Automated Alert System of Second-Line Uterotonic Drug Administration.

Multidisciplinary team management of postpartum hemorrhage (PPH) is needed to optimize care and improve outcomes. Lucile Packard Children's Hospital, Stanford, is a tertiary referral center with 4600 deliveries/y (>70% high-risk deliveries), and there have been times when the obstetric anesthesia team was alerted late or not at all for PPHs. Introduction of an automated alert process to the obstetric anesthesia team when a second-line uterotonic drug was administered has ensured prompt evaluation. Utilization of this automated drug alert system has improved communication and reduced failure to inform the obstetric anesthesiology team of PPH after vaginal and cesarean deliveries.

Virtual Compared to In-Person Obstetric Anesthesiology Trainee Education During the COVID-19 Pandemic: A Short Report.

BACKGROUND: The COVID-19 pandemic brought many changes to medical training, including in-person education platforms being disbanded and replaced with virtual education. At our institution, dedicated obstetric anesthesiology teaching for residents and fellows occurs daily and is highly valued and rated. In March 2020 due to the COVID-19 pandemic, we changed the teaching platform from in-person to virtual teaching (via video communication). We subsequently surveyed residents, fellows, and attendings to determine the impact of virtual compared with in-person teaching. METHODS: To assess the impact of this change, an electronic survey was sent to 10 anesthesiology residents on their 2nd obstetric anesthesiology rotation, and 10 residents on their 1st rotation, respectively. The electronic survey was also sent to three fellows and eight obstetric anesthesiology attendings. Answers were based on a 5-point Likert scale (1 = strongly disagree, 5 = strongly agree). RESULTS: The results for 1st rotation residents were higher in all domains compared with 2nd rotation residents and fellows, where "quality" achieved statistical significance (p=0.009) between 1st and 2nd rotation residents. "Engagement" was overall the most impacted domain for trainees. Attendings did not feel that virtual teaching impacted their ability to provide adequate education, however, learner engagement was again the lowest rated domain, and teachers strongly favored resuming in-person teaching. CONCLUSIONS: Virtual teaching is an appropriate alternative when in-person teaching is not possible. Future initiatives are needed to improve engagement and better facilitate virtual teaching.

A strategy for disaster preparedness in obstetrics.

BACKGROUND: Many hospital units, including obstetric (OB) units, were unprepared when the novel coronavirus began sweeping through communities. National and international bodies, including the World Health Organization, Centers for Disease Control Prevention, and the American College of Obstetricians and Gynecologists, directed enormous efforts to present the latest evidence-based practices to healthcare institutions and communities. The first hospitals that were affected in China and the United States (US) did heroic work in assisting their colleagues with best practices they had acquired. Despite these resources, many US hospitals struggled with how to best incorporate and implement this new information into disaster plans, and many protocol changes had to be established de novo. In general, disaster planning for OB units lagged behind other disaster planning performed by specialties such as emergency medicine, trauma, and pediatrics. PARTICIPANTS: Fortunately, two pre-existing collaborative disaster groups, the OB Disaster Planning Workgroup and the Western Regional Alliance for Pediatric Emergency Management, were able to rapidly deploy during the pandemic due to their pre-established networks and shared goals. MAIN OUTCOME: These groups were able to share best practices, identify and address knowledge gaps, and disseminate information on a broad scale. The case will be made that the OB community needs to establish more such regional and national disaster committees that meet year-round. This will ensure that in times of urgency, these groups can increase the cadence of their meetings, and thus rapidly disperse time-sensitive policies and procedures for OB units nationwide. CONCLUSION: Given the unique patient population, it is imperative that OB units establish regional coalitions to facilitate a coordinated response to local and national disasters.

Emergency Resources in Obstetrics.

Utilization of emergency resources in obstetrics can help to optimize health care providers' care to pregnant and postpartum patients. There is a vast array of resources with various accessibility modalities that can be used before, during, and/or after an obstetric emergency. These resources can also be included as teaching material to increase knowledge and awareness with the aim to reduce maternal morbidity and mortality and improve patient outcomes.

Maternal sepsis update.

PURPOSE OF REVIEW: Maternal sepsis is the second leading cause of maternal death in the United States. A significant number of these deaths are preventable and the purpose of this review is to highlight causes such as delays in recognition and early treatment. RECENT FINDINGS: Maternal sepsis can be difficult to diagnose due to significant overlap of symptoms and signs of normal physiological changes of pregnancy, and current screening tools perform poorly to identify sepsis in pregnant women. Surveillance should not only include during pregnancy, but also throughout the postpartum period, up to 42 days postpartum. Education and awareness to highlight this importance are not only vital for obstetric healthcare provides, but also for nonobstetric healthcare providers, patients, and support persons. SUMMARY: Through education and continual review and analysis of evidence-based practice, a reduction in maternal morbidity and mortality secondary to maternal sepsis should be attainable with dedication from all disciplines that care for obstetric and postpartum patients. Education and vigilance also extend to patients and support persons who should be empowered to escalate care when needed.

Cognitive Aids in Obstetric Units: Design, Implementation, and Use.

Obstetrics has unique considerations for high stakes and dynamic clinical care of ≥2 patients. Obstetric crisis situations require efficient and coordinated responses from the entire multidisciplinary team. Actions that teams perform, or omit, can strongly impact peripartum and perinatal outcomes. Cognitive aids are tools that aim to improve patient safety, efficiency in health care management, and patient outcomes. However, they are intended to be combined with clinician judgment and training, not as absolute or exhaustive standards of care for patient management. There is simulation-based evidence showing efficacy of cognitive aids for enhancing appropriate team management during crises, especially with a reader role, with growing literature supporting use in obstetric and nonobstetric clinical settings when combined with local customization and implementation efforts. The purpose of this article is to summarize current understanding and available resources for cognitive aid design, implementation, and use in obstetrics and to highlight existing gaps that can stimulate further enhancement in this field.

Postpartum tubal ligation: A retrospective review of anesthetic management at a single institution and a practice survey of academic institutions.

STUDY OBJECTIVE: The primary aim was to evaluate institutional anesthetic techniques utilized for postpartum tubal ligation (PPTL). Secondarily, academic institutions were surveyed on their clinical practice for PPTL. DESIGN: An institutional-specific retrospective review of patients with ICD-9 procedure codes for PPTL over a 2-year period was conducted. Obstetric anesthesia fellowship directors were surveyed on anesthetic management of PPTL. SETTING: Labor and delivery unit. Internet survey. PATIENTS: 202 PPTL procedures were reviewed. 47 institutions were surveyed; 26 responses were received. MEASUREMENTS: Timing of PPTL, anesthetic management, postoperative pain and length of stay. MAIN RESULTS: There was an epidural catheter reactivation failure rate of 26% (18/69 epidural catheter reactivation attempts). Time from epidural catheter insertion to PPTL was a significant factor associated with failure: median [IQR; range] time for successful versus failed epidural catheter reactivation was 17h [10-25; 3-55] and 28h [14-33; 5-42], respectively (P=0.028). Epidural catheter reactivation failure led to significantly longer times to provide surgical anesthesia than successful epidural catheter reactivation or primary spinal technique: median [IQR] 41min [33-54] versus 15min [12-21] and 19min [15-24], respectively (P<0.0001). Fifty-eight percent (15/26) of respondents routinely leave the labor epidural catheter in-situ if PPTL is planned. Sixty-five percent (17/26) and 7% (2/26) would not attempt to reactivate the epidural catheter for PPTL if >8h and >24h post-delivery, respectively. CONCLUSIONS: Epidural catheter reactivation failure increases with longer intervals between catheter placement and PPTL. Failed epidural catheter reactivation increases anesthetic and operating room times. Our results and the significant variability in practice from our survey suggest recommendations on the timing and anesthetic management are needed to reduce unfulfilled PPTL procedures.

Maternal mortality and the role of the obstetric anesthesiologist.

Maternal mortality is increasing in the United States and remains unacceptably high in many parts of the world. Pre-existing conditions and social determinants of health frequently contribute to maternal death. General solutions to enhance maternal safety focus on systems to identify women at high risk and to tailor the management before, during, and after pregnancy. This review highlights condition-specific solutions for the leading etiologies of maternal death, including cardiac disease, sepsis, hemorrhage, venous thromboembolism, hypertensive disorders of pregnancy, and amniotic fluid embolism. Although anesthesia is an exceedingly rare cause of maternal death, specific hazards remain, including airway management, high neuraxial block, and unintentional dural puncture. The review concludes with an overview of strategies to create an institutional culture of both safety and equity, including multidisciplinary team training, simulation, shared decision-making, family-centered care, and serious morbidity review.