Introducing a safety bundle to reduce neonatal and maternal morbidity from operative vaginal birth.

Abstract

Statement of Problem: In 2019 in Victoria, the Consultative Council on Obstetric and Paediatric Mortality and Morbidity reported a series of poor neonatal and maternal outcomes from operative vaginal birth (OVB) state-wide, with common underlying themes including failure to recognize malposition of the fetal head, deviation from safety guidelines and poor interdisciplinary communication. In response, a multidisciplinary task force at Monash Health created a safety bundle to address these concerns. Description of the Intervention: The OVB safety bundle includes recommending routine intrapartum ultrasound to confirm fetal head position as well as performing a structured team time-out before and procedural checklist during OVB. The bundle was piloted from November 2021 to August 2022 and feedback from maternity staff incorporated. From August 2022, the bundle was recommended for all OVB and incorporated into annual compulsory multidisciplinary emergency simulation training. Obstetric staff underwent upskilling in the use of intrapartum ultrasound. Findings to Date: From August 2022 to March 2023 there were 818 second stage operative deliveries at Monash Health, including 515 (63.0%) forceps, 227 (27.8%) ventouse and 76 (9.2%) fully dilated cesarean sections. Over this time, we observed increased uptake of ultrasound from 27 to 54%, of the time-out from 25% to 67% and the checklist from 40 to 85% of all OVB. We compared cases where ultrasound was (n = 304) and was not (n = 514) used during this period. We calculated propensity scores for the probability of ultrasound use in each case. To control confounding by indication, odds ratios comparing neonatal and maternal outcome rates between groups were adjusted for the propensity scores with multivariable logistic regression models. In 514 cases where ultrasound was not used, there were 16 (3.2%) cases where the infant was delivered in an unexpected position, resulting in potential preventable maternal or neonatal trauma in six cases (37.5%). In 304 births where ultrasound was used, there were no such cases (0% vs. 3.2%, p = 0.0003). There were no significant differences in other neonatal and maternal outcomes; however, there was a non-significant trend to reduced composite neonatal morbidity including Apgar 5 min <7, cord lactate >8mmol/L, neonatal intensive care unit admission or need for resuscitation (17.7% vs. 21.1%, adjusted OR 0.69 [95% CI 0.46 to 1.03], p = 0.07). Lessons Learned: We developed and successfully implemented an OVB safety bundle at Monash Health. Use of ultrasound prior to OVB prevented cases of delivering infants in an unexpected position which may increase the risk of trauma for mother and infant.