Predictors of neonatal brachial plexus palsy subsequent to resolution of shoulder dystocia.

OBJECTIVE: The objective was to ascertain factors among deliveries complicated by shoulder dystocia (SD) and neonatal brachial plexus palsy (NBPP). METHODS: At 11 hospitals, deliveries complicated by SD were identified. The inclusion criteria were vaginal delivery of non-anomalous, singleton at 34-42 weeks. Adjusted odds ratios (aOR) with 95% confidence intervals (CI) were calculated. Receiver operating characteristic (ROC) curves were created to evaluate the predictive value of the models for NBPP. RESULTS: Of the 62,939 individuals who delivered vaginally, 1,134 (1.8%) had SD and met other inclusion criteria. Among the analytic cohort, 74 (6.5%) had NBPP. The factor known before delivery which was associated with NBPP was diabetes (aOR = 3.87; 95% CI = 2.13-7.01). After delivery, the three factors associated with NBPP were: (1) birthweight of at least 4000 g (aOR = 1.83; 95% CI = 1.05-3.20); (2) calling for help during the SD (aOR = 4.09, 95% CI = 2.29-7.30), and (3) the duration of SD ≥120 sec (aOR = 2.47, 95% CI = 1.30-4.69). The AUC under the ROC curve for these independent factors was 0.79 (95% CI = 0.77 - 0.82). CONCLUSIONS: Few factors were identified that were associated with NBPP after SD, but they could not reliably predict which neonates will experience the complication.

Development and Implementation of an Obstetric Milestone Pathway.

To improve key discharge metrics and achieve more consistency in clinical care, a team at our large health care system developed and implemented the use of an obstetric milestone pathway (OMP). The OMP was integrated into daily multidisciplinary discharge rounds, during which nurses discussed the plan of care and progress toward discharge for each woman and her newborn. The OMP provided nursing staff with a tool for implementing a plan of care and for preparing a woman and her newborn for discharge. Use of the OMP was associated with a decrease in clinical errors, improved patient satisfaction scores, and decreased costs related to length of stay. By using Six Sigma techniques and gaining participation of front-line staff, our team developed a clinical pathway intended to improve the quality, safety, and efficiency of maternal/newborn care.

Adherence to Consensus Guidelines for the Management of Labor Arrest Disorders in a Single Academic Tertiary Care Medical Center.

OBJECTIVE: To evaluate the degree of adherence to the new the American College of Obstetricians and Gynecologists/Society for Maternal-Fetal Medicine guidelines in labor arrest management. STUDY DESIGN: A retrospective study of term, live, singleton deliveries with intrapartum primary cesarean delivery solely for failed induction of labor or labor arrest. Adherence was defined according to the Safe Prevention of the Primary Cesarean Delivery 2014 criteria. We evaluated adherence and compared maternal and perinatal outcomes, delivery time frame, and billing provider. Multivariable Poisson regression models with robust error variance were used to calculate adjusted relative risk (aRR) and 95% confidence interval (CI). RESULTS: Two-hundred six deliveries met the inclusion criteria; 73% were deemed not adherent to the guidelines. The majority of cases were under the care of nonacademic private practice OB/GYN physicians. The adherence rate was higher in the active phase of labor (45%) than in second stage (17%) and latent phase (14%). There were no differences in perinatal outcomes between the two groups. The adherence to guidelines was higher among academic OB/GYN physicians (aRR, 2.24, 95% CI, 1.49-3.36) and during the weekday-night shift (aRR, 1.81, 95% CI, 1.10-2.98). CONCLUSION: Despite recent guidelines aimed to reduce the primary cesarean delivery rate, most cesarean deliveries performed for labor arrest disorders were not adherent to the guidelines.