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El-Dib M, El-Shibiny H, Walsh B, Cherkerzian S, Boulanger J, Bates SV, Culic I, Gupta M, Hansen A, Herzberg E, Joung K, Keohane C, Patrizi S, Soul JS, Inder T. Establishing a regional registry for neonatal encephalopathy: impact on identification of gaps in practice. Pediatr Res 2024; 95:213-222. [PMID: 37553453 DOI: 10.1038/s41390-023-02763-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Revised: 06/15/2023] [Accepted: 06/19/2023] [Indexed: 08/10/2023]
Abstract
BACKGROUND Neonatal encephalopathy (NE) continues to be a significant risk for death and disability. To address this risk, regional guidelines were developed with the support of a malpractice insurance patient safety organization. A NE registry was also established to include 14 centers representing around 50% of deliveries in the state of Massachusetts. The aim of this study was to identify areas of variation in practice that could benefit from quality improvement projects. METHODS This manuscript reports on the establishment of the registry and the primary findings to date. RESULTS From 2018 to 2020, 502 newborns with NE were evaluated for Therapeutic Hypothermia (TH), of which 246 (49%) received TH, representing a mean of 2.91 per 1000 live births. The study reports on prenatal characteristics, delivery room resuscitation, TH eligibility screening, and post-natal management of newborns with NE who did and did not receive TH. CONCLUSIONS The registry has allowed for the identification of areas of variation in clinical practices, which have guided ongoing quality improvement projects. The authors advocate for the establishment of local and regional registries to standardize and improve NE patient care. They have made the registry data collection tools freely available for other centers to replicate this work. IMPACT Malpractice insurance companies can take an active role in supporting clinicians in establishing clinical practice guidelines and regional registries. Establishing a collaborative regional neonatal encephalopathy (NE) registry is feasible. Data Collection tools for a NE registry have been made publicly available to be adopted and replicated by other groups. Establishing a regional NE registry allowed for the identification of gaps in knowledge, variations in practice, and the opportunity to advance care through quality improvement projects.
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Affiliation(s)
- Mohamed El-Dib
- Division of Newborn Medicine, Department of Pediatrics, Brigham and Women's Hospital, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
| | - Hoda El-Shibiny
- Division of Newborn Medicine, Department of Pediatrics, Brigham and Women's Hospital, Boston, MA, USA
| | - Brian Walsh
- Division of Newborn Medicine, Department of Pediatrics, Brigham and Women's Hospital, Boston, MA, USA
- Department of Neonatology, Cork University Maternity Hospital, Cork, Ireland
| | - Sara Cherkerzian
- Division of Newborn Medicine, Department of Pediatrics, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Jason Boulanger
- Department of Patient Safety, CRICO/Risk Management Foundation of the Harvard Medical Institutions, Boston, MA, USA
| | - Sara V Bates
- Harvard Medical School, Boston, MA, USA
- Division of Newborn Medicine, Mass General Hospital for Children, Boston, MA, USA
| | - Ivana Culic
- Department of Neonatology, Beth Israel Hospital, Boston, MA, USA
- Department of Pediatrics, Beverley Hospital, Boston, MA, USA
| | - Munish Gupta
- Harvard Medical School, Boston, MA, USA
- Department of Neonatology, Beth Israel Hospital, Boston, MA, USA
| | - Anne Hansen
- Harvard Medical School, Boston, MA, USA
- Division of Newborn Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Emily Herzberg
- Harvard Medical School, Boston, MA, USA
- Division of Newborn Medicine, Mass General Hospital for Children, Boston, MA, USA
| | - Kyoung Joung
- Division of Newborn Medicine, Mass General Hospital for Children, Boston, MA, USA
- Department of Pediatrics, St. Elizabeth Medical Center, Brighton, MA, USA
| | - Carol Keohane
- Senior Vice President, Chief Quality and Safety Officer, South Shore Health, South Weymouth, MA, USA
| | - Silvia Patrizi
- Division of Newborn Medicine, Department of Pediatrics, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Newton Wellesley Hospital, Wellesley, MA, USA
| | - Janet S Soul
- Harvard Medical School, Boston, MA, USA
- Department of Neurology, Boston Children's Hospital, Boston, MA, USA
| | - Terrie Inder
- Division of Newborn Medicine, Department of Pediatrics, Brigham and Women's Hospital, Boston, MA, USA
- Center for Neonatal Research, Children's Hospital of Orange County, Orange County, CA, USA
- University of California, Irvine - College of Medicine, Irvine, CA, USA
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Alòs-Pereñíguez S, O'Malley D, Daly D. Women's views and experiences of augmentation of labour with synthetic oxytocin infusion: A qualitative evidence synthesis. Midwifery 2023; 116:103512. [PMID: 36323076 DOI: 10.1016/j.midw.2022.103512] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 10/06/2022] [Accepted: 10/07/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To explore and synthesise women's views and experiences of augmentation of labour with synthetic oxytocin infusion. DESIGN A qualitative evidence synthesis was conducted. The SPIDER acronym was used to develop the search terms and determine the inclusion criteria. Six bibliographic databases: MEDLINE, CINAHL, EMBASE, PsycINFO, Maternity and Infant Care and Web of Science Core Collection were searched in October 2021. Grey literature sources, EThOS, DART-Europe, and the World Health Organization's Clinical Trials Registry were searched, and reference lists of included studies were reviewed. Methodological quality of included studies was assessed using the Evidence for Policy and Practice Information and Co-ordinating (EPPI) Centre assessment tool. Data were synthesised thematically. The confidence of each review finding was assessed using the Grading of Recommendations Assessment, Development and Evaluation-Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual). Research ethical approval was not required. SETTING AND PARTICIPANTS Women of any age, parity, and cultural background who underwent augmentation of labour with synthetic oxytocin infusion were included. FINDINGS A total of 9306 citations were retrieved. Twenty-five studies conducted across 14 countries met the inclusion criteria and contributed data. Three principal analytical themes emerged: feeling stuck; past and present shaping the future; and cause and effect of augmentation of labour. The decision to augment women's labour was often performed without their informed consent. Women's views and experiences of augmentation of labour were shaped according to their knowledge, beliefs and support received during labour. Irrespective of the context, women consistently associated augmentation of labour with pain. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE Clinical guidelines on augmentation of labour need to be informed by research that includes women's views and experiences as a main outcome. Future research exploring the experience of augmentation of labour rather than the experience of labour dystocia would be beneficial. Increasing women's awareness and knowledge of augmentation of labour may help to ensure that their informed consent is obtained. Healthcare providers should discuss the effects, side effects and implications of augmentation of labour with women, ideally before labour.
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Affiliation(s)
- Silvia Alòs-Pereñíguez
- School of Nursing & Midwifery, Faculty of Health Sciences, Trinity College Dublin, Dublin, D02 T283, Ireland.
| | - Deirdre O'Malley
- Nursing, Midwifery & Health Studies, Dundalk Institute of Technology, Dundalk, A91 K584, Ireland
| | - Deirdre Daly
- School of Nursing & Midwifery, Faculty of Health Sciences, Trinity College Dublin, Dublin, D02 T283, Ireland
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Yasuaki K, Mizue T, Akimichi S, Yoshio S. Current Status of the Obstetric Compensation System for Cases of Cerebral Palsy at a General Hospital in Tochigi, Japan. Glob Pediatr Health 2020; 7:2333794X20973845. [PMID: 33241087 PMCID: PMC7672716 DOI: 10.1177/2333794x20973845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 10/23/2020] [Accepted: 10/26/2020] [Indexed: 11/29/2022] Open
Abstract
Objective. The Japan Obstetric Compensation System for Cerebral Palsy (JOCSC) was launched in January 2009 as the first nationwide nofault compensation system. The aim of the study was to clarify the present status of functioning of the JOCSC in pediatric and obstetric departments at a general hospital. Method. Children eligible for compensation are as follows: (1) Gestational week at 32 weeks or later and birth weight of 1400 g or more, or 28 weeks or later with apparent asphyxia at birth. (2) Severe cerebral palsy related to hypoxia at delivery, not caused by congenital reasons or factors during the neonatal period. Results. Applications for the JOCSC were submitted for 11 cases (5 cases born at our hospital and 6 cases born at other childbirth facilities). Eight cases (4 cases born at our hospital and 4 cases born at other childbirth facilities) were authorized for the JOCSC. Remaining 3 cases were judged as not being eligible because of 2 cases with congenital reasons for the condition and 1 case with the judgement as mild cerebral palsy. Conclusion. Ten years have elapsed since the establishment of the JOCSC. Improved awareness of the medical staff and caregivers of children with cerebral palsy about the JOCSC should be promoted.
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Affiliation(s)
| | - Tsukui Mizue
- Japanese Red Cross Ashikaga Hospital, Ashikaga City, Tochigi, Japan
| | - Shibata Akimichi
- Japanese Red Cross Ashikaga Hospital, Ashikaga City, Tochigi, Japan
| | - Suda Yoshio
- Japanese Red Cross Ashikaga Hospital, Ashikaga City, Tochigi, Japan
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Yatham SS, Whelehan V, Archer A, Chandraharan E. Types of intrapartum hypoxia on the cardiotocograph (CTG): do they have any relationship with the type of brain injury in the MRI scan in term babies? J OBSTET GYNAECOL 2019; 40:688-693. [PMID: 31612740 DOI: 10.1080/01443615.2019.1652576] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Electronic foetal monitoring using cardiotocography is aimed at the timely recognition and management of foetal hypoxia. The primary objective of this study was to examine whether a relationship exists between the types of foetal hypoxia (acute, subacute, evolving, chronic), as identified on cardiotocography and the nature of hypoxic ischaemic encephalopathy, as observed on MRI scans after birth. We conducted a retrospective study of 16 babies born (out of 52,187 births) at St George's Hospital in London during 2006-2017 with a postnatal diagnosis of HIE. Of the 16 babies, only 11 had both MRI scans and CTG traces available. Of those, 9 showed evidence of intrapartum hypoxia on CTG, but only 6 demonstrated evidence of HIE on MRI. Those with acute hypoxia showed abnormalities in the basal ganglia and thalami. A gradually evolving hypoxia or subacute hypoxia was associated with lesions in myelination and cerebral cortex.Impact StatementWhat is already known on this subject? It has been reported that inter-observer agreement for CTG interpretation is low (30%) when pattern recognition based guidelines are used (Rhöse et al. 2014; Reif et al. 2016), even amongst 'experts' (Hruban et al. 2015). Furthermore, it has been shown that CTG traces do not reliably predict neonatal encephalopathy (Spencer et al. 1997).What do the results of this study add? Our study indicates that if 'types of intrapartum hypoxia' are used for interpretation, then inter-observer agreement increases to 81%, from the reported 30% when traces are classified into 'normal, suspicious and pathological' using guidelines based on 'pattern recognition'. Furthermore, our study shows a good correlation between the type of intrapartum hypoxia observed on CTG trace and the nature of injury observed on the MRI.What are the implications of these findings for clinical practise and/or further research? Improving inter-observer agreement of CTGs with the use of pattern recognition in combination with the good correlation to MRI scan findings ultimately leads to better management and post-natal outcomes. This is evidenced by the fact that after the introduction of physiology-based CTG interpretation and mandatory competency testing on CTG interpretation for all staff in 2010, St. George's Maternity Unit has half the nationally reported rate of cerebral palsy.
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Affiliation(s)
| | - Virginia Whelehan
- Department of Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Abigail Archer
- Department of Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Edwin Chandraharan
- Department of Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust, London, UK
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Thellesen L, Bergholt T, Sorensen JL, Rosthoej S, Hvidman L, Eskenazi B, Hedegaard M. The impact of a national cardiotocography education program on neonatal and maternal outcomes: A historical cohort study. Acta Obstet Gynecol Scand 2019; 98:1258-1267. [PMID: 31140581 DOI: 10.1111/aogs.13666] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Revised: 05/16/2019] [Accepted: 05/20/2019] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Studies indicate an association between errors in cardiotocography (CTG) management and hypoxic brain injuries among newborns. Continuing professional education is recommended. We aimed to examine whether the implementation of a national interprofessional CTG education program in Denmark was associated with a decrease in risk of fetal hypoxia measured by umbilical cord pH < 7.00, 5-minute Apgar score <7 or neonatal therapeutic hypothermia. As a secondary aim, we assessed whether the educational intervention was associated with an increase in operative deliveries. MATERIAL AND METHODS We conducted a historical cohort study from 2009 to 2015 including all intended vaginal deliveries with liveborn singletons in cephalic presentation and gestational age ≥37 weeks. Data were retrieved from the Medical Birth Register and the National Patient Register. The study period was divided in three: pre-implementation (2009-2012), implementation (2013) and post-implementation (2014-2015). Using logistic regression we estimated odds ratios (OR) of fetal hypoxia outcomes using the pre-implementation period as reference. Analyses were adjusted for potential maternal, neonatal and delivery-associated confounders. Missing data were accounted for by multiple imputation. RESULTS In all, 331 282 deliveries were included. Overall risks of pH < 7.00, Apgar score <7 and therapeutic hypothermia were respectively 0.45%, 0.58% and 0.06%. Adjusted OR in the post-implementation period were 1.12 (95% confidence interval [CI] 1.00-1.26), 0.99 (95% CI 0.90-1.10) and 1.34 (95% CI 0.99-1.82) for the three outcomes, respectively. The pH missingness equaled 12.4%. Odds of emergency cesarean section was unaltered, whereas the odds of assisted vaginal delivery decreased by 14% (0.86, 95% CI 0.84-0.89). CONCLUSIONS Healthcare professionals are considered the weakest link of CTG technology. We did not find that increasing healthcare professionals' CTG interpretation skills affected the risk of fetal hypoxia. Missing data for pH values were substantial and represent a limitation of the study. We cannot with certainty rule out that missingness masked a true effect of the intervention. Our study indicates that assisted vaginal deliveries can be decreased without an increased risk of fetal hypoxia. Dilution of effect in a complex clinical setting, rare outcomes, insufficient intervention and a possible overestimation of the impact of errors in CTG management might explain the lack of effect.
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Affiliation(s)
- Line Thellesen
- Department of Obstetrics, The Juliane Marie Center for Children, Women, and Reproduction, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Thomas Bergholt
- Department of Obstetrics, The Juliane Marie Center for Children, Women, and Reproduction, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Jette Led Sorensen
- Department of Obstetrics, The Juliane Marie Center for Children, Women, and Reproduction, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Susanne Rosthoej
- Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Lone Hvidman
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark
| | - Brenda Eskenazi
- Center for Environmental Research and Children's Health (CERCH), School of Public Health, University of California, Berkeley, CA, USA
| | - Morten Hedegaard
- Department of Obstetrics, The Juliane Marie Center for Children, Women, and Reproduction, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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Ravlo M, Lieng M, Khan Bukholm IR, Haase Moen M, Vanky E. Approved claims for compensation from gynecological patients in Norway-What characterizes the cases? A 14-year nationwide study. Acta Obstet Gynecol Scand 2019; 98:1070-1076. [PMID: 30860293 DOI: 10.1111/aogs.13605] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Accepted: 03/07/2019] [Indexed: 01/08/2023]
Abstract
INTRODUCTION The Norwegian System of Patient Injury Compensation (NPE) evaluates all patient-reported claims in Norway. Our aim was to study the cases from gynecological patients approved by NPE in order to identify the main reasons for the injuries, the consequences of the treatment failure for the women, and the time course when the treatment failure occurred. MATERIAL AND METHODS A retrospective, descriptive study of approved gynecological compensation claims during a 14-year period, based on patient files from NPE. RESULTS In all, 1454 women claimed compensation for injury related to gynecological treatment in Norway from 2000 to 2013. Compensation was approved for 438 (30.1%) women. Eleven women declined participation in the study and 16 cases were excluded, leaving 411 cases for further analyses. Consent to participate was given by 211 (51.3%) women, who gave full access to all their NPE files. Anonymized resumes and expert statements were used for the 138 (33.6%) women who did not respond and the 62 (15.1%) women who were deceased. Guidelines or good clinical practice were not followed in 40.5% of the cases. The most common reasons for injury were surgical complications (67.6%), delayed (22.4%) and incorrect (17.0%) diagnoses, and failure of communication (11.7%). The main consequences of injuries were need for extensive treatment (64.2%), permanent injury (55.2%) and impaired physical ability (41.9%). Worsening of cancer prognosis occurred in 58 women (14.1%) and death due to treatment failure in 29 (7.1%) women. Most failures occurred during the treatment period (75.2%). CONCLUSIONS We found that the main reason for injuries in gynecological patients was non-adherence to guidelines or good clinical practice. Surgery-related injuries were most common. Increased focus on adherence to guidelines and surgical skills might improve patient safety for gynecological patients in Norway.
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Affiliation(s)
- Merethe Ravlo
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway.,Department of Obstetrics and Gynecology, St. Olav's Hospital, University Hospital of Trondheim, Trondheim, Norway
| | - Marit Lieng
- Department of Gynecology, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Ida R Khan Bukholm
- Norwegian System of Patient Injury Compensation, Oslo, Norway.,Department of Surgery, Akershus University Hospital, Lørenskog, Norway
| | - Mette Haase Moen
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Eszter Vanky
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway.,Department of Obstetrics and Gynecology, St. Olav's Hospital, University Hospital of Trondheim, Trondheim, Norway
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Thellesen L, Sorensen JL, Hedegaard M, Rosthoej S, Colov NP, Andersen KS, Bergholt T. Cardiotocography interpretation skills and the association with size of maternity unit, years of obstetric work experience and healthcare professional background: a national cross-sectional study. Acta Obstet Gynecol Scand 2017; 96:1075-1083. [PMID: 28524258 DOI: 10.1111/aogs.13171] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 05/09/2017] [Indexed: 11/30/2022]
Abstract
INTRODUCTION We aimed to examine whether cardiotocography (CTG) knowledge, interpretation skills and decision-making measured by a written assessment were associated with size of maternity unit, years of obstetric work experience and healthcare professional background. MATERIAL AND METHODS A national cross-sectional study in the setting of a CTG teaching intervention involving all 24 maternity units in Denmark. Participants were midwives (n = 1260) and specialists (n = 269) and residents (n = 142) in obstetrics and gynecology who attended a 1-day CTG course and answered a 30-item multiple-choice question test. Associations between mean test score and work conditions were analyzed using multivariable robust regression, in which the three variables were mutually adjusted. RESULTS Participants from units with > 3000 deliveries/year scored higher on the test than participants from units with < 1000 deliveries/year (3000-3999 deliveries/year: mean difference 0.8, p < 0.0001; > 4000 deliveries/year: mean difference 0.5, p = 0.006). Participants with < 15 years of work experience scored higher than participants with > 15 years of experience (15-20 years of experience: mean difference - 0.6, p = 0.007; > 20 years experience: mean difference - 0.9, p < 0.0001). No differences were detected concerning professional background. CONCLUSIONS CTG knowledge, interpretation skills and decision-making measured by a written assessment were positively associated with working in large maternity units and having < 15 years of obstetric work experience. This might indicate a challenge in maintaining CTG skills in small units and among experienced staff but could also reflect different levels of motivation, test familiarity and learning culture. Whether the findings are transferable to the clinical setting was not examined.
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Affiliation(s)
- Line Thellesen
- Department of Obstetrics, Juliane Marie Center for Children, Women and Reproduction, Rigshospitalet University Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Jette L Sorensen
- Department of Obstetrics, Juliane Marie Center for Children, Women and Reproduction, Rigshospitalet University Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Morten Hedegaard
- Department of Obstetrics, Juliane Marie Center for Children, Women and Reproduction, Rigshospitalet University Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Susanne Rosthoej
- Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Nina P Colov
- Department of Obstetrics, Juliane Marie Center for Children, Women and Reproduction, Rigshospitalet University Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Kristine S Andersen
- Department of Obstetrics, Juliane Marie Center for Children, Women and Reproduction, Rigshospitalet University Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Thomas Bergholt
- Department of Obstetrics, Juliane Marie Center for Children, Women and Reproduction, Rigshospitalet University Hospital, University of Copenhagen, Copenhagen, Denmark
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Milland M, Mikkelsen KL, Christoffersen JK, Hedegaard M. Severe and fatal obstetric injury claims in relation to labor unit volume. Acta Obstet Gynecol Scand 2015; 94:534-41. [DOI: 10.1111/aogs.12606] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Accepted: 01/29/2015] [Indexed: 11/28/2022]
Affiliation(s)
- Maria Milland
- Department of Obstetrics; Rigshospitalet Copenhagen University Hospital; Copenhagen Denmark
| | | | | | - Morten Hedegaard
- Department of Obstetrics; Rigshospitalet Copenhagen University Hospital; Copenhagen Denmark
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