Clinical, Hospital and Physician

Initiatives
Laura E. Riley, M.D.
Medical Director of Labor and Delivery
Massachusetts General Hospital
Boston, Ma
 MGH Quality Assurance and
Improvement as it relates to preterm
delivery

1. Social Inductions
2. Elective repeat cesarean delivery
3. Evaluation and management of
threatened preterm labor
 Social Inductions
CY 05 CY 06 CY 07 CY08

Total Deliveries 3448 3287 3430 3526

Total Inductions 795 (23.1%) 746 (22.7%) 712 (20.7%) 782 (22.2%)

Average gestational
for elective 38.7 39.3 39.2 39.1
inductions

Average gestational 39.9 39.8 39.7 39.6

age for all inductions

Raw data, MGH OBEMR

What practice pattern’s exist:

• R/O labor
• Indications for induction
• R/O labor practice pattern example
 Indications for Inductions
Specific algorithms are suggested for:

All indicated inductions

Postdates inductions
Diabetes mellitus

Chronic hypertensive women with or without medication do not require induction

prior to 40 0/7 weeks in the absence of other complications such as growth restriction
or oligohydramnios.

Other conditions such as intrauterine growth restriction, antiphospholipid antibody

syndrome, and cholestasis may be indications for induction at particular gestational
ages. Management of these cases should be individualized.

In general, “social” circumstances are not indications for induction. However,

management of these cases should be individualized.

.
 Indications for Inductions

Counseling for induction:

Risks/benefits of medications
Risk of cesarean delivery

When scheduling an induction for any indication:

Specify Bishop score and indication when scheduling the procedure.
 Evaluation for R/O Preeclampsia
I. Goals

The primary goal of this management proposal is to improve the

efficiency of the evaluation of a patient with suspected hypertensive complication
of pregnancy in triage on Labor and Delivery at MGH. This goal will be achieved
by both decreasing the number of patients who come to triage for evaluation and
by decreasing the length of stay in triage.
a. An evidence-based approach should be used to determine patient selection
for evaluation.

b. It is recommended that whenever possible the evaluation of suspected

hypertensive complication of pregnancy should be performed in the outpatient
office setting. L&D triage evaluation should be reserved for patients who are
potentially sicker and may need to be admitted to the hospital.

c. Attempts should be made to decrease the length of time necessary to

complete the evaluation in triage.
 Evaluation for R/O Preeclampsia
II. Definition of preeclampsia

a. Mild preeclampsia is BP>=140/90, proteinuria >=300mg/24 hours

b. Severe preeclampsia is BP>= 160/110 x2, 6 hours apart, proteinuira>=5grams/24

hours, symptoms ( HA,visual changes,RUQ pain), elevated LFTs, PLT <100K or IUGR

III. Patient Selection

A patient is a candidate for evaluation of hypertensive complication of pregnancy if she is

identified as possibly developing preeclampsia or preeclampsia superimposed on chronic
hypertension.

a. Any patient who meets the above definition of preeclampsia should be evaluated.

b. A normotensive variant of preeclampsia is rare and should be considered only if

there are other clinical findings and /or if the a priori risk is very high.

c. The need for evaluation should be determined by risk factors such as presence or
absence of preeclampsia in a past pregnancy, age, multiples, or underlying medical
problems. Furthermore, in order to determine acuity current data should be compared
with that obtained earlier in pregnancy or if available, prior to pregnancy.
 Evaluation for R/O Preeclampsia
IV. Location of evaluation

It is the goal within our group practice to complete the evaluation of a

patient with suspected hypertensive complication of pregnancy in the
outpatient office setting. This will permit the patient’s primary provider to
provide continuity of care and avoid the duplication of evaluations and
confusion in plan that occurs when multiple providers are
involved. This will also decrease the in house waiting time for patients
pending their results. However the following patients are candidates for
evaluation in L&D triage.

a. A patient at any gestational age (>20 weeks) who may have severe PET
should be evaluated in triage on L&D

b. A patient with mild preeclampsia at >or= 39 weeks with a favorable cervix should be
admitted directly to L&D by their primary provider for induction without stopping in triage.

c. A patient who has extremely difficult circumstances which might make their outpatient
evaluation of PET incomplete may be evaluated in triage.

d. If none of the above apply and a patient is a suspect for mild preeclampsia we recommend
that the evaluation for preeclampsia is completed as an outpatient.
–
B
Postdate Decision Tree

Pregnancy
≥ 41 YES
0/7 Weeks

Favorable
Cervix
(Bishop >5)
YES

NO

NST /Fluid
Check or BPP
Reassuring

NO YES

Expectant
Tx to L & D Management Schedule
for Induction Reassess fetal Induction
status with NST Within 4 days
@ 41+ weeks &
Schedule
Induction by 42
Weeks

Raw data, MGH OBEMR

Scheduled Repeat Cesarean Section

Patients with lower segment incisions, who

decline a trial of labor, can be delivered at
term. If the cesarean section is scheduled
>14 days prior to the EDD, then assessment
of fetal lung maturity. Alternately, the
patient and the clinician may choose to
await the onset of labor.

CRICO/RMF 1999-2006
 Election Repeat C/S prior to 39 weeks
2005 2006 2007 2008

Total C Singletons 1013 987 994 972

Repeat c/s (singleton) 296 316 301 305

Average GA for E c/s 38.95 38.83 38.9 38.86

Singleton c/s less than 39 weeks 83 117 105 115

Raw data MGH OB EMR

 Barriers to Efficient Evaluation of
Preterm Labor
Education Assessment
US unavailable
Knowledge of “best practice”
FFN Contraindications FFN kit unavailable

Lack of consensus about Vaginal exam prior to FFN

“best practices” Partial evaluation as OP

Efficient
Dissatisfied w/dx evaluation
Not available
Fear of PTD
Unable to comply with f/u Unable to make decision
Fearful of misdiagnosis
Refuses discharge
Varying expectations Lack of OP support staff
Patients Provider
 P re te rm L a b o r A s s e s s m e n t i n T ri a g e

G e s t a t io n a l ≥A2g3ew k s< 3 4w k s S: cx t x,
c ra m p, as b d p a, pi ne l v i c p re s, sPuprero ,m
b a c k a c, vh ae g i n a/c,l db l e e d i,ns pg o t t i n g
(3 4– 3 7 w e e k s i n d i v i d) u a l i z e

In itia l a s s e s s: m e n t
S te r ile S p e c u lu m
F F N& R/O R u p tu re

•GBS C x
• G C/c h la m y d ia c x
• U r in e c x
• T o x s c re e n

> 2c m o>r 8 0% m u l tip

w i th o u t C T X
≥ 2 o r ≥8 0% p ri m i p Or
o r m u ltip w ith < 2 c m o<r 8 0% p ri m i p
C T X o r PPR O M

re p e a t e x a m
in 1–2 h o u rs

A d m it
•A b x if in d ic a(PteRdO )M
•P C N fo r G B S u n k n o w n F F NΘ F F N⊕
• ßm e t h a s o n e if ⊕ C x ch an ge ⊕ C x ch a n g e
< 3 4w k s
•In d o m e th a <c in
3 2wif k so r F F N+ F F NΘ
M a g n e s iu m s u 4lfa8hter .sx Θ C x ch a ng e Θ C x chan ge < 2c m >2 c m
b e tw e 3e 2-3
n 4w e e k s < 8 0% > 8 0%

d/c to h o m e E x t e n d m o n it o r in g
E x t e n d m o n ito r in g x
C a ll in2 4-4 8h o u r s x 4 h r s&
4 h o u r s o r c o n s id e r A d m it to c o ly& s is
BO P and F/U w ith7d in R e e x a m in e
ßm e t h a s o n e
ßm e t h a s o n e
N o ch a n g e
C a ll in2 4h o u ,r sF o llo-uw p w it h
d/c h o m e o u tp a t ie n t .awpitpht in2-3 d a y s
 Compliance with PT L Protocol

45
40
35
No of PTL Patients

30 FFN contraindicated
25
FFN done
20
15 FFN missed
10
5
0
Jan Feb Mar Apr May June
Month
 Next Steps:
1. Drill down
2. Data or Practice
3. Re-educate
4. Re-evaluate