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Successfully reducing newborn asphyxia in the labour unit in a large academic medical centre: a quality improvement project using statistical process control
  1. Rikke von Benzon Hollesen1,
  2. Rie Laurine Rosenthal Johansen1,
  3. Christina Rørbye2,
  4. Louise Munk2,
  5. Pierre Barker3,
  6. Anette Kjaerbye-Thygesen2
  1. 1 Danish Society for Patient Safety, Frederiksberg, Denmark
  2. 2 Department of Obstetrics and Gynecology, Copenhagen University Hospital, Hvidovre, Denmark
  3. 3 Institute for Healthcare Improvement, Cambridge, Massachusetts, USA
  1. Correspondence to MA and RN  Rikke von Benzon Hollesen, Danish Society for Patient Safety, Nordre Fasanvej 57, 2000 Frederiksberg, Denmark; rh{at}


Background A safe delivery is part of a good start in life, and a continuous focus on preventing harm during delivery is crucial, even in settings with a good safety record. In January 2013, the labour unit at Copenhagen University Hospital, Hvidovre, undertook a quality improvement (QI) project to prevent asphyxia and reduced the percentage of newborns with asphyxia by 48%.

Methods The change theory consisted of two primary elements: (1) the clinical content, including three clinical bundles of evidence-based care, a ‘delivery bundle’, an ‘oxytocin bundle’ and a ‘vacuum extraction bundle’; (2) an implementation theory, including improving skills in interpretation of cardiotocography, use of QI methods and participation in a national learning network. The Model for Improvement and Deming’s system of profound knowledge were used as a methodological framework. Data on compliance with the care bundles and the number of deliveries between newborns with asphyxia (Apgar <7 after 5 min or pH <7) were analysed using statistical process control.

Results Compliance with all three clinical care bundles improved to 95% or more, and the percentages of newborns with pH <7 and Apgar <7 after 5 min were reduced by 48% and 31%, respectively. In general, the QI approach strengthened multidisciplinary teamwork, systematised workflow and structured communication around the deliveries. Changes included making a standard memo in the medical record, the use of a bedside whiteboard, bedside handovers, shared decisions with a peer when using an oxytocin infusion and the use of a checklist before vacuum extractions.

Conclusion This QI project illustrates how aspects of patient safety, such as the prevention of asphyxia, can be improved using QI methods to more reliably implement best practice, even in high-performing systems.

  • healthcare quality improvement
  • implementation science
  • PDSA
  • statistical process control
  • obstetrics and gynaecology

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  • Twitter Follow Rikke von Benzon Hollesen at @RHollesen and Rie Laurine Rosenthal Johansen at @JohansenRie

  • Contributor RvBH was external improvement advisor in the QI team in the labour unit and Programme Director at the Danish Perinatal Quality Improvement Programme. RvBH and RLRJ analysed data and drafted the paper. CR, LM and AKT were subject matter people and members of the QI team and provided subject matter knowledge and profound knowledge of the local QI work. PB revised the manuscript and assisted with methodological reflections and guidance. All authors took part in revising the manuscript and have approved the final version.

  • Funding Danish Regions

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.