Using healthcare failure mode and effect analysis as a method of vaginal birth after caesarean section management.

AIMS AND OBJECTIVES: This research was conducted to explore the effectiveness of employing the healthcare failure mode and effect analysis method in the management of trial of labour after caesarean, with the aims of increasing vaginal birth after caesarean section rate and reducing potential risks that might cause severe complications. BACKGROUND: Previously high caesarean section rate in China and the "two children" policy leads to the situation where multiparas are faced with the choice of another caesarean or trial of labour after caesarean. Despite evidences showing the benefits of vaginal birth after caesarean, obstetricians and midwives in China tend to be conservative due to limited experience and insufficient clinical routines. Thus, its management needs further optimisation in order to make the practice safe and sound. DESIGN: A prospective quality improvement programme using the healthcare failure mode and effect analysis. METHODS: With the structured methodology of healthcare failure mode and effect analysis, we determined core processes of antepartum and intrapartum management, conducted risk priority numbers and devised remedial protocols for failure modes with high risks. The programme was then implemented as a clinical routine under the agreement of the institutional review board and vaginal birth after caesarean success rates were compared before and after the quality improvement programme, both descriptively and statistically. Standards for Quality Improvement Reporting Excellence 2.0 checklist was chosen on reporting the study process. RESULTS: Seventy failure modes in seven core processes were identified in the management process, with 14 redressed for actions. The 1-year follow-up trial of labour after caesarean and vaginal birth after caesarean rate was increased compared with the previous 3 years, with a vaginal birth after caesarean rate of 86.36%, whereas the incidence of uterine rupture was not compromised. CONCLUSIONS: The application of healthcare failure mode and effect analysis can not only promote trial of labour after caesarean and vaginal birth after caesarean rate, but also maintaining a low risk of uterine rupture. RELEVANCE TO CLINICAL PRACTICE: This modified vaginal birth after caesarean management protocol has been shown effective in increasing its successful rate, which can be continued for further comparison of severe complications to the previous practice.

A checklist for timeout on labor and delivery: a pilot study to improve communication and safety.

OBJECTIVE: To assess the impact on staff communication of a standardized checklist for timeout for patients undergoing a trial of labor after cesarean section and/or elective induction at term. STUDY DESIGN: A comparison of presurvey and postsurvey questionnaire results for labor and delivery personnel assessing communication before and after checklist implementation. RESULTS: From October 2011 through March 2012, 52.9% (N=37) of 70 eligible patients had the standardized checklist for timeout performed. Prior to implementation of the checklist, 66% of respondents (48.8% of nurses, 100% of residents, 90% of attendings) slightly or strongly agreed that their opinions were heard versus 83% of respondents during the study period (73.7% of nurses, 100% of residents, 100% of attendings). Following the intervention, nurses reported that they were more likely to feel as though their opinions were heard (p = 0.05). CONCLUSION: Implementation of a formalized obstetric timeout improved the subjective perception of communication among obstetric staff. This tool has the potential to improve patient safety in labor and delivery.

Survey of Connecticut Nurse-Midwives.

Descriptive data on nurse-midwifery income, workload, job definitions, employment benefits, and clinical practices are limited. Information about nurse-midwifery practice today is important for the growth of the profession and for future policy initiatives. A survey of nurse-midwives in Connecticut was conducted in 2005. This article reports state-specific data about income, workload, job definitions, employment benefits, and clinical issues, such as vaginal birth after cesarean. Full-time midwives in Connecticut worked an average of 77 hours per week, had a mean salary of 79,554 dollars, and 87% had on-call responsibilities. A "typical" Connecticut midwife had an "average" full-time work week consisting of two 24-hour call days and three 7-hour office days, seeing 19 to 24 patients per office day. Most held Master of Science in Nursing degrees, worked in physician-owned practices, and attended births in hospitals or medical centers. Health insurance, paid sick time, and retirement plans were offered to most respondents. Almost all respondents provide gynecologic, antepartum, and postpartum care, but few offer newborn care. There is significant variation in restrictions on midwives offering vaginal birth after cesarean and on length of scheduled appointments. Data on expanded practices, such as first-assisting caesarean sections and endometrial biopsies, are reported for the first time.