s3ecia/ editi21 •fa// 2011 a risk management newsletter€¦ · · 2013-07-26cracking the...

A risk management newsletterRiskRx Special Edition • Fall 2011

Obstetrics Safety Program Takes Care of LivesRM&PSI Introduces the MOREOB Program to Build Your Perinatal

High Reliability Organization

In This Issue ...

Obstetrics Safety

Program Takes Care

of Lives .............................1

Perspective on Vaginal

Birth After Cesarean

Delivery............................8

ContributingAuthors

J. Patrick Lavery, MD

Mary Thomas

Mary Ellen Filbey, RN,

BSN, JD, CPHRM

(Continued on page 2)

At the Risk Management and Patient Safety Institute (RM&PSI), we focus on risk andsafety. Sometimes, that means modifying systems and processes to ensure that people andfacilities are protected from harm.

We are excited about a comprehensive program that helps do just that in obstetricsdepartments. Managing Obstetrical Risk Efficiently — or MOREOB — is a multidisciplinaryobstetrical patient safety program built on proven principles ofhigh reliability, quality improvement and risk management.Most importantly, it allows healthcare professionals totake the best possible care of mothers and babies.

Why are we passionate about the MOREOB

Program? This article will address thedemonstrated need for this type of patientsafety program and the type of organizationwhere it would most likely thrive.

Women and infants continue to facerisk

While maternal morbidity and mortality rateshave decreased over the years, the latest statisticsare still alarming. In addition to the percentage ofwomen who die from pregnancy-related causes, manyothers suffer serious injuries and disabilities. When laboringwomen are at risk, their babies are also in danger.

Maternal morbidity and mortality

• About 20 percent of women in the United States experience major complicationsduring pregnancy.1

• About 25 percent of women in the United States will have serious complicationsduring and after delivery.2

• About 43 percent of women in the United States experience some type of maternalmorbidity3 (e.g., any illness or injury caused by, aggravated by or associated withpregnancy or childbirth).

• The maternal mortality ratio in 2007 was 12.7 deaths per 100,000 live births.4

Contributing Editors• Caroline Brill, Publication

Editor

• Erroll Imre, Editor

• Kristen Wilson,

Managing Editor

• Cindy Siders, Senior

Editor

• Linda Oman, Editorial

Coordinator

RMPSI/MI-03

2 • RISKRx Special Edition Fall 2011

It has been argued that ineffective communication,inadequate monitoring, improper management ofoperative deliveries and untimely responses areamong the building blocks of OBcatastrophes.5 Indeed, when any or all ofthese systems or processes fail, patientsand the OB department itself are putat risk. The leading causes of OBharm include:

• Failure to recognizenon-reassuring fetal status

• Failure to effect a timelycesarean section birth

• Failure to properly resuscitatea depressed baby

• Inappropriate use ofoxytocin/misoprostol

• Inappropriate use of vacuum/forceps6

Why do such grave issues still persist in some modernhospitals? At RM&PSI, we believe that the problems liein piecemeal, reactive approaches to patient safety.

Cracking the safety code

Dr. Albert Wu, a leading patient safety expert from theJohns Hopkins Bloomberg School of Public Health, madea presentation at a recent RM&PSI conference.7 Dr. Wuasserted that the industry has not made significantenough changes in the past decade to protect patientsfrom harm.8 He described the Comprehensive Unit-based Safety Program (or CUSP) adopted by JohnsHopkins, offering it as a good example of how patientsafety concepts must be implemented both globally(system-wide) and locally (at the unit level).9

The fundamentals of a CUSP within a department or afacility are:

1. Safety culture assessment

2. Science of safety training

3. Having staff members identify safety hazards

4. Senior executive partnership

5. Learning from safety defects/applying tools toimprove

6. Reassessing the safety culture10

Obstetrics Safety Program Takes Care of Lives(Continued from page 1)

The key is high reliability

Of course, CUSPs are more likely to succeed when theyare introduced into an environment in which

safety has already been established as acore value, a top priority and an integral

part of the curriculum.11 As such,facilities that operate as high

reliability organizations and functionaccording to high reliabilityprinciples are where CUSPs willmake the greatest impact.

Let’s define both terms for thehealthcare setting.

High reliability organizations(HROs) are:

• Complex, internally dynamic andintermittently intensely interactive

• Places where exacting tasks are performed under considerable time pressure

• Able to demonstrate low incident rates and analmost complete absence of catastrophic failuresover many years12

High reliability principles (HRPs) include:

• Safety is the priority and is everyone’s responsibility.

• Communication is highly valued.

• Operations are a team effort.

• Emergencies are rehearsed.

• Hierarchy disappears in an emergency; decisionson safety issues can be made at any level of theorganization.

• Events and routines are reviewed by multi-disciplinary personnel.13

HROs achieve success by:

• Having peers who respect and trust one another

• Providing a safe environment for all

• Reflecting and learning from their past experiences

“High Reliability Organization Theory (HROT) . . .states that organizations can handle complex andhazardous activities at acceptable levels ofperformance with the proper management ofpeople, technology and processes.”14

RISKRx Special Edition Fall 2011 • 3

The quality connection

In healthcare, safety and quality go hand in hand. Soanyone exploring HRO concepts in the medical realmwould logically use the Agency for Healthcare Researchand Quality (AHRQ) as a resource. This federal agency,housed under the Department of Health and HumanServices, aims to improve the quality, safety, efficiencyand effectiveness of healthcare for all Americans.

In its report, Transforming Hospitals Into High ReliabilityOrganizations, the AHRQ identifies several challengesshared by organizations pursuing high reliability, includingthe following:

• Hypercomplexity. HROs exist in complexenvironments that depend on multi-teamsystems that must coordinate for safety. . .

• Tight coupling. HROs consist of tightly coupledteams in which the members depend on tasksperformed across their team. . .

• Extreme hierarchical differentiation.

In HROs, roles are clearly differentiated anddefined. Intensive coordination efforts areneeded to keep members of the teams workingcohesively. . .

• Multiple decision makers in a complex

communication network. HROs consist ofmany decisionmakers working to make important,interconnected decisions. . .15

The dangers of old patterns

Safety clearly remains a top concern in hospital settings,but the methods that are employed have not necessarilykept up with the pace of modern healthcare. So whywould we return to these systems if they’re notsufficiently protecting patients and minimizing risk?Albert Einstein said, “We cannot solve our problemswith the same thinking we used when we createdthem.16”

We agree, that’s why RM&PSI feels so strongly aboutthe value of the MOREOB Program. It’s a modern,proven patient safety system that works.

More about the MOREOB Program

The OB unit is one of the most complex, internallydynamic areas of any hospital. The pace may change inseconds, there is considerable time pressure to performexacting tasks, and patient flow is constantly changing.Where better to apply high reliability principles,implement a CUSP and adhere to AHRQ standards?

The MOREOB Program has already been implementedinternationally and has involved more than 11,000participants. It has also been endorsed by the AmericanCollege of Obstetricians and Gynecologists (ACOG).The primary objective of the MOREOB Program is toprovide a road map so that any obstetrics departmentmay develop into a high reliability unit. At the end of athree-year commitment, the participating labor anddelivery unit will have been trained by expert facilitatorsand empowered by hospital administrators infundamental patient safety processes.

This program was created to:

• Improve the quality of work life in OB units

• Decrease the risk of adverse events

• Retain and recruit health professionals

• Improve clinical outcomes in obstetrics

• Establish or enhance a patient safety culture forOB units

Distinctly different

The MOREOB Program is different from other safetyprograms because it looks at each hospital individuallywhile providing a common programmatic structure andframework for the perinatal unit. Every participating unitis given the freedom to customize the program’simplementation at its site. Wherever and however theMOREOB Program is implemented, it offers:

1. Onsite and ongoing support

2. Shared learning with the core team

3. Adaptation to the local environment

4. Ownership at the frontline

5. Education credits for program activities

6. Inter-professionalism in every aspect

7. Leadership at all levels

Modules of change

The MOREOB Program is built upon the participation ofindividual staff members and providers in three modules;each module lasts approximately one year. The modulesare delivered sequentially and include:

Module 1: Learning Together

Module 2: Working Together

Module 3: Changing the Culture

Optional additional modules allow the team to advanceeven further and build on their new successes.


Tying HRO principles to the OB unit

How, then, does the MOREOB Program put HROprinciples to work in the perinatal unit? Let’s answer thatquestion by looking at the fundamental goal of establishing apatient safety culture. Since the MOREOB Program is asupported CUSP, participants may watch as the unit’sculture changes over the course of three years. With thehelp of the program consultant, the organization willtransform its values (what’s important), its beliefs (howthings work) and its behaviors (the way it does things).

This will even be true in facilities where the culture hashistorically mirrored the philosophies of senior leaders,even if the philosophies of staff members tend to differ.This happens because the MOREOB Program recognizesthat the first step in changing culture is obtainingleadership buy-in. The individuals driving change in anyHRO are integral to the operation’s complex systems.Only when top management provides the urgency tochange will real, effective change occur.

The best way to achieve this is to develop a core inter-professional oversight team that champions the projectand works as a catalyst for necessary change. These arethe people who will live and breathe the HRO principleson behalf of all participants. They will obtain support andenthusiasm for safety from the frontline staff members,conveying the “safety first” message to all.

Effecting cultural change

Changing culture is a step-by-step process:

1. Sharing — The program begins by creating ashared body of knowledge that is evidence based.All members of the delivery team are placed on alevel playing field, which helps reduce the powergradient and builds trust. Hierarchy issues improvebecause of greater mutual respect.

2. Learning — Busy healthcare professionals needeasy access to information, so all of the content ofthe MOREOB Program is available online. Patientsafety, organizational theory and clinical contentare posted online so that participants may remaincurrent. Professional development occurs withinthe work environment. The clinical content isupdated annually by a MOREOB Oversight ClinicalCore Committee and is then reviewed by ACOG.

3. Observation — When professionals have theopportunity to gain skills in their work environment,

greater reflective learning occurs. The MOREOB

Program contains practice modification andevaluation tools and methods of relationalcoordination that help improve clinicians’performance.

4. Measurement — Participants completepre-program and post-program knowledge testsfor each discipline. In all of the tests administeredto date, we have seen improvement in theknowledge rates across all professions in the unit.This is a critical component in fostering theincreased trust and respect that are essential toimproving patient safety performance in the workenvironment.

5. Confidence — Participants in the MOREOB

Program report higher levels of professionalconfidence and competence, even in managingeveryday situations. Their enhancements inknowledge, skills and attitude help them deal withcritical and routine scenarios in the department.

6. Assessment — All participants complete a surveyat the beginning and end of each module of theprogram, assessing the before and after patientsafety cultures of their units. Six elements of HROprinciples are evaluated. The results are used todetermine the next steps that department will takein the MOREOB Program.

Committing three years to safety

The MOREOB Program is implemented over three years(with optional additional years available). Why does theprogram take three years to complete? The simpleanswer — changing a culture takes time.

In the first year, team members begin to learn the sameevidence-based information together and build teamknowledge and cohesiveness by attending workshops. Ittakes the first 12 months for the team members to adaptto new levels of trust and respect. In the second year,individuals are better prepared to work together. At thisstage, participants engage in emergency drills and usestructured communication and teamwork tools to focuson building a strong working team that works to enhanceinter-professional communication. The third year of theMOREOB Program gives participants an opportunity toexperience the culture change and address difficultsituations, such as event review and disclosure.



Benefiting both sides of the clinical coin

Improved teamwork and communication in theworkplace naturally leads to happier workers. TheMOREOB Program has been shown to improve healthcareprofessional satisfaction in their departments. Participantshave reported an increase in on-the-jobsatisfaction, along with a decrease in work-related stress. Accordingly, the MOREOB

Program helps enhance safety forwomen and infants while alsoimproving the professional lives ofhealthcare providers.

Lessons in emergencyrehearsal

Most HROs—including well-runhealthcare facilities—practice theunexpected. Managing unexpectedevents is the core of risk management.But sometimes, these hospital“rehearsals” are really only supported bythe nursing staff. The MOREOB Program notonly simulates and practices emergency perinatalscenarios; these drills are performed by multidisciplinaryteams. Clinicians and staff members have a greaterchance of reflecting on potential process issues when allof the affiliated professions are present and fullyengaged.

Even high-volume units that see emergencies every daywill benefit from the drills in the MOREOB Program.These seasoned professionals get the opportunity toexamine internal processes more thoroughly, watchingfor opportunities to enhance patient outcomes. Inaddition, the MOREOB Program rehearsals offerdebriefing tools that ask participants to find ways toreduce hierarchies in emergencies. By practicing theseimportant HRO principles in simulated emergencies anddebriefing afterwards, participants get used toimplementing the principles during routine events.

The MOREOB Program emergency rehearsal participantsreport feeling more empowered, confident andcompetent. Their roles within the scenario are betterdefined and the teams function more efficiently as awhole. Healthcare professionals say the practice drillsmake real emergencies seem calmer and less chaotic.

Proven “MORE” effective

Overwhelmingly positive data demonstrate the power ofthe MOREOB Program.17 Obstetrics departments thathave implemented the program give consistently high

marks when asked how the program has affected theiroperations. The individual tools and activitiesincorporated into the core content have been shown toguide both veteran clinicians and newcomers towardcommon safety goals. The MOREOB Program has a vastnumber of tools that are ready to go, freeing participants

from needing to build emergency drills or createworkshops on their own.

Most profoundly, the program makespositive clinical impacts:

• Decreased in variation of care byproviders

• Improved core knowledge baseby OB team providers

• Decreased gaps betweenexisting practice and best

practice

• Improved provider performancethrough completion of simulationtraining and exercises

• Increased documentation accuracy

• Improved use of evidence-based healthcarepractices

• Reduced risk of error

A multi-site review

In the Canadian province of Alberta, an independentthird party conducted a study to evaluate the impact ofthe MOREOB Program.18 Here are the facts from thatreview:

• Alberta reports approximately 50,000 births peryear.

• The MOREOB Program was implementedvoluntarily in 65 hospitals across nine healthregions spanning the province.

• Outcomes:• Decreased tears/lacerations (3rd & 4th degree)*• Decreased length of stay ≤ 2 days*• Infants on ventilator reduced*• Severe infant morbidity reduced*• NICU admission (in hospitals 1,000 + births

— reduced up to 11 percent)• Hypoxic-ischemic encephalopathy — reduced

up to 33 percent19

* Statistical significance at p< 0.05 level



The Impact of the MOREOB Program on ClaimCosts

Since the implementation of the program in 2002,average incurred costs for claims related to labor anddelivery have been reduced to below the costs of averageclaims for all other departments.20

Can we afford not to do “MORE”?

Most facilities have at least one obstetrical qualityinitiative already in place. Many such programs evenfeature drills and other components found in theMOREOB Program. The problem with many programs isthat they take a piecemeal approach. None deliver theunit-based, high reliability strategies inherent in theMOREOB Program. No other program builds on the earlysteps of trust and respect quite like the MOREOB

Program.

When hospitals abandon quality initiatives, it is often dueto an ability to sustain the progress made. Improvementsappear in the short-term, but fade over time.

With the MOREOB Program, multidisciplinary teams arenot only involved, they are fully committed andempowered. Patient safety drives all decisions anddefines the facility-wide culture.

Quality may cost, but mistakes cost even more dearly.The price of unchecked perinatal risk is simply too high.The MOREOB Program helps provide the foundation toprotect providers, facilities, mothers and babies byplacing safety at the top of every unit’s priority list.

For more information about the MOREOB Program,please visit www.rmpsi.com.

References

1 Women Deliver, “Why So High? – USA Facts on Maternal

Mortality,” Global Conference, London, UK, October 18-20,

2007, citing Stacie E. Geller et al., “Morbidity and Mortality in

Pregnancy: Laying the Groundwork for Safe Motherhood,”

University of Illinois, Chicago, IL, 2006, pp. 177-179.

2 Ibid.

3 Ibid.

4 Jiaquan Xu, Kenneth D. Kochanek, Sherry L. Murphy and

Betzaida Tejada-Vera, Division of Vital Statistics, Centers for

Disease Control and Prevention (CDC), “Deaths: Final Data for

2007,” National Vital Statistics Reports, Vol. 58, No. 19, May 20,



Trend Lines for the Average Incurred Cost from 1989-2009

At-Test assuming unequal variances was performed with a p-value equal to 0.000006439

Copyright © 2009 Healthcare Insurance Reciprocal of Canada (HIROC), data taken from 39 participating MOREOB hospitals.

MOREOB is a registered trademark of Salus Global Corporation. All Rights Reserved


2010, p. 13, http://www.cdc.gov/nchs/data/nvsr/nvsr58

/nvsr58_19.pdf, 07/29/2011.

5 G. Eric Knox, Kathleen Rice Simpson and Thomas J. Garite, “High

Reliability Perinatal Units: An Approach to the Prevention of

Patient Injury and Medical Malpractice Claims,” Journal of

Healthcare Risk Management, Spring 1999, pp. 24-31.

6 F. Mazza, J. Kitchens, M. Akin, et al., “The Road to Zero

Preventable Birth Injuries,” The Joint Commission Journal on

Quality and Patient Safety, Vol. 34, No. 4, April 2008, citing G. E.

Knox, K. R. Simpson and K. E. Townsend, “High Reliability

Perinatal Units: Further Observations and a Suggested Plan for

Action,” ASHRM Journal, Vol. 23, Fall 2003, pp. 17–21.

7 Albert Wu “Ten Years Later: Why Are We Still Harming

Patients?” 2010 RM&PSI Annual Risk Management Seminar,

Traverse City, MI.

8 Ibid

9 Ibid.

10 Ibid.

11 Ibid.

12 K. H. Roberts, “Some Characteristics of High Reliability

Organizations,” Organization Science, Vol. 1, No. 2, 1990,

pp. 160-177.

13 The MOREOB Program materials, citing reprint permission

obtained from the American Society for Healthcare Risk

Management (ASHRM).

14 B. J. Youngberg, “Assessing Your Organization’s Potential to

Become a High Reliability Organization,” ASHRM Journal of

Healthcare Risk Management, Vol. 24, No. 3, 2004.

15 U. S. Department of Health & Human Services, Agency for

Healthcare Research and Quality (AHRQ), “Becoming a High

Reliability Organization – Transforming Hospitals Into High

Reliability Organizations,” AHRQ Publication No. 08-0022,

AHRQ, Rockville, MD, April 2008,

http://www.ahrq.gov/qual/hroadvice/, 07/29/2011.

16 Albert Einstein http://www.brainyquote.com/quotes/quotes/a/

alberteins133991.html

17 C. Frick, T. Nguyen, P. Jacobs, R. Sauve, M. Wanke and A.

Hense, “Outcomes Following Province-Wide Implementation of

the Managing Obstetrical Risk Efficiently (MOREOB) Program in

Alberta,” Presented at SOGC’s 65th Annual Clinical Meeting,

Halifax, June 2009, Abstract in Journal of Obstetrics and

Gynaecology Canada, Vol. 31, No. 5, Supplement 2, May 2009,

p. S32.

18 Ibid.

19 Ibid.

20 HIROC Data taken from 39 participating in the MOREOB

Program, 2009.

21 Ibid.

Total Cost per Claim Incurred from 2002-2008L&D Claims Costs for 39 MOREOB Hospitals (Data 12/31/09)

Current and likely incurred costs for claims (less than 20 million) are significantly lower than projected costs (over 60 million)

per claim.21

Copyright © 2009 Healthcare Insurance Reciprocal of Canada (HIROC), data taken from 39 participating MOREOB hospitals.

MOREOB is a registered trademark of Salus Global Corporation. All Rights Reserved

Many women who have given birth by cesarean section feel very strongly about attemptingvaginal deliveries in subsequent pregnancies. For these patients, the desire to give birthnon-surgically is often both an intangible emotional issue and a concrete physical goal. Asalways, clinicians must balance patient preferences with safety considerations.

Healthcare professionals should know the latest facts about vaginal births after cesarean(VBAC) in order to discuss the pros and cons with their patients. Physicians and hospitalsshould also know the potential complications. Recent studies and updated professionalguidelines shed light on multiple risk factors, enabling patients and providers to makedecisions that help protect everyone concerned.

Changing trends

The popularity of VBAC (also known as “trial of labor after cesarean,” or TOLAC) peakedin the late 1990s. According to the National Institutes of Health (NIH), nearly one-third ofwomen who had previously delivered by cesarean section attempted vaginal birth between1996 and 1998.1 However, as word spread through clinical and lay media about the risks ofuterine rupture during a VBAC, interest in the procedure waned. By 2006, the rate ofVBAC attempts had dropped to 8.5 percent.2, 3

Also contributing to the decrease in VBAC during these years was a change in guidelinesissued by the American College of Obstetricians and Gynecologists (ACOG). In 1995,ACOG recommended that physicians be “readily available” for patients attempting VBAC.4

But in 1999, new guidelines stated that doctors should be “immediately available.”5

These factors combined to tamp down enthusiasm for VBAC and raise the interest insurgical deliveries. By 2008, 32 percent of all births nationally took place by cesareansection.6

It is important to note, however, that 60 to 80 percent of women who attemptVBAC/TOLAC have successful vaginal deliveries, according to ACOG.7, 8

The small but real risk of uterine rupture

Uterine rupture is a statistically rare occurrence. ACOG put the rate at 0.7 to 0.9percent.9 Still, when it occurs, it can be catastrophic for both mother and

infant, so physicians and facilities must do all they can to minimize the risk.While a successful VBAC is good for everyone, a failed VBAC is

associated with more complications than elective repeat cesareansections.10

A two-layer uterine closure in the first cesarean delivery appeared tooffer some protection from uterine rupture.11 Recently, findings withtransvaginal ultrasound of the hysterotomy scar following cesareansection suggested changes that may be associated with uterinerupture in future pregnancies.12 Further research will be needed in this

area.

In its new guidelines, ACOG clarifies that ruptures and other VBACcomplications often arise when pregnancies are timed closely together.

Clinical data suggest that cesarean section scar tissue requires at least sixmonths to become sufficiently strengthened for the uterus to accommodate the

normal expansion that occurs during gestation.13

Perspectives on Vaginal Birth After Cesarean Delivery




Latest ACOG update addresses various risks

ACOG released new information in August 2010 thatspecifically addresses the ways in which healthcareprofessionals may protect themselves and their patientswith regard to VBAC. Practice Bulletin #115: VaginalBirth after Previous Cesarean Delivery offers theorganization’s fifth review of thiscontroversial topic since 1995. Thepractice bulletin acknowledges thechallenges facilities face when tryingto balance patient safety, patientautonomy, administrativeresources and physician practicepatterns.14 It also states that whilepotential complications for themother and infant are generallylow with VBAC, complicationrates depend on multiple factors.15

For example, labor induction inpatients with prior cesarean deliveriesis supported by Bulletin #115, but datasuggest that infusion rates in excess of 20mIu/minute of oxytocin are associated with increasedrates of uterine rupture.16 Additionally, the morestringent requirement for VBAC/TOLAC in Bulletin#115 is for “immediate availability” of staff members inlight of the risk of uterine rupture, which as noted aboveis 0.7 to 0.9 percent. Curiously, this risk is similar to theneed for “crash” cesarean deliveries for women in laboras seen in a large tertiary center (1 percent).17

Practice Bulletin #115 advises healthcare professionals asfollows:18

• Factor in previous cesarean history —

VBAC should be allowed after two priorlow-transverse cesarean sections. Prior ACOGrecommendations stated that VBAC should onlybe attempted after a single cesarean section.

• Attempt in unusual circumstances — VBACshould be allowed after true “low vertical”incisions (which are extremely uncommon).

• Consider induction — Labor may be inducedand augmented if deemed clinically appropriate.However, excessive infusion of oxytocin mayintroduce a higher risk of uterine rupture.19 Also,patients with a Bishop’s score greater than six arebetter candidates for VBAC.

• Accommodate twin deliveries — Womendelivering twins should be allowed to attemptVBAC.

• Listen to the laborer — ACOG now stressesthe importance of patient autonomy; physiciansshould weigh patient preferences when consideringVBAC as a delivery option. However, the patientshould provide written consent after beingcounseled on the specific risk factors of the

procedure. Ideally, the patient and the providershould decide on the labor plan by the

34th week of her pregnancy, to avoidurgent, last-minute decision making.

• Stand by — ACOG confirmedthat providers and staff membersare to be “immediately available”for intervention as needed.Surgical teams should be on handto ensure that no more than 18minutes pass between when thedecision to operate is made andthe baby is delivered.

• Adapt according to facility

size — While larger facilities will havethe resources to provide emergency deliveries,

small facilities offering VBAC should developsystems to accommodate emergency responsesas needed. ACOG recommends cross-coverageamong physicians when feasible, as well assimulation exercises and education for staffmembers to prepare for potential high-riskscenarios.

The importance of teamwork

Any facility offering VBAC must ensure that the variousmembers of the patient care team are appropriatelytrained and prepared for emergencies. Obstetricians,anesthesiologists, pediatricians, labor and delivery staff,operating room staff, and administration and riskmanagement personnel must all collaborate to minimizerisk to the facility and patients. The facility’s VBACpolicy must be clearly defined and based on clinical andresearch information and best practices. Everyoneresponsible for executing the policy should be bothfamiliar and comfortable with the policy.

Making predictions

An increasing amount of work is being done to “predict”the likelihood of a successful VBAC. A paper published inObstetrics and Gynecology suggested using a nomogram,or number system, to evaluate the potential risk of eachcase.20 Physicians should score the patient and herchances of VBAC success according to the following sixfactors:

• Maternal age

• Body mass index

• Maternal race

• Recurring indication

• Prior vaginal delivery(s)

• VBAC history21

The paper’s authors reported thatsignificantly less maternal andneonatal morbidity was incurredwhen the predicted VBAC successrate was at least 70 percent.22 Atthis level, the complications betweenthe trial-of-labor group and the repeatcesarean section group were similar.23

Clinicians do, however, have a more difficult timepredicting the failure of VBAC.24 Researchers found thattrial-of-labor failure rates were only 33 to 58 percent,while predictions of success ranged from 88 to 95percent.25 Since a failed VBAC substantially increasesmaternal complications (14.1 percent versus 2.4percent),26 these statistics are perhaps more significantthan the rates of successful predictions.

The lesson here is that doctors should beselective in their choices of suitable

VBAC candidates.

Delivering safety

There is no way to guarantee theoutcome of any delivery, whetherit is attempted via VBAC orcesarean section. The ACOGbulletin and other reports offer

doctors and facilities an expandedperspective with which to update

their techniques and protocols. In arecent article, J. R. Scott looks to a

common sense approach for assessingcandidates for VBAC/TOLAC. Appreciating that the

overall U.S. cesarean section rate may reach 56.2percent by 2020, he suggests some approaches topractice which may mitigate that trend.27 Carefulselection of candidates based on risk factors and closevigilance in labor management may minimize thecomplications and improve successes.

Perspectives on Vaginal Birth After Cesarean Delivery(Continued from page 9)


Maternal morbidity and mortality

• Between 1996 and 1998, approximately 30 percent of potential candidates attempted VBAC.28

• By 2006, the rate of VBAC attempts dropped to 8.5 percent.29, 30

• By 2008, the total cesarean rate rose to 32 percent of all births in the United States.31

• VBAC/TOLAC is now achieved in 60 percent to 80 percent of attempts.32, 33

• Risk of uterine rupture currently stands at 0.7 percent to 0.9 percent of VBAC attempts.34

• Risk of maternal death from VBAC complications stands at 0.02 percent.35

• Risk of newborn hypoxia following VBAC attempt stands at 0.89 to 1.29 percent.36

• Risk of neonatal death following VBAC attempt stands at 0.13 to 0.38 percent.37

There is no way to guarantee the outcome of any delivery,

whether it is attempted via VBAC or cesarean section.

The ACOG bulletin and other reports offer doctors and facilities

an expanded perspective with which to update

their techniques and protocols.



References

1 National Institutes of Health (NIH), “Vaginal Birth after Cesarean:New Insights,” NIH Consensus Development ConferenceStatement, NIH Consensus and State-of-the-Science Statements,Vol. 27, No. 3, March 8-10, 2010.

2 M. Lydon-Rochelle, V. L. Holt, T. R. Easterling and D. P. Martin,“Risk of Uterine Rupture During Labor Among Women with aPrior Cesarean Delivery,” New England Journal of Medicine,Vol. 345, 2001, pp. 3-8.

3 M. B. Landon, J. C. Hauth, K. J. Leveno, et al., “Maternal andPerinatal Outcomes Associated with a Trial of Labor after PriorCesarean Delivery,” New England Journal of Medicine, Vol. 351,December 16, 2004, pp. 2581- 89.

4 ACOG, “Vaginal Delivery after Previous Cesarean Birth,” ACOGPractice Patterns No.1, August 1995.

5 ACOG, “Vaginal Birth after Previous Cesarean Delivery,” ACOGPractice Bulletin No. 5, July 1999.

6 National Institutes of Health (NIH).

7 ACOG, “Vaginal Birth after Previous Cesarean Delivery,” ACOGPractice Bulletin No. 115, August 2010.

8 K. D. Gregory, L. M. Korst, M. Fridman, et al., “Vaginal Birth afterCesarean: Clinical Risk Factors Associated with AdverseOutcome,” American Journal of Obstetrics & Gynecology, Vol. 198,No. 4, April 2008, pp. e1-12.


10 Ibid.

11 E. Bujold, M. Goyet, S. Marcoux, et al., “The Role of UterineClosure in the Risk of Uterine Rupture,” Obstetrics & Gynecology,Vol. 116, 2010, pp. 43-50.

12 O. V. Osser and L. Valentin, “Clinical Importance of Appearanceof Cesarean Hysterotomy Scar in Transvaginal Ultrasonography innon-Pregnant Women,” Obstetrics & Gynecology, Vol. 117, 2011,pp. 525-532.

13 D. M. Stamilio, E. Defranco, E. Pare et al., “Short InterpregnancyInterval: Risk of Uterine Rupture and Complications of VaginalBirth after Cesarean Delivery,” Obstetrics & Gynecology, Vol. 110,Issue 5, November 2007, pp. 1075-1082.


15 Ibid.

16 A. G. Cahill, B. M. Waterman, D. M. Stamilio, et al., “HigherMaximum Doses of Oxytocin are Associated with anUnacceptably High Risk for Uterine Rupture in PatientsAttempting Vaginal Birth after Cesarean Delivery,” AmericanJournal of Obstetrics & Gynecology, Vol. 199, No. 1, July 2008,pp. 32.e1-5.

17 D. C. Lagrew, M. C. Bush, A. M. McKeown, et al., “Emergent(Crash) Cesarean Delivery: Indications and Outcomes,” AmericanJournal of Obstetrics & Gynecology, Vol. 194, 2006, pp. 1638-1643.


19 A. G. Cahill, B. M. Waterman, D. M. Stamilio, et al.

20 W.A. Grobman, Y. Lai, M. B. Landon, et al., “Development of aNomogram for Prediction of Vaginal Birth after CesareanDelivery,” Obstetrics & Gynecology, Vol. 109, No. 4, April 2007, pp.806-812.

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RISKRx ©2011 Risk Management and Patient Safety Institute. The information contained in this newsletter is copyrighted material. You have permission to forward this newsletter, in its entirety only, to yourcolleagues, provided this copyright notice remains part of your transmission. All other rights reserved. None of this material may be reprinted without the expressed written permission of the editor.

DISCLAIMERThe subject matter suggested in this newsletter should not be considered rules or standards, and they do not ensure a successful outcome. The principles are not all inclusive of proper methods of care nor exclusiveof other methods that may be reasonably directed at obtaining the same results. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider in light of allcircumstances presenting in the individual situation.The information in this newsletter is presented for general educational purposes only and is in no way intended to serve as medical or legal advice. For advice on handling specific medicolegal problems, always consultwith an attorney or your risk management staff. The views and opinions expressed by the guest authors may not reflect the views of the Risk Management and Patient Safety Institute.


21 Ibid.

22 Ibid.

23 Ibid.

24 K. B. Eden, M. McDonagh, M. A. Denman, et al., “New Insightson Vaginal Birth after Cesarean: Can it be Predicted?” Obstetrics &Gynecology, Vol. 116, No. 4, October 2010, pp. 967-981.

25 Ibid.

26 ACOG, “Vaginal Delivery after Previous Cesarean Birth,” ACOGPractice Patterns No.1, August 1995.

27 J. R. Scott, “Vaginal Birth after Cesarean Delivery: A Common-Sense Approach,” Obstetrics & Gynecology, Vol. 118, 2011,pp. 342-350.


29 M. Lydon-Rochelle, V. L. Holt, T. R. Easterling and D. P. Martin.

30 M. B. Landon, J. C. Hauth, K. J. Leveno, et al.



33 K. D. Gregory, L. M. Korst, M. Fridman, et al.


35 Ibid.

36 K. D. Gregory, L. M. Korst, M. Fridman, et al.

37 Ibid.

Perspectives on Vaginal Birth After Cesarean Delivery(Continued from page 11)

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