601471.
16. Crofts JF, Fox R, Ellis D, et al. Observations from 450 shoulder dystocia simulations: lessons for skills training. Obstet Gynecol 2008 Oct;112(4):906-12. PMID: 18827135.
17. Draycott TJ, Crofts JF, Ash JP, et al. Improving neonatal outcome through practical shoulder dystocia training. Obstet Gynecol 2008 Jul;112(1):14-20. PMID: 18591302.

Slide 40: References

18. Audureau E, Deneux-Tharaux C, Lefevre P, et al. Practices for prevention, diagnosis and management of postpartum haemorrhage: impact of a regional multifaceted intervention. BJOG 2009 Sep;116(10):1325-33. PMID: 19538416.
19. Lyndon A, Lagrew D, Shields L, et al., eds. Improving Health Care Response to Obstetric Hemorrhage (California Maternal Quality Care Collaborative Toolkit to Transform Maternity Care). Developed under contract #08-85012 with the California Department of Public Health; Maternal, Child and Adolescent Health Division. Stanford, CA: California Maternal Quality Care Collaborative; 2010.
20. Harvey CJ, Dildy GA. Obstetric Hemorrhage. Washington, DC: Association of Women’s Health, Obstetric, and Neonatal Nurses; 2012.
21. American Congress of Obstetricians and Gynecologists. ACOG Practice Bulletin: Clinical Management Guidelines for Obstetrician-Gynecologists Number 76, October 2006: postpartum hemorrhage. Obstet Gynecol. 2006 Oct;108(4):1039-47. PMID: 17012482.
22. Begley CM, Gyte GM, Devane D, et al. Active versus expectant management for women in the third stage of labour. Cochrane Database Syst Rev 2011(11):CD007412. PMID: 22071837.

Slide 41: References

23. Oladapo OT, Okusanya BO, Abalos E. Intramuscular versus intravenous prophylactic oxytocin for the third stage of labour. Cochrane Database Syst Rev 2012;2:CD009332. PMID: 22336865.
24. Westhoff G, Cotter AM, Tolosa JE. Prophylactic oxytocin for the third stage of labour to prevent postpartum haemorrhage. Cochrane Database Syst Rev 2013;10:CD001808. PMID: 24173606.
25. Liabsuetrakul T, Choobun T, Peeyananjarassri K, et al. Prophylactic use of ergot alkaloids in the third stage of labour. Cochrane Database Syst Rev 2007(2):CD005456. PMID: 17443592.
26. Burke C. Active versus expectant management of the third stage of labor and implementation of a protocol. J Perinat Neonatal Nurs 2010 Jul-Sep;24(3):215-28; quiz 29-30. PMID: 20697238.
27. Tuncalp O, Souza JP, Gulmezoglu M, et al. New WHO recommendations on prevention and treatment of postpartum hemorrhage. Int J Gynaecol Obstet 2013 Dec;123(3):254-6. PMID: 24054054.

Slide 42: References

28. McDonald SJ, Middleton P, Dowswell T, et al. Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes. Cochrane Database Syst Rev 2013;7:CD004074. PMID: 23843134.
29. Du Y, Ye M, Zheng F. Active management of the third stage of labor with and without controlled cord traction: a systematic review and meta-analysis of randomized controlled trials. Acta Obstet Gynecol Scand 2014 Jul;93(7):626-33. PMID: 24828584.
30. Hofmeyr GJ, Abdel-Aleem H, Abdel-Aleem MA. Uterine massage for preventing postpartum haemorrhage. Cochrane Database Syst Rev 2013;7:CD006431. PMID: 23818022.
31. Soltani H, Hutchon DR, Poulose TA. Timing of prophylactic uterotonics for the third stage of labour after vaginal birth. Cochrane Database Syst Rev 2010(8):CD006173. PMID: 20687079.
32. Skupski DW, Lowenwirt IP, Weinbaum FI, et al. Improving hospital systems for the care of women with major obstetric hemorrhage. Obstet Gynecol 2006 May;107(5):977-83. PMID: 16648399.

Slide 43: References

33. ACOG Patient Safety and Quality Improvement Committee. ACOG Committee Opinion No. 526: Standardization of practice to improve outcomes. Obstet Gynecol 2012 May;119(5):1081-2. PMID: 22525933.
34. Rizvi F, Mackey R, Barrett T, et al. Successful reduction of massive postpartum haemorrhage by use of guidelines and staff education. BJOG 2004 May;111(5):495-8. PMID: 15104617.
35. American Congress of Obstetricians and Gynecologists. Patient Safety Checklist No. 10: postpartum hemorrhage from vaginal delivery. Obstet Gynecol 2013;121(5):1151-2.
36. Schorn MN. Measurement of blood loss: review of the literature. J Midwifery Womens Health 2010 Jan-Feb;55(1):20-7. PMID: 20129226.
37. Larsson C, Saltvedt S, Wiklund I, et al. Estimation of blood loss after cesarean section and vaginal delivery has low validity with a tendency to exaggeration. Acta Obstet Gynecol Scand 2006;85(12):1448-52. PMID: 17260220.
38. Gabel KT, Weeber TA. Measuring and communicating blood loss during obstetric hemorrhage. J Obstet Gynecol Neonatal Nurs 2012 Jul-Aug;41(4):551-8. PMID: 22548283.

Slide 44: References

39. Dildy GA, 3rd, Paine AR, George NC, et al. Estimating blood loss: can teaching significantly improve visual estimation? Obstet Gynecol 2004 Sep;104(3):601-6. PMID: 15339775.
40. Zhang WH, Deneux-Tharaux C, Brocklehurst P, et al. Effect of a collector bag for measurement of postpartum blood loss after vaginal delivery: cluster randomised trial in 13 European countries. BMJ 2010;340:c293. PMID: 20123835.
41. Zuckerwise LC, Pettker CM, Illuzzi J, et al. Use of a novel visual aid to improve estimation of obstetric blood loss. Obstet Gynecol 2014 May;123(5):982-6. PMID: 24785850.
42. Association of Women’s Health, Obstetric and Neonatal Nurses. Practice Brief: Clinical Management Guidelines for Women's Health and Perinatal Nurses: Quantification of Blood Loss. 2014 May. http://www.pphproject.org/downloads/awhonn_qbl.pdf. Accessed May 2, 2016.
43. California Maternal Quality Care Collaborative. OB Hemorrhage Toolkit V 2.0. Improving Health Care Response to Obstetric Hemorrhage, Version 2.0: A California Toolkit to Transform Maternity Care. Released March 2015. https://www.cmqcc.org/resources-tool-kits/toolkits/ob-hemorrhage-toolkit. Accessed May 3, 2016.

Slide 45: References

44. Wisconsin Association for Perinatal Care. Postpartum Hemorrhage: Resources. 2014 http://www.perinatalweb.org/major-initiatives/postpartum-hemorrhage/resources. Accessed May 2, 2016.
45. American Congress of Obstetrics and Gynecology. ACOG Simulations Consortium Learning Objectives: Postpartum Hemorrhage Caused by Uterine Atony. n.d. http://www.acog.org/~/media/Departments/Simulations%20Consortium/Learning%20Objectives/Postpartum_Hemorrhage.pdf. Accessed May 2, 2016.
46. Macones GA, Hankins GD, Spong CY, et al. The 2008 National Institute of Child Health and Human Development workshop report on electronic fetal monitoring: update on definitions, interpretation, and research guidelines. J Obstet Gynecol Neonatal Nurs 2008 Sep-Oct;37(5):510-5. PMID: 18761565.
47. Holbrook BD, Phelan ST. Umbilical cord prolapse. Obstet Gynecol Clin North Am 2013 Mar;40(1):1-14. PMID: 23466132.
48. Phelan ST, Holbrook BD. Umbilical cord prolapse: a plan for an OB emergency. Contemp OB/GYN. 2013 Sept 1. http://contemporaryobgyn.modernmedicine.com/contemporary-obgyn/news/umbilical-cord-prolapse?page=full. Accessed May 2, 2016.

Slide 46: References

49. Government of Western Australia, Department of Health. Obstetric and Gynaecology Clinical Guidelines Section B. Obstetrics and Midwifery Care, Section b11.3.2  Umbilical Cord Prolapse. January 2015. http://kemh.health.wa.gov.au/development/manuals/O&G_guidelines/sectionb/11/b11.3.2.pdf. Accessed July 4, 2016.
50. Perinatal Services BC. Core Competencies for Management of Labor, Decision Support Tool 8A—Obstetrical Emergencies Cord Prolapse. 2014 April 14. http://www.perinatalservicesbc.ca/health-professionals/guidelines-standards/standards/core-competencies-for-management-of-labour. Accessed May 2, 2016.
51. Siassakos D, Hasafa Z, Sibanda T, et al. Retrospective cohort study of diagnosis-delivery interval with umbilical cord prolapse: the effect of team training. BJOG 2009 Jul;116(8):1089-96. PMID: 19438496.

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