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RPC Improvements

Katie Page, CNM

Questionnaire for Submitting a Physiologic Birth Improvement Story

What did you set out to change or improve?
We have been working as part of the Reducing Primary Cesarean Collaborative to evaluate outcomes including NTSV cesarean, via implementing bundles to promote physiologic labor and comfort & coping in labor.

How did you change it? What new policy, process, or practice did you put in place?Since January 2016, we have implemented new provider documentation forms for labor induction, labor progress, Pitocin augmentation, and cesarean delivery that use standard diagnoses and definitions consistent with ACOG/SMFM statement on reducing primary cesarean and JCAHO/ACOG indications for labor induction. For labor progress, we have yet to implement a partogram, but created a table form for charting progress which made it easier to see how cervical dilatation changed overtime. In our health system, OB providers do not document in our EHR. We presented the goals of the Collaborative at the first quarter department meeting along with our data from 2015 that we would collect in 2016. We also presented the new forms and how to use them.

In March 2016, we asked the nurses to complete a self-efficacy survey on care for women in labor, and then held town hall meetings to present our work with the Collaborative and to talk about how we can promote physiologic labor progress and comfort/coping. Through these efforts, we explored how we already support these processes and what we needed to be able to fully implement the bundles. This allowed for nurse buy-in and also allowed us to involve these stakeholders as we develop new policies aimed at supporting physiologic birth.

We have written a new policy for intermittent auscultation for low risk women and added the Coping with Labor Algorithm to the hospital's pain management policy to allow to assess for coping instead of pain in labor. We updated the policy on hydrotherapy removing certain contraindications (like meconium stained amniotic fluid) to make this method more accessible. We also introduced the use of nitrous oxide for labor analgesia that is nurse-led, including provider buy-in, training, and policy development. For non-pharmacologic coping and comfort, we bought a Kaya birth stool to add to our collection of yoga and peanut balls, birth pool in a box, Jacuzzi tubs/shower, and sound machines. We also purchased 4 more telemetry units to allow ambulation for labors that need continuous fetal monitoring in all of our 12 labor/delivery rooms. The midwife practice recently implemented a plan to encourage women with low-risk labors to eat and drink as they please in all stages of labor.

We have been having open discussions with nurses and providers about benefits of not admitting women until active labor. In 2017, we aim to implement a unit policy related to timing of admission. Our nurses have become empowered to encourage delayed admission and/or discharge home if women are not in active labor if no cervical change has been demonstrated at <6cm. Nurses have also become empowered to discuss indication for inductions with providers and decline to initiate induction if diagnosis and/or bishop score criteria are not met.

Who was involved in making the change and what was each person's role?
Our team is 2 CNMs, 2 staff RNs, 1 OBGYN, 1 anesthesiologist, the L&D unit manager, a member of Patient Quality and Safety who is a former L&D nurse, and the Director of Women's & Children's Services. Our midwives have been spearheading this initiative and have written the policies that have been presented to the nursing and obstetrical departments. The RNs have been content experts and early adopters and have been invaluable in their on-going peer education and peer support. They will help with nurse education and policy development in the next phase of our work. Our OBGYN champion has been able to provide great perspective related to labor augmentation and labor support in their very busy OB practice. In 2017, we plan to expand physician involvement to include a representative from each physician practice within the department. The anesthesiologist has been a guide as we expand our eating/drinking in labor practice beyond liquids for low risk women. Our administrators have been very supportive and helped us move forward with the changes for the pain management policy which was outside of the department, requiring approval through several more committees. They have also been helpful as we evaluate pain management in labor and postpartum more broadly within the context of JCAHO requirements so that our assessments and documentation are consistent with evidence, the needs of our clients, and hospital guidelines.

How did you determine if the change worked? What data did you collect? How did you define "success"? How did you ensure your change didn't have any unintended negative consequences?
We have been collecting data per the Collaborative Primary metrics: mode of delivery and APGAR scores; Secondary metrics: induction of labor, Pitocin augmentation, use of pharmacologic pain methods (nitrous oxide, IV opioids, epidural), centimeters at epidural placement, episiotomy, midwifery care in labor, independent midwifery care in labor, continuous labor support (by midwife/physician, RN, or doula), use of hydrotherapy, use of a graphing tool for labor progress. What is great about this is we have the same data set for all of 2015 and now 2016 so we have been able to really see trends prior to any implementation and then through 2016 as we have made new changes to practice. We have yet to fully implement the bundles, but have already noticed a significant reduction in NTSV cesarean rate which has been sustained.

We also collect and audit charts for completeness with particular focus on whether or not an indication for Pitocin was documented along with discussion of risks/benefits/indication/alternatives of Pitocin use with the laboring woman/family prior to Pitocin initiation. Additionally, we have begun to analyze our data and evaluate interventions and outcomes when women are admitted prior to active labor to look for practice patterns and opportunities for additional improvement. We have noticed that many women admitted in early labor also have SROM or PROM. We hope to explore this patient population to determine if we can implement practice and policy change department wide to delay admission for low risk women with PROM.

So far in 2016, we have achieved a 20% reduction in our NTSV rate from 18% to 15%. We have improved access to and use of non-pharmacologic methods, and are shifting our culture to focus on coping in labor for all women (not just women who express a desire for unmedicated birth).

What was the biggest barrier to making the change?
Related to supporting physiologic labor and birth, our biggest barrier is our busy unit predominantly physician attended births who are concerned about the increased time women may spend laboring without Pitocin. Many practitioners view Pitocin as a benign and normal part of labor, so shifting to recognize this as a high risk intervention has been a process. We also have a high epidural rate, little prenatal education for patients on alternative methods for labor comfort, and little staff knowledge and skill in how to provide labor support. They are also concerned about the staffing needs with continuous labor support and feel they are unable to provide this.

How did you overcome that barrier?
In July 2016, we presented data to the providers in the OB department (physicians and midwives) about Pitocin use in labor at department level, Pitocin use by practice, and then incomplete or absent documentation by individual provider for indication and risks/benefits of Pitocin use. Our lead midwife presented this information along with the evidence about risks of Pitocin, benefits of physiologic birth, and ACOG/SMFM indications for oxytocin augmentation. This created awareness and discussion about our institutional use of this medication and what we believe about labor progress. We have yet to see a significant change in physiologic labor rates, but it is early in this process. Nursing staff has been very interested and eager in adopting delayed admission until active labor, and have been increasing comfort with and use of intermittent auscultation.

Regarding comfort and coping in labor, we have needed more incremental, one-to-one education and work with nursing staff on how to provide labor support and the benefit to them and the patients from this approach. Last fall, prior to the start of our work with Collaborative, one of our midwives partnered with a local non-profit to host a Labor Comfort Measures Workshop that included portions for birth workers and women/partners that provided information on the evidence of continuous labor support, physiologic labor/birth, and non-pharmacologic comfort methods. Nurses in attendance were able to see couples practicing many techniques and had opportunity to practice with couples as well. Since then, we have done in-services at the hospital on labor comfort and the midwives have worked to model these practices. In 2017, we plan to have on-unit in-service for staff by one of our community doulas and will highlight a comfort/coping method once per month.

If you had one piece of advice for someone who wanted to make a similar change in their setting, what would you advise?
For others wanting to improve practice through implementation of bundles, I would recommend spending time with the bundle and setting a timeline plan on how to evaluate, implement, and assess each item. With multi-part bundles, it can be easy to feel "lost in the trees" like nothing is happening or changing, until you look at the individual parts and see the beautiful wood.

Did you use BirthTOOLS during the process of making the change? If so, how?
We used the policies samples and bundles from BirthTOOLS. We have also used the "Birth Matters" paper and shared this with our administrators as we have been teaching them how this work support physiologic labor, birth, and coping with labor pairs with our institutional focus on the patient experience and patient centered care. The sample policies have been great for us to adapt to our unit we didn't have to recreate the wheel.

If you have data or other evidence that your change was successful, please provide that data.
We have had increased utilization of hydrotherapy and nitrous oxide from our data. We have anecdotally noticed increased utilization of upright positioning/mobility prior to epidural placement, but there are no data points to measure this. Our use of hydrotherapy was increased in the first 2 quarters compared to last year, but the Jacuzzi tubs were out of service at the end of the summer and we have yet to see a recovery in the use of this comfort method. We have also had a sustained increase in our rate of spontaneous labor and birth which we attribute to the data sharing at the department level of provider rates of induction, spontaneous vaginal birth, and operative birth. Department-wide discussions about indications for labor induction and a policy to restrict elective inductions to Bishop score of >/=8, may also play a role.

If you have a tool or policy that was developed during the process of making your change and are willing to share this with the site, please do so.
-Labor Progress Form
-Labor Progress Chart
-Nitrous policy
-Pain policy

Your contact information:
Katie Page, CNM
Centra Virginia Baptist Hospital
Centra Medical Group Women's Center
[email protected]
434-944-6937 (Cell)
434-385-8948 (office)


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