Using improvement science to increase accuracy and reliability of gestational age documentation.

Our aim was to improve the reliability of recording gestational age (GA) in the mother's obstetric record, as this record is used for clinical management, research databases, and eventual transmission to the Ohio Department of Health birth certificates. We performed a prospective cohort study, including all hospital births. We began quality improvement interventions in October 2009. Improvement test cycles were targeted to four working groups, including nursing staff, community obstetric providers, and the process itself. Test cycle results were evaluated to determine which successful interventions could spread further. Rates of process outcome measurements were compared by statistical process control and univariate analysis pre- and postintervention. During the preintervention period, the median daily GA reliability was 25%. To date, over 30 small sample size tests of change have been completed. Of 8795 births studied, significant improvement in GA accuracy/completeness was detected (median postintervention = 78%, p < 0.01). Increased communication of and completion of the prenatal record, in addition to GA recording in high-risk groups, such as premature infants, were also achieved (all p < 0.01). GA reliability can be increased using standardized improvement science methods. Better communication of GA will enable better clinical decisions and foster population-based perinatal research.

Neonatal morbidity after documented fetal lung maturity in late preterm and early term infants.

OBJECTIVE: Fetal lung maturity often is used as the sole criterion that late preterm infants are ready for postnatal life. We therefore tested the hypothesis that fetal lung maturity testing does not predict the absence of morbidity in late preterm infants. STUDY DESIGN: We performed a retrospective cohort study to examine 152 infants who were born in the late preterm (34 0/7 to 36 6/7 weeks) and early term (37 0/7 to 38 6/7 weeks) periods after mature fetal lung indices and compared them with 262 infants who were born at ≥39 weeks' gestation and who were matched by mode of delivery. RESULTS: Despite documented fetal lung maturity, infants who were born at <39 weeks had significantly higher rates of neonatal morbidities compared with infants who were born at ≥39 weeks' gestation. After adjustment for significant covariates, we found that infants who were born at <39 weeks' gestation had an increased risk of composite adverse outcome (odds ratio, 3.66; 95% confidence interval, 1.48-9.09; P < .01). CONCLUSION: Fetal lung maturity testing is insufficient to determine an infant's readiness for postnatal life.

Neonatal mortality from respiratory distress syndrome: lessons for low-resource countries.

Respiratory distress syndrome (RDS) is a major contributor to neonatal mortality worldwide. However, little information is available regarding rates of RDS-specific mortality in low-income countries, and technologies for RDS treatment are used inconsistently in different health care settings. Our objective was to better understand the interventions that have decreased the rates of RDS-specific mortality in high-income countries over the past 60 years. We then estimated the effects on RDS-specific mortality in low-resource settings. Of the sequential introduction of technologies and therapies for RDS, widespread use of oxygen and continuous positive airway pressure were associated with the time periods that demonstrated the greatest decline in RDS-specific mortality. We argue that these 2 interventions applied widely in low-resource settings, with appropriate supportive infrastructure and general newborn care, will have the greatest impact on decreasing neonatal mortality. This historical perspective can inform policy-makers for the prioritization of scarce resources to improve survival rates for newborns worldwide.

Lessons for low-income regions following the reduction in hypertension-related maternal mortality in high-income countries.

OBJECTIVES: To evaluate pre-eclampsia/eclampsia-associated maternal mortality in high-income countries to understand better the potential improvements in pre-eclampsia/eclampsia-related mortality in low-income countries. METHODS: We searched Medline, PubMed, and the Cochrane Database (1900-2010) using relevant search terms. Studies of the incidence of pre-eclampsia/eclampsia and case fatality rates in various geographic regions were included. The incidence of pre-eclampsia/eclampsia and the pre-eclampsia/eclampsia-associated case fatality rates are presented by location and year. RESULTS: Most declines in maternal mortality associated with pre-eclampsia/eclampsia in high-income countries occurred between 1940 and 1970 and were associated with a 90% reduction in the incidence of eclampsia and a 90% reduction in the case fatality rate in women with eclampsia. The most important interventions were widespread use of prenatal care with blood pressure and urine protein measurement, and increased access to hospital care for timely induction of labor or cesarean delivery for women with severe pre-eclampsia or seizures. CONCLUSIONS: A substantial reduction in pre-eclampsia/eclampsia-related mortality could be made in low-income countries by widespread hypertension and proteinuria screening and early delivery of women with severe disease. Magnesium sulfate may reduce mortality, but should not be the cornerstone of maternal mortality reduction programs.

Adrenal insufficiency in newborns with congenital diaphragmatic hernia.

Newborns with congenital diaphragmatic hernia frequently have catecholamine-unresponsive systemic hypotension and respiratory failure. We found that adrenal insufficiency frequently complicates the clinical course of infants with congenital diaphragmatic hernia and was associated with increased severity of illness.

Neonatal outcomes after elective cesarean delivery.

OBJECTIVE: To examine the outcomes of neonates born by elective repeat cesarean delivery compared with vaginal birth after cesarean (VBAC) in women with one prior cesarean delivery and to evaluate the cost differences between elective repeat cesarean and VBAC. METHODS: We conducted a retrospective cohort study of 672 women with one prior cesarean delivery and a singleton pregnancy at or after 37 weeks of gestation. Women were grouped according to their intention to have an elective repeat cesarean or a VBAC (successful or failed). The primary outcome was neonatal intensive care unit (NICU) admission and measures of respiratory morbidity. RESULTS: Neonates born by cesarean delivery had higher NICU admission rates compared with the VBAC group (9.3% compared with 4.9%, P=.025) and higher rates of oxygen supplementation for delivery room resuscitation (41.5% compared with 23.2%, P<.01) and after NICU admission (5.8% compared with 2.4%, P<.028). Neonates born by VBAC required the least delivery room resuscitation with oxygen, whereas neonates delivered after failed VBAC required the greatest degree of delivery room resuscitation. The costs of elective repeat cesarean were significantly greater than VBAC. However, failed VBAC accounted for the most expensive total birth experience (delivery and NICU use). CONCLUSION: In comparison with vaginal birth after cesarean, neonates born after elective repeat cesarean delivery have significantly higher rates of respiratory morbidity and NICU-admission and longer length of hospital stay. LEVEL OF EVIDENCE: II.