Patient Safety Movement

1. Optimizing Obstetric Safety:
Reducing Unnecessary C-Sections
Webinar
December 13, 2017
Patient Safety Movement Foundation Presents
Ariana Longley, MPH, Vice President, PSMF
Expert Presenter:
David C. Lagrew, Jr., MD, Executive Medical Director, Southern California
Providence St. Joseph Health System

2. • 10 Minutes: Introduction to Patient Safety Movement
Foundation and Actionable Patient Safety Solutions
(APSS)
• 35 Minutes: Patient Safety Movement Foundation’s
Expert Presentation led by
–David C. Lagrew, Jr., MD
• 15 Minutes: Q & A
Agenda

3. 0X2020

4. Fostering New Efforts and Building On Existing
Patient Safety Programs Through
Commitments to ZERO

5. • Hospitals & Healthcare Organizations
– Make a Commitment
• Committed Partners
– Sign the Commitment to Action letter
• Healthcare Technology Companies
– Sign the Open Data Pledge
• Patient & Family Advocates
– Share their Patient Story, Utilize Resources
Who Can Take Action?

6. • Download at patientsafetymovement.org/apss
1. Culture of Safety
2. Healthcare-associated
Infections (HAIs)
3. Medication Errors
4. Failure to Rescue:
Monitoring for Opioid
Induced Respiratory
Depression
5. Anemia and Transfusions 6. Hand-off
Communications
8. Airway Safety7. Neonatal Safety
9. Early Detection &
Treatment of Sepsis 11. Optimizing Obstetric
Safety
12. Venous
Thromboembolism
10. Optimal Resuscitation
13. Mental Health:
Access to Acute Psychiatric
Beds
14. Falls and Fall
Prevention
15. Nasogastric Feeding and
Drainage Tube Placement &
Verification
16. Person and Family
Engagement
Actionable Patient Safety Solutions (APSS)

8. David C. Lagrew, Jr., MD
Executive Medical Director, Southern California
Providence St. Joseph Health System

9. Reducing Cesarean Section: A long term
strategy to reduce maternal mortality
Presented by
David C. Lagrew Jr MD
Executive Medical Director, Southern California
Providence St. Joseph Health System

10. WHAT IS MATERNAL MORTALITY? AREN’T WE
DOING REALLY WELL?

11. • Pregnancy-associated death- All deaths during or within 1 year
of pregnancy
• Pregnancy-related death (subset of above)- all deaths during or
within the 1 year of pregnancy due to:
– Complication of pregnancy
– Aggravation of unrelated condition by the physiology of pregnancy
– Chain of events initiated by pregnancy
• Using all available data
Maternal Mortality Study Group
(CDC/ACOG 1986)

12. Maternal Mortality Ratio (maternal deaths per 100,000 delivers)

13. Maternal Mortality Worldwide

14. WE WERE DOING WELL, UNTIL YOU LOOK
CLOSER….

15. Reducing Maternal Mortality

16. Is US Maternal Mortality Rising?
• The estimated maternal mortality rate (per 100,000 live births) for 48 states
and Washington D.C. (excluding California and Texas, analyzed separately)
increased by 26.6%, from 18.8 in 2000 to 23.8 in 2014. California showed a
declining trend, while Texas had a sudden increase in 2011–2012. Analysis
of the measurement change suggests that U.S. rates in the early 2000s
were higher than previously reported.
• Despite the United Nations Millennium Development Goal for a 75%
reduction in maternal mortality by 2015, the estimated maternal mortality
rate for 48 states and Washington D.C. increased from 2000–2014, while
the international trend was in the opposite direction
MacDorman et al Obstet Gynecol. 2016 September ; 128(3): 447–455.

18. Yearly rate of decline in Maternal Mortality Ratio
1990–2008

19. And some state rates
are going above 30

20. Rates above 30 per 100,000

21. We are nearing a rate
per 100,000 that
ranks up with some
really bad diseases!

22. Tip of the Iceberg
• Using the New York
Data for every
maternal death there
are 362 SMM events
• New York severe
maternal morbidity
measure, New York
hospital deliveries
2008–2013

23. SMM in the United States 1993-2004

24. WHAT IS CAUSING THE RISE, WHAT IS
DIFFERENT?

25. Berg CJ et al. Obstet Gynecol 2005.
Cause of Death % of All Deaths % Preventable
Cardiomyopathy 21% 22%
Hemorrhage 14 93
PIH 10 60
CVA 9 0
Chronic condition 9 89
AFE 7 0
Infection 7 43
Pulmonary
embolism
6 17

26. Maternal Risk Factors Increased
The “Big 3” we are seeing…
• Maternal Age
• Maternal Weight
• Current C-Section and Prior C-Section

27. The Double Edge:
Low CSR correlated with
lowering maternal mortality-
until 19%
JAMA. 2015;314(21):2263-2270

28. CESAREAN SECTION IS REALLY SAFE IN A
MODERN SETTING, ISN’T IT?….

29. Correlated?

30. CA-PAMR Found significant correlation in maternal deaths

31. Relatively Common Complications
(per 100 deliveries)
Cesarean Section Vaginal
Endometritis Vag/Perineal laceration
Bleeding/Anemia Prolonged urinary dysfxn
Wound infection Mild fecal incontinence
UTI
Ileus
Transient tachypnea

32. Relatively Uncommon Complications
(per 1,000-10,000 deliveries)
Cesarean Section Vaginal
Wound deheiscence Uterine rupture/inversion
Hysterectomy Necrotizing fascitis
Ureteral damage Vaginal hematoma
Bowel damage Incontinence
DVT/Thromboembolism Retained placenta
Fetal laceration Shoulder dystocia/trauma/ICH
PPHN Sepsis/asphyxia

33. We are forgetting: “Compounded” Risk
• Consider that we must not only compare two outcomes
but all possible outcomes in probability this is called a
compounded event:
– A compound event is one in which there is more than
one possible outcome. Determining the probability of a compound
event involves finding the sum of the probabilities of the individual
events and, if necessary, removing any overlapping probabilities.
Probability is the likelihood that an event will occur

34. If 1st delivery was cesarean compared to vaginal:
Outcome RR Absolute Risk
Uterine Rupture 42.18 1/316 vs. 1/13,318
PP with bleeding 2.06 1/227 vs. 1/468
Abruptio Placenta 1.87 1/171 vs. 1/255
Thromboembolism 2.81 1/330 vs. 1/928
Cord pH < 7.00 2.49 1222 vs. 1/552
Perinatal Death 1.33 1/246 vs. 1/328
Hysterectomy 6.07 1/359 vs. 1/2,177
Rageth et al Obstet Gynecol 1999;93:332-7.

35. Previous Vaginal Delivery is the safest delivery!
Galyean, Lagrew, et al. J Perinatol. 2009 Nov;29(11):726-30.
Table 1: Maternal/Neonatal Outcomes
Rate/1000 Rate/1000 RR 95%ile P
Prev CS Vaginal
Abruption 5.05 2.96 1.70 1.19-2.44 <0.01
Placenta previa 7.96 4.42 1.79 1.35-2.40 <0.001
CS NRFHR-AP 7.73 2.48 3.13 2.25-4.35 <0.001
CS NRFHR-IP 22.34 13.95 1.60 1.35-1.90 <0.001
Breech 37.78 20.50 1.84 1.61-2.11 <0.001
Suspected Rupture 2.69 0.11 25.72 8.24-80.25 <0.001
Stillbirth 3.70 2.65 1.40 0.93-2.10 NS
5 min Apgar <7 5.83 4.28 1.36 0.98-1.88 NS
Thick meconium 22.18 30.53 0.75 0.64-0.88 <0.001
Resus by Tube 22.34 11.55 1.93 1.67-2.24 <0.001
Shoulder Dystocia 14.85 24.47 0.61 0.44-0.83 <0.001
Emergency CS 2.13 1.43 1.49 0.87-2.55 NS
D and C 0.11 0.07 0.67 0.26-1.49 NS
Hysterectomy 3.05 0.56 5.43 2.95-9.97 <0.001

36. •
Abnormal Placentation

37. Wu S, Kocherginsky M, Hibbard JU. Abnormal placentation:
twenty-year analysis. Am J Obstet Gynecol 2005;192:1458–61.

38. Chance of Previa relative to prior Cesarean Sections
0
2
4
6
8
10
0 1 2 3 4+
# of Cesarean Sections
% With Previa
Clark SL, Koonings PP, Phelan JP.
Placenta previa/accreta and
prior cesarean section. Obstet
Gynecol 1985;66:89–92.

39. If Previa then….
0
10
20
30
40
50
60
70
0 1 2 3 4+
# of Prior Cesarean Sections
% Accreta, If Previa
Clark SL, Koonings PP, Phelan JP.
Placenta previa/accreta and
prior cesarean section. Obstet
Gynecol 1985;66:89–92.

40. Real increasing incidence of hysterectomy for placenta accreta
“1975-2010. The frequency of placenta accreta
correlated steadily with the CS rate until 2000.
Since then, the incidence has nearly doubled in
women with previous CS scars, suggesting an
additional causative influence on risk.”
Higgins et al Eur J Obstet Gynecol 2013

41. World Wide Review of Peripartum Hysterectomy
Indications Risk Factors Mortality
Placental pathology (38%)
Uterine Atony (27%)
Uterine Rupture (26%)
Current pregnancy CS (OR 11.4)
Previous CS (OR 7.5)
Older Age
Higher Parity
Average blood loss 3.7 L
Overall mortality: 5.2 per 100
Poorer settings: 11.9 per 100
Richer settings: 2.5 per 100
van den Akker T, et al. Obstet Gynecol. 2016.

42. CDC Report: Changes in SMM
• Compared with the 1993–2004 period, 13 SMM indicators had
substantial (50% and more) rate increases in 2013–2014. The largest
increases were among the following indicators:
– Acute renal failure at 369%.
– Blood transfusion at 363%.
– Shock (body is not getting adequate blood flow) at 233%.
– Adult respiratory distress syndrome at 189%.
– Cardiac arrest (sudden loss of heart function) or ventricular fibrillation
(heart beats so quickly and irregularly that it stops pumping blood) at
158%.
– Acute myocardial infarction (heart attack) at 133%.
– Aneurysms of the aorta (balloon-like bulge in the body’s largest artery) at
1,110%.
https://www.cdc.gov/reproductivehealth/maternalinfanthealth/severematernalmorbidity.html

43. “Medicine used to be simple,
ineffective and relatively safe; now
it is complex, effective and
potentially dangerous”
Cyril Chantler MD
Chantler C. The role and education of doctors in the delivery of health care.
Lancet 1999;353:1178-81

44. BUT CAN WE DO ANYTHING ABOUT IT?

45. There is a Large Variation in Cesarean Rates
Among California Hospitals

46.  Readiness
 Recognition and
Prevention
 Response to
Every Labor
Challenge
 Reporting
The Toolkit is Aligned with the ACOG/SMFM
Consensus Statement and the AIM Patient Safety
Bundle

47. The CMQCC Toolkit
 Comprehensive, evidence-based
“How-to Guide” to reduce primary
cesarean delivery in the NTSV
population
 Will be the resource foundation for
the CA QI collaborative project
 The principles are generalizable to
all women giving birth
 Released on the CMQCC website
April 28, 2016
 Has a companion Implementation
Guide
47

48. CONCLUSIONS

49. Betran et al PLOS ONE DOI:10.1371/journal.pone.0148343 February 5, 2016
International problem!

50. Summary
• Rising maternal mortality is a worldwide
issue
• Cesarean section and compounded long
term risk appears to be contributing
• Therefore, long term reduction of maternal
mortality (and morbidity) will require work to
reduce unnecessary cesarean sections
• Efforts are started
• Research, new strategies and technology
are needed

51. Q & A

52. Thank you!