Statewide Quality Improvement Initiative to Reduce Early Elective Deliveries and Improve Birth Registry Accuracy.

OBJECTIVE: To evaluate the success of a quality improvement initiative to reduce early elective deliveries at less than 39 weeks of gestation and improve birth registry data accuracy rapidly and at scale in Ohio. METHODS: Between February 2013 and March 2014, participating hospitals were involved in a quality improvement initiative to reduce early elective deliveries at less than 39 weeks of gestation and improve birth registry data. This initiative was designed as a learning collaborative model (group webinars and a single face-to-face meeting) and included individual quality improvement coaching. It was implemented using a stepped wedge design with hospitals divided into three balanced groups (waves) participating in the initiative sequentially. Birth registry data were used to assess hospital rates of nonmedically indicated inductions at less than 39 weeks of gestation. Comparisons were made between groups participating and those not participating in the initiative at two time points. To measure birth registry accuracy, hospitals conducted monthly audits comparing birth registry data with the medical record. Associations were assessed using generalized linear repeated measures models accounting for time effects. RESULTS: Seventy of 72 (97%) eligible hospitals participated. Based on birth registry data, nonmedically indicated inductions at less than 39 weeks of gestation declined in all groups with implementation (wave 1: 6.2-3.2%, P<.001; wave 2: 4.2-2.5%, P=.04; wave 3: 6.8-3.7%, P=.002). When waves 1 and 2 were participating in the initiative, they saw significant decreases in rates of early elective deliveries as compared with wave 3 (control; P=.018). All waves had significant improvement in birth registry accuracy (wave 1: 80-90%, P=.017; wave 2: 80-100%, P=.002; wave 3: 75-100%, P<.001). CONCLUSIONS: A quality improvement initiative enabled statewide spread of change strategies to decrease early elective deliveries and improve birth registry accuracy over 14 months and could be used for rapid dissemination of other evidence-based obstetric care practices across states or hospital systems.

A Statewide Progestogen Promotion Program in Ohio.

OBJECTIVE: To promote use of progestogen therapy to reduce premature births in Ohio by 10%. METHODS: The Ohio Perinatal Quality Collaborative initiated a quality improvement project in 2014 working with clinics at 20 large maternity hospitals, Ohio Medicaid, Medicaid insurers, and service agencies to use quality improvement methods to identify eligible women and remove treatment barriers. The number of women eligible for prophylaxis, the percent prescribed a progestogen before 20 and 24 weeks of gestation, and barriers encountered were reported monthly. Clinics were asked to adopt protocols to identify candidates and initiate treatment promptly. System-level changes were made to expand Medicaid eligibility, maintain Medicaid coverage during pregnancy, improve communication, and adopt uniform data collection and efficient treatment protocols. Rates of singleton births before 32 and 37 weeks of gestation in Ohio hospitals were primary outcomes. We used statistical process control methods to analyze change and generalized linear mixed models to estimate program effects accounting for known risk factors. RESULTS: Participating sites tracked 2,562 women eligible for treatment between January 1, 2014, and November 30, 2015. Late entry to care, variable interpretation of treatment guidelines, maintenance of Medicaid coverage, and inefficient communication among health care providers and insurers were identified as treatment barriers. Births before 32 weeks of gestation decreased in all hospitals by 6.6% and in participating hospitals by 8.0%. Births before 32 weeks of gestation to women with prior preterm birth decreased by 20.5% in all hospitals, by 20.3% in African American women, and by 17.1% in women on Medicaid. Births before 37 weeks of gestation were minimally affected. Adjusting for risk factors and birth clustering by hospital confirmed a program-associated 13% (95% confidence interval 0.3-24%) reduction in births before 32 weeks of gestation to women with prior preterm birth. CONCLUSION: The Ohio progestogen project was associated with a sustained reduction in singleton births before 32 weeks of gestation in Ohio.

The role of continuous fetal monitoring in the management of preterm premature rupture of membranes.

OBJECTIVE: Continuous fetal monitoring (CFM) is often used in the management of preterm premature rupture of membranes (PPROM) but there is little evidence to support this approach. The objective of this study was to evaluate the clinical outcome of PPROM when managed by CFM. METHODS: A retrospective review was conducted of 129 cases PPROM outcomes for the period January 1, 1998 to December 31, 2003. All women underwent CFM. Delivery was carried out for non-reassuring fetal testing, vaginal bleeding, evidence of infection, positive vaginal pool phosphatidylglycerol when available, and spontaneous labor. RESULTS: Delivery was carried out because of an abnormal fetal heart tracing in 15 women (11.7%). The mean gestational age at admission was 32.2 weeks (95% CI 31.7-32.7), the mean gestational age at delivery was 32.7 weeks (95% CI 32.2-33.1), and the mean latency period was 3.3 days (95% CI 1.5-5.0). Gestational age at rupture of membranes was inversely correlated with latency period (n = 128, r = -0.372, p < 0.001). With regard to gestational age, gravidity, and latency period there was no significant difference noted with respect to why the subjects delivered. No intrauterine deaths occurred in the study. CONCLUSION: In our series, fetal heart rate tracing abnormalities were the indication for delivery in a small but significant percentage of conservatively managed PPROM cases. Our review suggests that a prospective trial of CFM versus intermittent monitoring techniques should be carried out.

Gastric rupture associated with pregnancy.

BACKGROUND: Spontaneous gastric rupture during pregnancy is rare. CASE: A young primigravida delivered a 34-week stillborn infant. Shortly after delivery, she developed signs of hypovolemic shock. Ultrasound examination showed a large amount of free intra-abdominal fluid. At laparotomy, gastric rupture was encountered and repaired. Congenital eventration of the left hemidiaphragm was also noted. After a complicated postoperative course, the patient recovered and has done well. CONCLUSION: Rapid surgical intervention for gastric rupture associated with pregnancy is necessary for maternal survival.