Research
Obstetrics
Does the presence of a condition-specific obstetric protocol lead to detectable improvements in pregnancy outcomes?

Presented at the 32nd annual meeting of the Society for Maternal-Fetal Medicine, Dallas, TX, Feb. 6-11, 2012.
https://doi.org/10.1016/j.ajog.2015.01.055Get rights and content

Objective

We sought to evaluate whether the presence of condition-specific obstetric protocols within a hospital was associated with better maternal and neonatal outcomes.

Study Design

This was a cohort study of a random sample of deliveries performed at 25 hospitals over 3 years. Condition-specific protocols were collected from all hospitals and categorized independently by 2 authors. Data on maternal and neonatal outcomes, as well as data necessary for risk adjustment were collected. Risk-adjusted outcomes were compared according to whether the patient delivered in a hospital with condition-specific obstetric protocols at the time of delivery.

Results

Hemorrhage-specific protocols were not associated with a lower rate of postpartum hemorrhage or with fewer cases of estimated blood loss >1000 mL. Similarly, in the presence of a shoulder dystocia protocol, there were no differences in the frequency of shoulder dystocia or number of shoulder dystocia maneuvers used. Conversely, preeclampsia-specific protocols were associated with fewer intensive care unit admissions (odds ratio, 0.28; 95% confidence interval, 0.18–0.44) and fewer cases of severe maternal hypertension (odds ratio, 0.86; 95% confidence interval, 0.77–0.96).

Conclusion

The presence of condition-specific obstetric protocols was not consistently shown to be associated with improved risk-adjusted outcomes. Our study would suggest that the presence or absence of a protocol does not matter and regulations to require protocols are not fruitful.

Section snippets

Materials and Methods

From 2008 through 2011, we performed a cohort study at 25 hospitals in the Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. This study, the Assessment of Perinatal Excellence (APEX), was designed to develop quality measures for intrapartum obstetrical care. The APEX study was approved by the institutional review board at each participating institution under a waiver of informed consent. This is a planned secondary analysis of

Results

Data were collected from 115,502 women. Unadjusted outcome rates are shown in Table 2. The frequencies of hemorrhage outcomes and ICU admission for preeclampsia were significantly different between hospitals with and without protocols in place. Hospitals with a hemorrhage protocol had higher rates of hemorrhage and hospitals that did not have a preeclampsia protocol in place had higher rates of ICU admissions.

Variables included in the final risk-adjustment models are shown in Table 1 and the

Comment

In these analyses, we did not find a consistent relationship between the presence of condition-specific protocols and the severity of obstetrics complications. The presence of hemorrhage or shoulder dystocia protocols did not appear to affect the frequency of the outcome itself or the severity of related adverse outcomes. Conversely, the presence of a preeclampsia protocol was associated with less hypertensive morbidity by some measures.

It is important to recognize the importance of risk

Acknowledgment

The authors thank the following subcommittee members who participated in protocol development and coordination between clinical research centers (Cynthia Milluzzi, RN, and Joan Moss, RNC, MSN), protocol/data management and statistical analysis (Madeline M. Rice, PhD, and Elizabeth Thom, PhD), and protocol development and oversight (Brian M. Mercer, MD, and Catherine Y. Spong, MD).

References (13)

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Other members of the Maternal-Fetal Medicine Units Network are listed in the Appendix.

This study was supported by grants from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) (HD21410, HD27869, HD27915, HD27917, HD34116, HD34208, HD36801, HD40500, HD40512, HD40544, HD40545, HD40560, HD40485, HD53097, HD53118) and the National Center for Research Resources (UL1 RR024989; 5UL1 RR025764).

Comments and views of the authors do not necessarily represent views of the NICHD.

The authors report no conflict of interest.

Cite this article as: Bailit JL, Grobman WA, McGee P, et al. Does the presence of a condition-specific obstetric protocol lead to detectable improvements in pregnancy outcomes? Am J Obstet Gynecol 2015;213:86.e1-6.

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