Kay Daniels

Abstract

Objective:To compare the efficacy of oral misoprostol to vaginal dinoprostone for labor induction in nulliparous women.Study design:Admissions for labor induction from January 2008 to December 2010 were reviewed. Patients receiving oral misoprostol were compared with those receiving vaginal dinoprostone. The primary outcome was time from induction agent administration to vaginal delivery. Secondary outcomes included vaginal delivery within 24 h, mode of delivery and maternal and fetal outcomes.Result:A total of 680 women were included: 483 (71%) received vaginal dinoprostone and 197 (29%) received oral misoprostol. Women who received oral misoprostol had a shorter interval to vaginal delivery (27.2 vs 21.9 h, P<0.0001) and were more likely to deliver vaginally in <24 h (47% vs 64%, P=0.001). There was no increase in the rate of cesarean delivery or adverse maternal or neonatal outcomes.Conclusion:Labor induction with oral misoprostol resulted in shorter time to vaginal delivery without increased adverse outcomes in nulliparous women.

View details for DOI 10.1038/jp.2013.133

View details for PubMedID 24157494

Abstract

Communication and teamwork deficiencies have been identified as major contributors to poor clinical outcomes in the labor and delivery unit. In response to these findings, multidisciplinary simulation-based team training techniques have developed to focus specifically on skills training for teams. The evidence demonstrates that multidisciplinary simulation-based team training minimizes poor outcomes by perfecting the elusive teamwork skills that cannot be taught in a didactic setting. Multidisciplinary simulation-based team training is also being used to detect latent system errors in existing or new units, to rehearse complicated procedures (surgical dress rehearsal), and to identify knowledge gaps of labor and delivery teams. Multidisciplinary simulation-based team training should be an integral component of ongoing quality-improvement efforts to ultimately produce teams of experts that perform proficiently.

View details for DOI 10.1053/j.semperi.2013.02.004

View details for PubMedID 23721769

Abstract

We documented time to key milestones and determined reasons for transport-related delays during simulated emergency cesarean.Prospective, observational investigation of delivery of care processes by multidisciplinary teams of obstetric providers on the labor and delivery unit at Lucile Packard Children's Hospital, Stanford, CA, USA, during 14 simulated uterine rupture scenarios. The primary outcome measure was the total time from recognition of the emergency (time zero) to that of surgical incision.The median (interquartile range) from time zero until incision was 9?min 27?s (8:55 to 10:27?min:s).In this series of emergency cesarean drills, our teams required approximately nine and a half minutes to move from the labor room to the nearby operating room (OR) and make the surgical incision. Multiple barriers to efficient transport were identified. This study demonstrates the utility of simulation to identify and correct institution-specific barriers that delay transport to the OR and initiation of emergency cesarean delivery.

View details for DOI 10.1038/jp.2012.98

View details for Web of Science ID 000316833300002

View details for PubMedID 22858890

Abstract

Obstetric services depend on the transfusion service (TS) to provide diagnostic testing and blood component therapy for clinical care pathways.We describe three quality improvement (QI) initiatives implemented to improve TS support of obstetric services.We implemented a pathway for patients requiring an ABO/Rh order for every admission to obstetric services, along with reconciliation of the daily hospital birth manifest and TS umbilical cord log to identify every woman eligible for RhIG. After assessment over 6 months, 21 (1%) of 2041 women lacked an admission ABO/Rh; all subsequently had ABO/Rh determinations. Umbilical cords were missing for eight (0.4%) mothers; four were D- and received RhIG. We developed algorithms for diagnostic blood ordering for patients deemed at "low,"moderate," or "high" risk of blood transfusion. A 27% reduction in total diagnostic test volumes and 24% reduction in charges was documented after compared to before implementation. We analyzed the impact of our massive transfusion protocol (MTP) on blood inventory management for 31 (0.25%) women undergoing 12,945 deliveries, representing 11% of 286 MTPs for all clinical services over a 32-month interval. O- uncrossmatched red blood cells (RBCs) represented 103 (24%) of 421 RBC units issued. Wastage rates of RBCs, plasma, and platelets ordered and issued in the MTPs were 0.7, 16, and 3%, respectively.QI initiatives for RhIG prophylaxis, diagnostic blood test ordering, and MTP improve TS support of obstetric services.

View details for DOI 10.1111/j.1537-2995.2011.03152.x

View details for Web of Science ID 000298340300006

View details for PubMedID 21542850

Abstract

To compare the labor room and operating room for perimortem cesarean delivery during simulated maternal arrests occurring outside the operating room. We hypothesized transport to the operating room for perimortem cesarean delivery would delay incision and other important resuscitation milestones.We randomized 15 teams composed of obstetricians, nurses, anesthesiologists, and neonatal staff to perform perimortem cesarean delivery in the labor room or operating room. A manikin with an abdominal model overlay was used for simulated cesarean delivery. The scenario began in the labor room with maternal cardiopulmonary arrest and fetal bradycardia. The primary outcome was time to incision. Secondary outcomes included times to important milestones, percentage of tasks completed, and type of incision.The median (interquartile range) times from time zero to incision were 4:25 (3:59-4:50) and 7:53 (7:18-8:57) minutes in the labor room and operating room groups, respectively (P=.004). Fifty-seven percent of labor room teams and 14% of operating room teams achieved delivery within 5 minutes. Contacting the neonatal team, placing the defibrillator, resuming compressions after analysis, and endotracheal intubation all occurred more rapidly in the labor room group.Perimortem cesarean delivery performed in the labor room was significantly faster than perimortem cesarean delivery performed after moving to the operating room. Delivery within 5 minutes was challenging in either location despite optimal study conditions (eg, the manikin was light and easily moved; teams knew the scenario mandated perimortem cesarean delivery and were aware of being timed). Our findings imply that perimortem cesarean delivery during actual arrest would require more than 5 minutes and should be performed in the labor room rather than relocating to the operating room.

View details for DOI 10.1097/AOG.0b013e3182319a08

View details for Web of Science ID 000296292600017

View details for PubMedID 22015877

Abstract

Errors by health care professionals result in significant patient morbidity and mortality, and the labor and delivery ward is one of the highest risk areas in the hospital. Parturients today are of higher acuity than anytime previously, and maternal mortality is increasing. Obstetrical staff must therefore be familiar with emergency protocols geared to the maternal-fetal dyad. However, the medical literature suggests that obstetrical providers are not optimally trained to render care during maternal cardiopulmonary arrest. We describe the evolution of immersive learning and simulation in the Neonatal Resuscitation Program, and suggest the development of a multidisciplinary team, simulation-enhanced obstetric crisis training program (OBLS) may likewise benefit obstetrical health care professionals. OBLS would emphasize high quality basic life support, uterine displacement, use of an automatic external defibrillator, and delivery of the fetus within 5 minutes of maternal arrest should resuscitative efforts prove ineffective.

View details for DOI 10.1053/j.semperi.2011.01.006

View details for Web of Science ID 000289600200006

View details for PubMedID 21440814

Abstract

Previous work suggests the potential for suboptimal cardiopulmonary resuscitation (CPR) in the parturient but did not directly assess actual performance.We evaluated 18 videotaped simulations of maternal amniotic fluid embolus and resultant cardiac arrest. A checklist containing 10 current American Heart Association recommendations for advanced cardiac life support (ACLS) in obstetric patients was utilized. We evaluated which tasks were completed correctly and the time required to perform key actions.Proper compressions were delivered by our teams 56% of the time and ventilations 50% of the time. Critical interventions such as left uterine displacement and placing a firm back support prior to compressions were frequently neglected (in 44% and 22% of cases, respectively). The mean +/- SD overall composite score for the tasks was 45 +/- 12% (range, 20-60%). The neonatal team was called in a median (interquartile range) of 1:42 (0:44-2:18) minutes:seconds; 15 of 18 (83%) teams called only after the patient was completely unresponsive. Fifty percent of teams did not provide basic information to the neonatal teams as required by neonatal resuscitation provider guidelines.Multiple deficits were noted in the provision of CPR to parturients during simulated arrests, despite current ACLS certification for all participants. Current requirements for ACLS certification and training for obstetric staff may require revision.

View details for DOI 10.1016/j.ajog.2010.02.022

View details for Web of Science ID 000280234500037

View details for PubMedID 20417476

Abstract

To determine the association between single-layer (one running suture) and double-layer (second layer or imbricating suture) hysterotomy closure at primary caesarean delivery and subsequent adhesion formation.A secondary analysis from a prospective cohort study of women undergoing first repeat caesarean section.Department of Obstetrics and Gynecology, Stanford University, Stanford, CA, USA.One hundred and twenty-seven pregnant women undergoing first repeat caesarean section.Patient records were reviewed to identify whether primary caesarean hysterotomies were closed with a single or double layer. Data were analysed by Fisher's exact tests and multivariable logistic regression.Prevalence rate of pelvic and abdominal adhesions.Of the 127 women, primary hysterotomy closure was single layer in 56 and double layer in 71. Single-layer hysterotomy closure was associated with bladder adhesions at the time of repeat caesarean (24% versus 7%, P = 0.01). Single-layer closure was associated in this study with a seven-fold increase in the odds of developing bladder adhesions (odds ratio, 6.96; 95% confidence interval, 1.72-28.1), regardless of other surgical techniques, previous labour, infection and age over 35 years. There was no association between single-layer closure and other pelvic or abdominal adhesions.Primary single-layer hysterotomy closure may be associated with more frequent bladder adhesions during repeat caesarean deliveries. The severity and clinical implications of these adhesions should be assessed in large prospective trials.

View details for DOI 10.1111/j.1471-0528.2010.02529.x

View details for Web of Science ID 000276509100007

View details for PubMedID 20236104

Abstract

Obstetric crises are unexpected and random. Traditionally, medical training for these acute events has included lectures combined with arbitrary clinical experiences. This educational paradigm has inherent limitations. During actual crises insufficient time exists for discussion and analysis of patient care. Our objective was to create a simulation program to fill this experiential gap.Ten L&D teams participated in high fidelity simulation training. A team consisted of two or three nurses, one anesthesia resident and one or two obstetric residents. Each team participated in two scenarios; epidural-induced hypotension followed by an amniotic fluid embolism. Each simulation was followed by a facilitated debriefing. All simulations were videotaped. Clinical performances of the obstetric residents were graded by two reviewers using the videotapes and a faculty-developed checklist. Recurrent errors were analyzed and graded using Health Failure Modes Effects Analysis. All team members completed a course evaluation.Performance deficiencies of the obstetric residents were identified by an expert team of reviewers. From this list of errors, the "most valuable lessons" requiring further focused teaching were identified and included 1) Poor communication with the pediatric team, 2) Not assuming a leadership role during the code, 3) Poor distribution of workload, and 4) Lack of proper use of low/outlet forceps. Participants reported the simulation course allowed them to learn new skills needed by teams during a crisis.Simulated obstetric crises training offers the opportunity for educators to identify specific performance deficits of their residents and the subsequent development of teaching modules to address these weaknesses.

View details for DOI 10.1097/SIH.0b013e31818187d9

View details for Web of Science ID 000207536200005

View details for PubMedID 19088659

Abstract

To estimate whether prophylactic antibiotics at the time of repair of third- or fourth-degree perineal tears after vaginal delivery prevent wound infection and breakdown.This was a prospective, randomized, placebo-controlled study. Patients who sustained third- or fourth-degree perineal tears after a vaginal delivery were recruited for the study. Each patient was given a single intravenous dose of a second-generation cephalosporin (cefotetan or cefoxitin) or placebo before repair of third- or fourth-degree perineal tears. Obstetricians and patients were blinded to study drug. The perineum was inspected for evidence of infection or breakdown at discharge from the hospital and at 2 weeks postpartum. Primary end points were gross disruption or purulent discharge at site of perineal repair by 2 weeks postpartum.One hundred forty-seven patients were recruited for the study. Of these, 83 patients received placebo and 64 patients received antibiotics. Forty patients (27.2%) did not return for their 2-week appointment. Of the patients seen at 2 weeks postpartum, 4 of 49 (8.2%) patients who received antibiotics and 14 of 58 (24.1%) patients who received placebo developed a perineal wound complication (P=.037). There were no differences between groups in parity, incidence of diabetes, operative delivery, or third-degree compared with fourth-degree lacerations.By 2 weeks postpartum, patients who received prophylactic antibiotics at the time of third- or fourth-degree laceration repair had a lower rate of perineal wound complications than patients who received placebo.ClinicalTrials.gov, www.clincaltrials.gov, NCT00186082.I.

View details for Web of Science ID 000256191400003

View details for PubMedID 18515507

Abstract

The leading causes of pregnancy-related death are embolism (20%), hemorrhage (17%), and pregnancy-induced hypertension (16%).The Obstetric and Mechanical Engineering Departments at Stanford University worked together to create inexpensive devices that were used in high fidelity simulations to replicate 2 of the leading causes of maternal mortality: hemorrhage and eclampsia (seizure).The mechanisms were designed to behave as similarly as possible to a human patient. The engineering team designed the eclampsia mechanism to jostle the mannequin's head at a frequency and randomness that matched those observed in human generalized seizures. The hemorrhage mechanism was designed to give visual and tactile cues similar to the actual physiology of a pregnant uterus. Both devices were remote controlled.The hemorrhage mechanism was used in a scenario of an amniotic fluid embolism with severe postpartum hemorrhage. The final flow rate was adjustable between 525 and 600 mL/min. The trainees' rapid response and control of the postpartum hemorrhage was deemed to be a vital part of a successful maternal resuscitation. The seizure mechanism was used in a simulation of a pregnant woman in labor with evidence of severe preeclampsia. If the trainees did not recognize the need for treatment of the preeclampsia, the patient simulator had a 45- to 60-second seizure. If corrective actions were not taken, another seizure occurred.The use of remote controlled mechanical devices designed to accurately replicate the visual, auditory, and tactile cues of hemorrhage and eclampsia enhanced high fidelity simulation training in obstetrical emergencies.

View details for DOI 10.1097/01.SIH.0000290632.83361.4b

View details for Web of Science ID 000207534800007

View details for PubMedID 19088641

Abstract

We hypothesized that prolonged second stage of labor increases the incidence of unintentional hysterotomy extensions at cesarean delivery.A retrospective cohort of term pregnant women who underwent primary cesarean delivery after failed second stage of labor at Stanford University was assessed for hysterotomy extensions and other maternal and neonatal morbidities. Groups included second stage length of 1-3 hours and >4 hours. Data were analyzed with the use of chi-square and Fisher's exact tests.Of the 239 women who were studied, the second stage of labor lasted 1-3 hours in 82 patients and >4 hours in 157 patients. Prolonged second stage of labor was associated with unintentional hysterotomy extensions (40% vs 26%; P = .03), particularly to the cervix (29% vs 5%; P = .005), and with surgery that lasted >90 minutes (9% vs 1%; P = .01). The incidence of hysterotomy extensions was associated positively with the length of the second stage. Other maternal and neonatal morbidities were similar between groups.Prolonged second stage of labor is associated with an increase in unintentional hysterotomy extensions at cesarean delivery and prolonged operative time. The future risk of hysterotomy extensions merits further investigation.

View details for DOI 10.1016/j.ajog.2007.07.005

View details for Web of Science ID 000249531300033

View details for PubMedID 17826431

Abstract

To examine whether the use of a community mobile health van (the Lucile Packard Childrens Hospital Women's Health Van) in an underserved population allows for earlier access to prenatal care and increased rate of adequate prenatal care, as compared to prenatal care initiated in community clinics.We studied 108 patients who initiated prenatal care on the van and delivered their babies at our University Hospital from September 1999 to July 2004. One hundred and twenty-seven patients who initiated prenatal care in sites other than the Women's Health Van, had the same city of residence and source of payment as the study group, and also delivered their babies at our hospital during the same time period, were selected as the comparison group. Gestational age at which prenatal care was initiated and the adequacy of prenatal care - as defined by Revised Graduated Index of Prenatal Care Utilization (RGINDEX) - were compared between cases and comparisons.Underserved women utilizing the van services for prenatal care initiated care three weeks earlier than women using other services (10.2 +/- 6.9 weeks vs. 13.2 +/- 6.9 weeks, P = 0.001). In addition, the data showed that van patients and non-van patients were equally likely to receive adequate prenatal care as defined by R-GINDEX (P = 0.125).Women who initiated prenatal care on the Women's Health Van achieved earlier access to prenatal care when compared to women initiating care at other community health clinics.

View details for DOI 10.1007/s10995-006-0174-z

View details for Web of Science ID 000246578900005

View details for PubMedID 17243022

Abstract

The purpose of this study was to examine perinatal outcomes between Asian American and Pacific Islander subgroups.This is a retrospective study of all Asian American/Pacific Islander women who were delivered at Stanford University Medical Center from 1998 to 2003. Asian American women were subdivided into the following groups: Indian/Pakistani, Chinese, Filipino, Japanese, Korean, Pacific Islanders (individuals from Tonga, Samoa, Guam, or Polynesia), and Vietnamese. Perinatal outcomes included gestational hypertension/preeclampsia, gestational diabetes mellitus, preterm delivery, cesarean delivery, birthweight <2500 g, and birthweight >4000 g.In the study population of 3779 Asian American women, there were statistically significant differences (P < .01) between most of the outcomes that were examined. Filipina women had the highest risk of gestational hypertension/preeclampsia (adjusted odds ratio, 2.21); Indian/Pakistani women had the highest risk of preterm delivery (adjusted odds ratio, 1.67), gestational diabetes mellitus (adjusted odds ratio, 1.39), and low birthweight at term (adjusted odds ratio, 2.30); and Pacific Islander women had the highest risk of macrosomia (adjusted odds ratio, 3.67).Significant differences in perinatal outcomes exist between subgroups of the Asian American and Pacific Islander community. Future research on race/ethnicity and perinatal outcomes should examine heterogeneity among these groups before collapsing these individual subgroups into the larger group "Asian." Individuals should be counseled regarding perinatal risk according to their specific Asian subgroup.

View details for DOI 10.1016/j.ajog.2006.06.079

View details for Web of Science ID 000240473500031

View details for PubMedID 16949421

Abstract

To evaluate the effect of parietal peritoneal closure at cesarean delivery on adhesion formation.A prospective cohort study of women undergoing first repeat cesarean delivery was designed. All surgeons were asked immediately after surgery to score the severity and location of adhesions. Patient records were then abstracted to assess prior surgical technique, including parietal peritoneal closure, other attributes of first surgery, and patient characteristics. Exclusion criteria included adhesions, other surgery, or use of permanent suture at the first cesarean, unavailable first postoperative note and course, wound infection or breakdown following first surgery, intervening pelvic surgery, insulin-dependent diabetes mellitus, and steroid-dependent disease. The chi2 test and multivariable logistic regression were used for statistical comparison and analysis. A total of 128 patients was required to have 80% power to detect a 50% reduction in adhesions when the parietal peritoneum was left open.One hundred seventy-three patients were enrolled. Prior parietal peritoneal closure was associated with significantly fewer dense and filmy adhesions (52% versus 73%, P = .006) and significantly fewer dense adhesions (30% versus 45%, P = .043). When controlling for potential confounding variables, including prior infection, visceral peritoneal closure, rectus muscle closure, payor status, ethnicity, maternal age, gestational diabetes, and labor, parietal peritoneal closure at primary cesarean delivery was 5-fold protective against all adhesions (odds ratio 0.20, 95% confidence interval 0.08-0.49), and 3-fold protective against dense adhesions (odds ratio 0.32, 95% confidence interval 0.13-0.79). Omental-fascial adhesions were decreased most consistently.Parietal peritoneal closure at primary cesarean delivery was associated with significantly fewer dense and filmy adhesions. The practice of nonclosure of the parietal peritoneum at cesarean delivery should be questioned.

View details for Web of Science ID 000230717800010

View details for PubMedID 16055575

Abstract

The study explores the prenatal Child Abuse Potential (pCAP) scores derived from the Child Abuse Potential Inventory administered to expectant adolescent mothers. The aim of the study was to assess the association of the pCAP scores with maternal negative prenatal behaviors, and evaluate the contribution of the pCAP scores to neonatal morbidity.The pCAP scores, demographic data, and self-report on prenatal behaviors were obtained during the second half of the pregnancy in a sample of 45 poor single adolescent mothers. A pediatrician blind to the prenatal data reviewed the neonatal records to assess neonatal morbidity. Maternal prenatal records were reviewed for obstetric risk assessment by an obstetrician who was blind to the rest of the data. The relations among the pCAP scores, prenatal behaviors, and neonatal morbidity were analyzed.In the prenatal period, the pCAP scores were positively correlated with self-reported prenatal smoking and substance use. The multiple linear regression analysis showed that the pCAP scores significantly contributed to neonatal morbidity independently of obstetric risk factors.The Child Abuse Potential scores obtained during pregnancy in poor single adolescent mothers reflect domains of maternal functioning that are associated with negative prenatal behaviors and appear to be important for predicting neonatal morbidity. Further studies are warranted to validate the prenatal use of the Child Abuse Potential Inventory.

View details for Web of Science ID 000172247300006

View details for PubMedID 11766012