Society for Maternal-Fetal Medicine Special Statement: Clinical quality measures in obstetrics.

This article provides an updated overview and critique of clinical quality measures relevant to obstetrical care. The history of the quality movement in the United States and the proliferation of quality metrics over the past quarter-century are reviewed. Common uses of quality measures are summarized: payment programs, accreditation, public reporting, and quality improvement projects. We present listings of metrics that are reported by physicians or hospitals, either voluntarily or by mandate, to government agencies, payers, "watchdog" ratings organizations, and other entities. The costs and other burdens of extracting data and reporting metrics are summarized. The potential for unintended adverse consequences of the use of quality metrics is discussed along with approaches to mitigating adverse consequences. Finally, some recent attempts to develop simplified core measure sets are presented, with the promise that the complex and burdensome quality-metric enterprise may improve in the near future.

Society for Maternal-Fetal Medicine Special Statement: Emergency checklist, planning worksheet, and system preparedness bundle for placenta accreta spectrum.

Placenta accreta spectrum is a life-threatening complication of pregnancy that is underdiagnosed and can result in massive hemorrhage, disseminated intravascular coagulation, massive transfusion, surgical injury, multisystem organ failure, and even death. Given the rarity and complexity, most obstetrical hospitals and providers do not have comprehensive expertise in the diagnosis and management of placenta accreta spectrum. Emergency management, antenatal interdisciplinary planning, and system preparedness are key pillars of care for this life-threatening disorder. We present an updated sample checklist for emergent and unplanned cases, an antenatal planning worksheet for known or suspected cases, and a bundle of activities to improve system and team preparedness for placenta accreta spectrum.

Society for Maternal-Fetal Medicine Special Statement: Checklists for transabdominal cerclage.

The recent Society for Maternal-Fetal Medicine Consult Series #65 provides a comprehensive review of transabdominal cerclage. The current article condenses the Consult recommendations regarding patient selection, counseling, and management into 2 simple one-page checklists, one for the primary obstetrical provider and the other for the maternal-fetal medicine consultant or cerclage provider. Moreover, we provide sample templates for medical record notes to document preprocedure counseling and informed consent.

Society for Maternal-Fetal Medicine Special Statement: Telemedicine in obstetrics-quality and safety considerations.

The frequency of telemedicine encounters has increased dramatically in recent years. This review summarizes the literature regarding the safety and quality of telemedicine for pregnancy-related services, including prenatal care, postpartum care, diabetes mellitus management, medication abortion, lactation support, hypertension management, genetic counseling, ultrasound examination, contraception, and mental health services. For many of these, telemedicine has several potential or proven benefits, including expanded patient access, improved patient satisfaction, decreased disparities in care delivery, and health outcomes at least comparable to those of traditional in-person encounters. Considering these benefits, it is suggested that payers should reimburse providers at least as much for telemedicine as for in-person services. Areas for future research are considered.

Society for Maternal-Fetal Medicine Special Statement: Quality metric on the rate of postpartum diabetes screening after pregnancies with gestational diabetes mellitus.

As many as 1 in 3 patients with gestational diabetes mellitus have impaired glucose metabolism when screened postpartum. These patients have a 40% to 70% lifetime risk of progression to type 2 diabetes mellitus, but progression can be delayed or prevented by lifestyle interventions or medication. The American College of Obstetricians and Gynecologists and the American Diabetes Association recommend a glucose tolerance test at 4 to 12 weeks postpartum for all patients with gestational diabetes mellitus. Despite these recommendations, postpartum screening rates are typically <50%, representing a major healthcare "quality gap." The Society for Maternal-Fetal Medicine proposes a uniform metric that identifies the percentage of persons with gestational diabetes mellitus who completed a 75-g, 2-hour glucose tolerance test within 12 weeks after delivery. The metric is designed to be measured using diagnosis and procedure codes in payor claims data. Barriers to screening are discussed. Possible uses of the metric for quality improvement projects are outlined. Increasing the rate of postpartum diabetes screening should facilitate timely referral to implement lifestyle modifications, medication, and long-term follow-up. Use of the metric in financial incentive programs is discouraged at this time.

Society for Maternal-Fetal Medicine Special Statement: Prophylactic low-dose aspirin for preeclampsia prevention-quality metric and opportunities for quality improvement.

Prophylactic low-dose aspirin reduces the rates of preeclampsia, preterm birth, fetal growth restriction, and perinatal death in patients with risk factors for preeclampsia. Despite recommendations from the US Preventive Services Task Force, the American College of Obstetricians and Gynecologists, and the Society for Maternal-Fetal Medicine, low-dose aspirin use is reported in <50% of patients with high-risk factors and <25% of patients with >1 moderate-risk factor. These low use rates represent an important "quality gap" and demonstrate the need for quality improvement activities. In this article, we outline the specifications for a process metric to standardize the measurement of the rate of aspirin use. Furthermore, we outline an approach to conducting a quality improvement project to increase the use of aspirin by patients with risk factors for preeclampsia.

Progestogen maintenance therapy for prolongation of pregnancy after an episode of preterm labour: A systematic review and meta-analysis.

BACKGROUND: Evidence for progestogen maintenance therapy after an episode of preterm labour (PTL) is contradictory. OBJECTIVES: To assess effectiveness of progestogen maintenance therapy after an episode of PTL. SEARCH STRATEGY: An electronic search in Central Cochrane, Ovid Embase, Ovid Medline and clinical trial databases was performed. SELECTION CRITERIA: Randomised controlled trials (RCT) investigating women between 16+0 and 37+0 weeks of gestation with an episode of PTL who were treated with progestogen maintenance therapy compared with a control group. DATA COLLECTION AND ANALYSIS: Systematic review and meta-analysis were conducted. The primary outcome was latency time in days. Secondary neonatal and maternal outcomes are consistent with the core outcome set for preterm birth studies. Studies were extensively assessed for data trustworthiness (integrity) and risk of bias. MAIN RESULTS: Thirteen RCT (1722 women) were included. Progestogen maintenance therapy demonstrated a longer latency time of 4.32 days compared with controls (mean difference [MD] 4.32, 95% CI 0.40-8.24) and neonates were born with a higher birthweight (MD 124.25 g, 95% CI 8.99-239.51). No differences were found for other perinatal outcomes. However, when analysing studies with low risk of bias only (five RCT, 591 women), a significantly longer latency time could not be shown (MD 2.44 days; 95% CI -4.55 to 9.42). CONCLUSIONS: Progestogen maintenance therapy after PTL might have a modest effect on prolongation of latency time. When analysing low risk of bias studies only, this effect was not demonstrated. Validation through further research, preferably by an individual patient data meta-analysis is highly recommended.

Selection of Standards for Sonographic Fetal Head Circumference by Use of z-Scores.

OBJECTIVE: This study aimed to evaluate which of five established norms should be used for sonographic assessment of fetal head circumference (HC). STUDY DESIGN: Cross-sectional study using pooled data from four maternal-fetal medicine practices. Inclusion criteria were singleton fetus, gestational age 220/7 to 396/7 weeks, biometry measured, and fetal cardiac activity present. Five norms of HC were studied: Jeanty et al, Hadlock et al, the INTERGROWTH-21st Project (IG-21st), the World Health Organization Fetal Growth Curves (WHO), and the National Institutes of Child Health and Human Development Fetal Growth Studies unified standard (NICHD-U). The fit of our HC measurements to each norm was assessed by these criteria: mean z-score close to 0, standard deviation (SD) of z close to 1, low Kolmogorov-Smirnov D-statistic, high Youden J-statistic, close to 10% of exams >90th percentile, close to 10% of exams <10th percentile, and close to 2.28% of exams >2 SD below the mean. RESULTS: In 23,565 ultrasound exams, our HC measurements had the best fit to the WHO standard (mean z-score 0.10, SD of z = 1.01, D-statistic <0.01, J-statistic 0.83-0.94). The SD of the Jeanty reference was much larger than all the other norms and our measurements, resulting in underdiagnosis of abnormal HC. The means of the IG-21st and NICHD-U standards were smaller than the other norms and our measurements, resulting in underdiagnosis of small HC. The means of the Hadlock reference were larger than all the other norms and our measurements, resulting in overdiagnosis of small HC. Restricting the analysis to a low-risk subgroup of 4,423 exams without risk factors for large- or small-for-gestational age produced similar results. CONCLUSION: The WHO standard is likely best for diagnosis of abnormal HC. The Jeanty (Chervenak) reference suggested by the Society for Maternal-Fetal Medicine had poor sensitivity for microcephaly screening. KEY POINTS: · There are >30 norms for fetal HC.. · It is unknown which norm should be used.. · The WHO standard fits our data best.. · The Chervenak reference is not sensitive for microcephaly..

Selection of Standards for Sonographic Fetal Femur Length by Use of z-scores.

OBJECTIVES: This study aimed to evaluate which of four established norms should be used for sonographic assessment of fetal femur length (FL). STUDY DESIGN: Cross-sectional study using pooled data from four maternal-fetal medicine practices. Inclusion criteria were singleton fetus, gestational age (GA) 220/7 to 396/7 weeks, biometry measured, and fetal cardiac activity present. Four norms of FL were studied: Hadlock et al, the INTERGROWTH-21st Project (IG-21st), the World Health Organization Fetal Growth Curves (WHO), and the National Institutes of Child Health and Human Development Fetal Growth Studies, unified standard (NICHD-U). The fit of our FL measurements to each norm was assessed by these criteria: mean z-score close to 0, standard deviation (SD) of z close to 1, Kolmogorov-Smirnov D-statistic close to zero, Youden J-statistic close to 1, approximately 5% of exams <5th percentile, and approximately 5% of exams >95th percentile. RESULTS: In 26,177 ultrasound exams, our FL measurements had the best fit to the WHO standard (mean z-score 0.15, SD of z 1.02, D-statistic <0.01, J-statistic 0.95, 3.4% of exams <5th percentile, 7.0% of exams >95th percentile). The mean of the IG-21st standard was smaller than the other norms and smaller than our measurements, resulting in underdiagnosis of short FL. The mean of the Hadlock reference was larger than the other norms and larger than our measurements, resulting in overdiagnosis of short FL. The SD of the NICHD-U standard was larger than the other norms and larger than our observations, resulting in underdiagnosis of both short and long FL. Restricting the analysis to a subgroup of 7,144 low-risk patients without risk factors for large- or small-for- GA produced similar results. CONCLUSION: Of the norms studied, the WHO standard is likely best for diagnosis of abnormal FL. KEY POINTS: · There are >30 norms for fetal FL.. · It is unknown which norm should be used.. · Our data fit the World Health Organization standard better than the other norms..

Society for Maternal-Fetal Medicine Special Statement: A critique of postpartum readmission rate as a quality metric.

Hospital readmission is considered a core measure of quality in healthcare. Readmission soon after hospital discharge can result from suboptimal care during the index hospitalization or from inadequate systems for postdischarge care. For many conditions, readmission is associated with a high rate of serious morbidity and potentially avoidable costs. In obstetrics, for postpartum care specifically, hospitals and payers can easily track the rate of maternal readmission after childbirth and may seek to incentivize obstetricians, maternal-fetal medicine specialists, or provider groups to reduce the rate of readmission. However, this practice has not been shown to improve outcomes or reduce harm. There are major concerns with incentivizing providers to reduce postpartum readmissions, including the lack of a standardized metric, a baseline rate of 1% to 2% that is too low to accurately discriminate between random variation and controllable factors, the need for risk adjustment that greatly complicates rate calculations, the potential for bias depending on the duration of the follow-up interval, the potential for the "gaming" of the metric, the lack of evidence that obstetrical providers can influence the rate, and the potential for unintended harm in the vulnerable postpartum population. Until these problems are adequately addressed, maternal readmission rate after a childbirth hospitalization currently has limited utility as a metric for quality or performance improvement or as a factor to adjust provider reimbursement.

Society for Maternal-Fetal Medicine Special Statement: Postpartum visit checklists for normal pregnancy and complicated pregnancy.

Rising maternal morbidity and mortality rates, widening healthcare disparities, and increasing focus on cardiometabolic risk modification in at-risk patients have together catalyzed a shift in the postpartum care paradigm. What was once a single office visit in the 6 weeks after delivery is now being reimagined as a continuum of care that transitions patients from pregnancy to lifelong health optimization. However, this shift in postpartum care also comes with increased visit complexity and additional provider burden, particularly when patients have had significant pregnancy complications or have chronic diseases. To ensure that the comprehensive needs of both healthy and medically complex people are consistently met under this revised postpartum care paradigm, a postpartum visit checklist for uncomplicated postpartum patients and another checklist for those with major medical or obstetrical morbidities are presented. These checklists are designed to ensure that essential elements of physical and mental well-being are routinely considered, that adequate follow-up or specialty referrals are made, and that relevant future health risks are appropriately reviewed and discussed.

Society for Maternal-Fetal Medicine Special Statement: Cognitive bias and medical error in obstetrics-challenges and opportunities.

The processes of diagnosis and management involve clinical decision-making. However, decision-making is often affected by cognitive biases that can lead to medical errors. This statement presents a framework of clinical thinking and decision-making and shows how these processes can be bias-prone. We review examples of cognitive bias in obstetrics and introduce debiasing tools and strategies. When an adverse event or near miss is reviewed, the concept of a cognitive autopsy-a root cause analysis of medical decision-making and the potential influence of cognitive biases-is promoted as part of the review process. Finally, areas for future research on cognitive bias in obstetrics are suggested.

Society for Maternal-Fetal Medicine Special Statement: Quality metrics for optimal timing of antenatal corticosteroid administration.

Preterm birth is a leading cause of perinatal morbidity and mortality. Antenatal corticosteroid administration before preterm birth reduces the risks of perinatal death, respiratory morbidity, necrotizing enterocolitis, and intraventricular hemorrhage and reduces the costs of perinatal care. Antenatal corticosteroids are optimally effective when administered within 7 days before preterm birth. However, only 20% to 40% of early preterm infants receive antenatal corticosteroids within 7 days before birth, in part because it is difficult to predict the precise timing of preterm birth. Until 2020, The Joint Commission had a Perinatal Care quality metric measuring the rate of antenatal corticosteroid administration at any time before early preterm birth. This metric incentivized providers to use antenatal corticosteroids liberally. The Joint Commission retired the metric in 2020 after the rate reached more than 97% in The Joint Commission-accredited hospitals. However, the metric did not evaluate whether the timing of antenatal corticosteroid administration was optimal, that is, within 7 days of birth. A 2016 multistakeholder Cooperative Workshop recommended the development of a new quality metric to assess the rate of optimally timed antenatal corticosteroids among early preterm births. In this statement, we outline proposed specifications for such a metric and discuss potential uses, advantages, limitations, and barriers. Furthermore, we propose a balancing metric that tracks the percentage of patients treated with antenatal corticosteroids who ultimately give birth at term. We suggest that the use of these new metrics may incentivize more conservative antenatal corticosteroid timing, which could, in turn, lead to meaningfully improved outcomes for preterm neonates.

Society for Maternal-Fetal Medicine Special Statement: A quality metric for evaluating timely treatment of severe hypertension.

Severe hypertension in pregnancy is a medical emergency. Although expeditious treatment within 30 to 60 minutes is recommended to reduce the risk of maternal death or severe morbidity, treatment is often delayed by >1 hour. In this statement, we propose a quality metric that facilities can use to track their rates of timely treatment of severe hypertension. We encourage facilities to adopt this metric so that future reports from different facilities will be based on a uniform definition of timely treatment.

Society for Maternal-Fetal Medicine Special Statement: Quality metric for timely postpartum follow-up after severe hypertension.

Hypertensive disorders of pregnancy are a leading cause of maternal morbidity and mortality. Because postpartum exacerbation of severe hypertension is common, the American College of Obstetricians and Gynecologists recommends that patients with severe hypertension during the childbirth hospitalization be seen within 72 hours after discharge. In this statement, the Society for Maternal-Fetal Medicine proposes a uniform metric reflecting the rate of timely postpartum follow-up of patients with severe hypertension. The metric is designed to be measured using automated calculations based on billing codes derived from claims data. The metric can be used in quality improvement projects to increase the rate of timely follow-up in patients with severe hypertension during the childbirth hospitalization. Suggested steps for implementing such a project are outlined.

Society for Maternal-Fetal Medicine Special Statement: Checklist for pregnancies resulting from in vitro fertilization.

The management of pregnancies resulting from in vitro fertilization includes several recommended interventions at various times by various providers. To minimize the chance of errors of omission, the Society for Maternal-Fetal Medicine presents a patient-oriented checklist summarizing the recommended management of such pregnancies.

Recurrent Preterm Birth Reduction by 17-Hydroxyprogesterone Caproate in Dichorionic/Diamniotic Twin Gestation.

OBJECTIVE: The study aimed to evaluate the impact of 17-hydroxyprogesterone caproate (17-OHPC) on recurrent preterm birth (PTB) in women with a prior PTB and a current dichorionic/diamniotic twin gestation. STUDY DESIGN: We combined individual patient-level data from two prospective randomized placebo-controlled trials of prophylactic 17-OHPC in twin gestation and compared the rates of recurrent spontaneous PTB in those women with a prior singleton PTB randomized to placebo or 17-OHPC (250 mg weekly). RESULTS: Only 7.4% of women with dichorionic/diamniotic twin gestation experienced a prior PTB. Among these 66 women, spontaneous delivery prior to 34 weeks occurred significantly less often (p = 0.03) in those randomized to 17-OHPC (20.6%) than in those randomized to placebo (46.9%). However, mean gestational length was not significantly different, and there was no statistically significant difference in composite neonatal outcome. CONCLUSION: 17-OHPC may be beneficial to women with a prior PTB and a current dichorionic/diamniotic twin gestation. These findings along with those reported by the Maternal Fetal Medicine Units Network in singletons suggest a common mechanism of action and a specific target population, those with a prior PTB, that may benefit from 17-OHPC treatment. A large prospective trial is needed to validate these findings. KEY POINTS: · 17-OHPC reduces recurrent PTB in women with dichorionic/diamniotic twins.. · PTB risk and response to 17-OHPC may differ according to the type of twinning.. · 17-OHPC may affect a common pathway in twins and singletons with a prior PTB..

Society for Maternal-Fetal Medicine Special Statement: Checklist for initial management of amniotic fluid embolism.

Amniotic fluid embolism is a rare syndrome characterized by sudden cardiorespiratory collapse during labor or soon after delivery. Because of its rarity, many obstetrical providers have no experience in managing amniotic fluid embolism and may therefore benefit from a cognitive aid such as a checklist. We present a sample checklist for the initial management of amniotic fluid embolism based on standard management guidelines. We also suggest steps that each facility can take to implement the checklist effectively.

Society for Maternal-Fetal Medicine Special Statement: Surgical safety checklists for cesarean delivery.

The routine use of surgical safety checklists can reduce perioperative complications. Generic surgical safety checklists are insufficient for cesarean delivery because each cesarean delivery involves 2 patients (the mother and the fetus or newborn), each with separate care teams and health and safety considerations. To address the added complexity of care coordination and communication inherent in cesarean delivery, the Society for Maternal-Fetal Medicine presents sample standard surgical safety checklists for cesarean delivery that include elements of care for both the mother and newborn. In addition, we present an alternative checklist for time-critical emergency cesarean deliveries in which there is no time to safely perform the standard checklist and a sample preoperative checklist for use before moving the patient to the operating room. We also recommend steps for implementation of the checklists at individual facilities.

SMFM Special Statement: Operative vaginal delivery: checklists for performance and documentation.

The frequency of operative vaginal delivery has been declining, even though it can be an attractive alternative to cesarean delivery in selected cases. Performance of operative vaginal delivery required consideration of many indications, contraindications, and prerequisites. Optimal documentation of operative vaginal delivery requires the recording of several specific elements that are unique to forceps or vacuum delivery. A cognitive aid such as a checklist is well suited to this situation in which there are numerous elements to consider, a low frequency of performance, and teams with variable expertise. We propose 2 checklists to help ensure that all relevant elements are considered for every operative vaginal delivery: (1) a checklist for preparation and performance of the procedure and (2) a checklist for documentation. We suggest practical tips to help facilities adapt these checklists to their own circumstances and implement them on their units.