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Oral Concurrent Session 7 - Epidemiology and Quality
Oral Concurrent Sessions
Expedited Sessions
Standardization of procedures improves outcomes. Dahlke JD et al (PMID:33030865) summarized 30 evidence-based steps (EBS) for cesarean delivery (CD). No prior studies have assessed the effect of bundled EBS. We sought to ascertain if standardization of CD EBS improves outcomes.
Study Design:
A StaRI (Standards for Reporting Implementation Studies) compliant, multi-center pre- and post-implementation (Imp) trial at 4 teaching hospitals was conducted. Pre-Imp consisted of CD in usual manner; educational intervention (e.g. didactics, badge cards, posters, video) occurred at month 4. CDs in post-Imp were intended to follow EBS. A pre-planned 10% randomized audit of both groups assessed adherence and uptake of EBS. The primary outcome was a composite maternal morbidity (CMM); secondary outcome was a composite neonatal morbidity (CNM). A priori Bayesian sample size calculation indicated 700 CD in each group was needed to demonstrate 20% relative reduction (15% to 12%) of CMM with 75% certainty. Poisson regression with robust error variance was used to calculate likelihood of net-improvement in adjusted relative risk (RR) with 95% credibility intervals (CrI).
Results:
A total of 1,425 consecutive CD (721 in pre- and 704 in post-Imp group) were examined. Audit data indicated a 20% uptake of the EBS in post-Imp period. Rates of CMM in the pre- and post-Imp groups were 25% and 22%, respectively (RR, 0.87; 95% CrI, 0.72-1.06), with a 92% Bayesian probability of reduction in CMM. The CNM occurred in 38% of the pre- and in 43% of the post-Imp group (RR, 1.10; 95% CrI 0.97-1.23), with an 80% Bayesian probability of worsening in CNM. When CMM and CNM were segregated by preterm ( < 37 wks) and term CD, the improvement in maternal outcomes persisted, as did potential for worsening neonatal outcomes (Tables 1 and 2).
Conclusion:
Standardization of the evidence-based steps of cesarean delivery resulted in a reduction of the composite maternal outcome; however, a paradoxical increase in neonatal composite morbidity was noted. Further studies are needed to understand the contribution to adverse neonatal outcomes.
Erin S. Huntley, DO (she/her/hers)
MFM Fellow
University of Texas Houston / MCGovern Medical School Department of Obstetrics, Gynecology and Reproductive Sciences McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth)
Houston, Texas, United States
Benjamin Huntley, MD
Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth)
Houston, TX, United States
Miguel Bonilla Moreno, BS
Medical Student
University of Texas Health Science Center at Houston / McGovern Medical School
Houston, Texas, United States
Ellen Crowe, BS
Medical Student
McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth)
Houston, TX, United States
Hector Mendez Figueroa, MD
Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth)
Houston, Texas, United States
Claudia Pedroza, PhD
McGovern Medical School, University of Texas Health Science Center at Houston
Houston, Texas, United States
Baha M. Sibai, MD
Professor
Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth)
Houston, Texas, United States
Sean C. Blackwell, MD
Professor
Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth)
Houston, Texas, United States
Suneet P. Chauhan, MD
Professor
Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth)
Houston, Texas, United States