- Obstetrics and Gynecology
Clinical Professor, Obstetrics & Gynecology - Maternal Fetal Medicine
CoDirector of OBSIm Program, Center for Pediatric and Perinatal Education (2004 - Present)
CoDirector of Disaster Planning, The Johnson Center at Lucile Packard Children's Hospital (2013 - Present)
Boards, Advisory Committees, Professional Organizations
Director of OB simulation, Stanford Children's Health (2004 - Present)
National OB/Gyn Simulation Consortium, ACOG (2009 - 2018)
Co-DIrector of Disaster Planning, Johnson Center for Pregnancy and Newborns Stanford Children's Health (2017 - Present)
Faculty Fellow with the Center for Innovation in Global Health, Stanford University (2015 - Present)
Medical Education: University of Colorado Anschutz Campus Registrar (1983) CO
Internship and Residency, Kaiser Permanente,Oakland, Obstetrics and Gynecology (1987)
Board Certification: American Board of Obstetrics and Gynecology, Obstetrics and Gynecology (1989)
Community and International Work
global women's health education
Opportunities for Student Involvement
Use of Simulation to train in country OB/GYN residents in low resource areas, HEODRA hosptial
ob emergencies, vaginal hysterectomy
Opportunities for Student Involvement
Current Research and Scholarly Interests
Special interest in :
1.Ob simulation as a teaching and training tool
2. Disaster planning for OB units
3. Global women's health
Independent Studies (5)
- Directed Reading in Obstetrics and Gynecology
OBGYN 299 (Aut, Win, Spr, Sum)
- Early Clinical Experience in Obstetrics and Gynecology
OBGYN 280 (Aut, Win, Spr, Sum)
- Graduate Research in Reproductive Biology
OBGYN 399 (Aut, Win, Spr, Sum)
- Medical Scholars Research
OBGYN 370 (Aut, Win, Spr, Sum)
- Undergraduate Research in Reproductive Biology
OBGYN 199 (Aut, Win, Spr, Sum)
- Directed Reading in Obstetrics and Gynecology
Med Scholar Project Advisor
Mixed methods evaluation of simulation-based training for postpartum hemorrhage management in Guatemala.
BMC pregnancy and childbirth
2022; 22 (1): 513
BACKGROUND: To assess if simulation-based training (SBT) of B-Lynch suture and uterine balloon tamponade (UBT) for the management of postpartum hemorrhage (PPH) impacted provider attitudes, practice patterns, and patient management in Guatemala, using a mixed-methods approach.METHODS: We conducted an in-country SBT course on the management of PPH in a governmental teaching hospital in Guatemala City, Guatemala. Participants were OB/GYN providers (n=39) who had or had not received SBT before. Surveys and qualitative interviews evaluated provider knowledge and experiences with B-Lynch and UBT to treat PPH.RESULTS: Multiple-choice surveys indicated that providers who received SBT were more comfortable performing and teaching B-Lynch compared to those who did not (p=0.003 and 0.005). Qualitative interviews revealed increased provider comfort with B-Lynch compared to UBT and identified multiple barriers to uterine balloon tamponade implementation.CONCLUSIONS: Simulation-based training had a stronger impact on provider comfort with B-Lynch compared to uterine balloon tamponade. Qualitative interviews provided insight into the challenges that hinder uptake of uterine balloon tamponade, namely resource limitations and decision-making hierarchies. Capturing data through a mixed-methods approach allowed for more comprehensive program evaluation.
View details for DOI 10.1186/s12884-022-04845-2
View details for PubMedID 35751071
What's in a Name? Enhancing Communication in the Operating Room with the Use of Names and Roles on Surgical Caps.
Joint Commission journal on quality and patient safety
2021; 47 (4): 258–64
A pilot study was conducted in a tertiary referral center to assess whether wearing caps labeled with providers' names and roles has an impact on communication in the operating room (OR).Two obstetricians observed surgeries for name uses and missed communications. Following each case, all providers were given a short survey that queried their attitude about the use of labeled surgical caps, their ability to know the names and roles of other providers during a case, and the impact of scrub attire on identifying others. They were also asked to rate the ease of communication and their ability to recall name and roles of the personnel specific to the case. Patients were asked how they perceived the use of labeled caps by providers.Twenty scheduled cesarean deliveries were randomized to either labeled (10) or nonlabeled (10) surgical caps. A total of 129 providers participated in the study, with 117 providing responses to the survey. Providers reported knowing the names and roles of colleagues more often with labeled caps vs. nonlabeled caps (names: 77.8% vs. 55.0%, 95% confidence interval [CI] = 64.4%-88.0% vs. 41.6%-67.9%, p = 0.011; roles: 92.5% vs. 78.3%, 95% CI = 81.8%-98.0% vs. 65.8%-88.0%, p = 0.036). Name uses increased (43 vs. 34, p = 0.208), and missed communications decreased (16 vs. 20, p = 0.614) when labeled caps were worn. Providers and patients had an overwhelmingly positive response to labeled caps.This pilot study demonstrated that wearing labeled caps in the OR led to more frequent name uses and less frequent missed communications. Providers and patients embraced the concept of labeled caps and perceived wearing labeled caps as improving communication in the OR.
View details for DOI 10.1016/j.jcjq.2020.11.012
View details for PubMedID 33384215
Single-center task analysis and user-centered assessment of physical space impacts on emergency Cesarean delivery.
2021; 16 (6): e0252888
OBJECTIVE: This study aimed to begin to address this gap using validated techniques in human factors to perform a participatory user-centered analysis of physical space during emergency Cesarean.METHODS: This study employed a mixed-methods design. Focus group interviews and surveys were administered to a convenience sample (n = 34) of multidisciplinary obstetric teams. Data collected from focus group interviews were used to perform a task and equipment analysis. Survey data were coded and mapped by specialty to identify reported areas of congestion and time spent, and to identify themes related to physical space of the OR and labor and delivery unit.RESULTS: Task analysis revealed complex interdependencies between specialties. Thirty task groupings requiring over 20 pieces of equipment were identified. Perceived areas of congestion and areas of time spent in the OR varied by clinical specialty. The following categories emerged as main challenges encountered during an emergency Cesarean: 1) size of physical space and equipment, 2) layout and orientation, and 3) patient transport.CONCLUSION: User insights on physical space and workflow processes during emergency Cesarean section at the institution studied revealed challenges related to getting the patients into the OR expediently and having space to perform tasks without crowding or staff injury. By utilizing human factors techniques, other institutions may build upon our findings to improve safety during emergency situations on labor and delivery.
View details for DOI 10.1371/journal.pone.0252888
View details for PubMedID 34111177
A strategy for disaster preparedness in obstetrics.
American journal of disaster medicine
2021; 16 (3): 207-213
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.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.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.Given the unique patient population, it is imperative that OB units establish regional coalitions to facilitate a coordinated response to local and national disasters.
View details for DOI 10.5055/ajdm.2021.0403
View details for PubMedID 34904705
Changing the Landscape of Obstetric Resident Education in LMIC Using Simulation-Based Training.
International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics
OBJECTIVE: Evaluate simulation-based training (SBT) in low-and-middle-income countries (LMIC) and the long-term retention of knowledge and self-efficacy.METHODS: We conducted a SBT course on the management of post-partum hemorrhage (PPH), shoulder dystocia (SD), and maternal cardiac arrest (MCA) in three governmental teaching hospitals in Guatemala. We evaluated changes in knowledge and self-efficacy using a multiple-choice questionnaire (MCQ) for 46 OB/GYN residents. A paired Student t-test was used to analyze changes at one week and six months after the SBT.RESULTS: There was an increase in scores in clinical knowledge of MCA, P <0. 001, 95% CI [0.81, 1.49], and SD, P<0.001, 95% CI [0.41, 1.02] one week following SBT and a statistically insignificant increase in PPH scores, P= 0.617, 95% CI [-0.96, 0.60]. This increase in scores was maintained after six months, for MCA, P< 0.001, 95% CI [0.69, 1.53], SD, P= 0.02 95% CI [0.07-0.85] and PPH, P=0.04 95% CI [0.01, 1.26]. For MCA and SD levels of self-efficacy were increased one-week following training, P<0.001 95% CI [0.83, 2.30] and P= 0.008 95% CI [0.60, 3.92], respectively, and at six-months P<0.001 95% CI [0.79, 2.42] and P= 0.006 95% CI [0.66, 3.81], respectively. There was a slight increase in PPH self-efficacy scores one-week after SBT, P=0.73, 95% CI [-6.05, 4.41], maintained after six-months P= 0.38 95% CI [-6.85, 2.85].CONCLUSION: SBT was found to be an effective and feasible method to increase short and long-term clinical knowledge and self-efficacy of obstetric emergencies in LMIC.
View details for DOI 10.1002/ijgo.13526
View details for PubMedID 33314149
Changing the Landscape of Obstetric Resident Education in LMIC Using Simulation Based Training
LIPPINCOTT WILLIAMS & WILKINS. 2020: 80S
View details for Web of Science ID 000554572900277
Safety and Ergonomic Challenges of Ventilating a Premature Infant During Delayed Cord Clamping
2019; 6 (4)
View details for DOI 10.3390/children6040059
View details for Web of Science ID 000467286300010
Safety and Ergonomic Challenges of Ventilating a Premature Infant During Delayed Cord Clamping.
Children (Basel, Switzerland)
2019; 6 (4)
Delayed cord clamping (DCC) is endorsed by multiple professional organizations for both term and preterm infants. In preterm infants, DCC has been shown to reduce intraventricular hemorrhage, lower incidence of necrotizing enterocolitis, and reduce the need for transfusions. Furthermore, in preterm animal models, ventilation during DCC leads to improved hemodynamics. While providing ventilation and continuous positive airway pressure (CPAP) during DCC may benefit infants, the logistics of performing such a maneuver can be complicated. In this simulation-based study, we sought to explore attitudes of providers along with the safety and ergonomic challenges involved with safely resuscitating a newborn infant while attached to the placenta. Multidisciplinary workshops were held simulating vaginal and Caesarean deliveries, during which providers started positive pressure ventilation and transitioned to holding CPAP on a preterm manikin. Review of videos identified 5 themes of concerns: sterility, equipment, mobility, space and workflow, and communication. In this study, simulation was a key methodology for safe identification of various safety and ergonomic issues related to implementation of ventilation during DCC. Centers interested in implementing DCC with ventilation are encouraged to form multidisciplinary work groups and utilize simulations prior to performing care on infants.
View details for PubMedID 31013884
Analyzing the heterogeneity of labor and delivery units: A quantitative analysis of space and design
2018; 13 (12)
View details for DOI 10.1371/journal.pone.0209339
View details for Web of Science ID 000454416400058
Development of the TeamOBS-PPH - targeting clinical performance in postpartum hemorrhage
ACTA OBSTETRICIA ET GYNECOLOGICA SCANDINAVICA
2018; 97 (6): 677–87
This study aimed to develop a valid and reliable TeamOBS-PPH tool for assessing clinical performance in the management of postpartum hemorrhage (PPH). The tool was evaluated using video-recordings of teams managing PPH in both real-life and simulated settings.A Delphi panel consisting of 12 obstetricians from the UK, Norway, Sweden, Iceland, and Denmark achieved consensus on (i) the elements to include in the assessment tool, (ii) the weighting of each element, and (iii) the final tool. The validity and reliability were evaluated according to Cook and Beckman. (Level 1) Four raters scored four video-recordings of in situ simulations of PPH. (Level 2) Two raters scored 85 video-recordings of real-life teams managing patients with PPH ≥1000 mL in two Danish hospitals. (Level 3) Two raters scored 15 video-recordings of in situ simulations of PPH from a US hospital.The tool was designed with scores from 0 to 100. (Level 1) Teams of novices had a median score of 54 (95% CI 48-60), whereas experienced teams had a median score of 75 (95% CI 71-79; p < 0.001). (Level 2) The intra-rater [intra-class correlation (ICC) = 0.96] and inter-rater (ICC = 0.83) agreements for real-life PPH were strong. The tool was applicable in all cases: atony, retained placenta, and lacerations. (Level 3) The tool was easily adapted to in situ simulation settings in the USA (ICC = 0.86).The TeamOBS-PPH tool appears to be valid and reliable for assessing clinical performance in real-life and simulated settings. The tool will be shared as the free TeamOBS App.
View details for PubMedID 29485679
Analyzing the heterogeneity of labor and delivery units: A quantitative analysis of space and design.
2018; 13 (12): e0209339
This study assessed labor and delivery (L&D) unit space and design, and also considered correlations between physical space measurements and clinical outcomes. Design and human factors research has increased standardization in high-hazard industries, but is not fully utilized in medicine. Emergency department and intensive care unit space has been studied, but optimal L&D unit design is undefined. In this prospective, observational study, a multidisciplinary team assessed physical characteristics of ten L&D units. Design measurements were analyzed with California Maternal Quality Care Collaborative (CMQCC) data from 34,161 deliveries at these hospitals. The hospitals ranged in delivery volumes (<1000->5000 annual deliveries) and cesarean section rates (19.6%-39.7%). Within and among units there was significant heterogeneity in labor room (LR) and operating room (OR) size, count, and number of configurations. There was significant homogeneity of room equipment. Delivery volumes correlated with unit size, room counts, and cesarean delivery rates. Relative risk of cesarean section was modestly increased when certain variables were above average (delivery volume, unit size, LR count, OR count, OR configuration count, LR to OR distance, unit utilization) or below average (LR size, OR size, LR configuration count). Existing variation suggests a gold standard design has yet to be adopted for L&D. A design-centered approach identified opportunities for standardization: 1) L&D unit size and 2) room counts based on current or projected delivery volume, and 3) LR and OR size and equipment. When combined with further human factors research, these guidelines could help design the L&D unit of the future.
View details for PubMedID 30586446
Opportunities to Foster Efficient Communication in Labor and Delivery Using Simulation.
2017; 7 (1): e44-e48
Introduction Communication errors are an important contributing factor in adverse outcomes in labor and delivery (L&D) units. The objective of this study was to identify common lapses in verbal communication using simulated obstetrical scenarios and propose alternative formats for communication. Methods Health care professionals in L&D participated in three simulated clinical scenarios. Scenarios were recorded and reviewed to identify questions repeated within and across scenarios. Questions that were repeated more than once due to ineffective communication were identified. The frequency with which the questions were asked across simulations was identified. Results Questions were commonly repeated both within and across 27 simulated scenarios. The median number of questions asked was 27 per simulated scenario. Commonly repeated questions focused on three general topics: (1) historical data/information (i.e., estimated gestational age), (2) maternal clinical status (i.e., estimated blood loss), and (3) personnel (i.e., "Has anesthesiologist been called?"). Conclusion Inefficient verbal communication exists in the process of transferring information during obstetric emergencies. These findings can inform improved training and development of information displays to improve teamwork and communication. A visual display that can report static historical information and specific dynamic clinical data may facilitate optimal human performance.
View details for DOI 10.1055/s-0037-1599123
View details for PubMedID 28255522
Building Comprehensive Strategies for Obstetric Safety: Simulation Drills and Communication.
Anesthesia and analgesia
2016; 123 (5): 1181-1190
As pioneers in the field of patient safety, anesthesiologists are uniquely suited to help develop and implement safety strategies to minimize preventable harm on the labor and delivery unit. Most existing obstetric safety strategies are not comprehensive, lack input from anesthesiologists, are designed with a relatively narrow focus, or lack implementation details to allow customization for different units. This article attempts to address these gaps and build more comprehensive strategies by discussing the available evidence and multidisciplinary authors' local experience with obstetric simulation drills and optimization of team communication.
View details for PubMedID 27749353
Impact of the Electronic Medical Record on Nurse's Time Allocation During Cesarean
LIPPINCOTT WILLIAMS & WILKINS. 2016: 154S
View details for DOI 10.1097/01.AOG.0000483613.77352.80
View details for Web of Science ID 000398934900542
Simulation Study Assessing Healthcare Provider's Knowledge of Pre-Eclampsia and Eclampsia in a Tertiary Referral Center.
Simulation in healthcare
2016; 11 (1): 25-31
The aim of the study was to assess knowledge of labor and delivery healthcare providers at a tertiary referral center in the management of pre-eclampsia and eclampsia.Thirteen multidisciplinary teams participated in this institutional review board-exempt study. Each group encountered the same scenario that involved a pre-eclamptic parturient who progressed to eclampsia. The participants were unaware of the scenario topic before the drill and that key interventions would be recorded and timed. Seven of 13 groups were randomized to have a cognitive aid available.Twelve of 13 groups attempted to lower the blood pressure; however, only 7 of 12 groups used the correct first-line antihypertensive medication as per the American College of Obstetricians and Gynecologists' guidelines. All groups requested and administered the correct bolus dose of magnesium (4-6 g intravenously). Only 2 of 13 groups took appropriate action to lower the blood pressure to a "safe range" before induction of general anesthesia, and 4 of the 13 anesthesiologists made drug modifications for induction of anesthesia. None of the 7 groups randomized to have a cognitive aid used it.Our results show widespread magnesium sulfate utilization; however, the use of antihypertensive medication is not universally administered in compliance with current guidelines. The importance of blood pressure management to reduce maternal morbidity and mortality in the setting of pre-eclampsia needs to be emphasized. Interestingly, availability of a cognitive aid did not ensure its utilization in this scenario. Findings suggest that for cognitive aids to be effectively used, it is essential that staff has been trained and become familiar with them before an emergent event.
View details for DOI 10.1097/SIH.0000000000000125
View details for PubMedID 26836465
Steps Toward a National Disaster Plan for Obstetrics
OBSTETRICS AND GYNECOLOGY
2014; 124 (1): 154-158
Hospitals play a central role in disasters by receiving an influx of casualties and coordinating medical efforts to manage resources. However, plans have not been fully developed in the event the hospital itself is severely damaged, either from natural disasters like earthquakes or tornados or manmade events such as a massive electrical failure or terrorist attacks. Of particular concern is the limited awareness of the obstetric units' specialized needs in the world of disaster planning. Within the same footprint of any obstetric unit, there exists a large variety of patient acuity and needs including laboring women, postoperative patients, and healthy postpartum patients with their newborns. An obstetric-specific triage method is paramount to accurately assess and rapidly triage patients during a disaster. An example is presented here called OB TRAIN (Obstetric Triage by Resource Allocation for Inpatient). To accomplish a comprehensive obstetric disaster plan, there must be 1) national adoption of a common triage and evacuation language including an effective patient tracking system to avoid maternal-neonatal separation; 2) a stratification of maternity hospital levels of care; and 3) a collaborative network of obstetric hospitals, both regionally and nationally. However, obstetric disaster planning goes beyond evacuation and must include plans for shelter-in-place and surge capacity, all uniquely designed for the obstetric patient. Disasters, manmade or natural, are neither predictable nor preventable, but we can and should prepare for them.
View details for DOI 10.1097/AOG.0000000000000326
View details for Web of Science ID 000337734000022
View details for PubMedID 24901273
The society for obstetric anesthesia and perinatology consensus statement on the management of cardiac arrest in pregnancy.
Anesthesia and analgesia
2014; 118 (5): 1003-1016
This consensus statement was commissioned in 2012 by the Board of Directors of the Society for Obstetric Anesthesia and Perinatology to improve maternal resuscitation by providing health care providers critical information (including point-of-care checklists) and operational strategies relevant to maternal cardiac arrest. The recommendations in this statement were designed to address the challenges of an actual event by emphasizing health care provider education, behavioral/communication strategies, latent systems errors, and periodic testing of performance. This statement also expands on, interprets, and discusses controversial aspects of material covered in the American Heart Association 2010 guidelines.
View details for DOI 10.1213/ANE.0000000000000171
View details for PubMedID 24781570
Multidisciplinary simulation drills improve efficiency of emergency medication retrieval.
Obstetrics and gynecology
2014; 123: 143S-4S
Postpartum hemorrhage resulting from uterine atony is one of the leading causes of maternal morbidity. If initial treatment for atony is unsuccessful, second-line uterotonics must be administered immediately.A retrospective observational study was performed to evaluate barriers to the management of postpartum hemorrhage on our unit. Fourteen multidisciplinary teams participated in postpartum hemorrhage simulation drills. Actions in the labor room and the medication room were video-recorded for analysis. Postsimulation video review revealed multiple system errors delaying the process of obtaining the secondary uterotonics: 1) computer-generated delay in entering the patient's identification; and 2) multiple locations for the three medications. A "postpartum hemorrhage kit" was developed by pharmacy services, which included methylergonovine, carboprost, and misoprostol. All three medications were then placed in the refrigerator in an insulated box. These changes 1) allowed all medications to be removed in a kit in one step; 2) the kit could be retrieved more easily as a result of adjustments made in the identification process; and 3) the foam insulation kept the carboprost cooled as required. The postpartum hemorrhage simulation scenario was repeated to evaluate delivery of uterotonic medications with access to the postpartum hemorrhage kit.After the corrections, time to retrieval of all three uterotonic medications decreased significantly from 2 minutes and 16 seconds before use of the kit to 29 seconds with the kit.Simulated scenarios exposed correctable delays in the retrieval of emergency medications. Simulation drills can be used to detect system errors, improve system processes, and potentially reduce maternal morbidity and mortality.
View details for DOI 10.1097/01.AOG.0000447124.24190.ec
View details for PubMedID 24770020
Oral misoprostol versus vaginal dinoprostone for labor induction in nulliparous women at term.
Journal of perinatology
2014; 34 (2): 95-99
Objective:To compare the efficacy of oral misoprostol to vaginal dinoprostone for labor induction in nulliparous women.Study design:Admissions for labor induction from January 2008 to December 2010 were reviewed. Patients receiving oral misoprostol were compared with those receiving vaginal dinoprostone. The primary outcome was time from induction agent administration to vaginal delivery. Secondary outcomes included vaginal delivery within 24 h, mode of delivery and maternal and fetal outcomes.Result:A total of 680 women were included: 483 (71%) received vaginal dinoprostone and 197 (29%) received oral misoprostol. Women who received oral misoprostol had a shorter interval to vaginal delivery (27.2 vs 21.9 h, P<0.0001) and were more likely to deliver vaginally in <24 h (47% vs 64%, P=0.001). There was no increase in the rate of cesarean delivery or adverse maternal or neonatal outcomes.Conclusion:Labor induction with oral misoprostol resulted in shorter time to vaginal delivery without increased adverse outcomes in nulliparous women.
View details for DOI 10.1038/jp.2013.133
View details for PubMedID 24157494
Moving forward in patient safety: Multidisciplinary team training.
Seminars in perinatology
2013; 37 (3): 146-150
Communication and teamwork deficiencies have been identified as major contributors to poor clinical outcomes in the labor and delivery unit. In response to these findings, multidisciplinary simulation-based team training techniques have developed to focus specifically on skills training for teams. The evidence demonstrates that multidisciplinary simulation-based team training minimizes poor outcomes by perfecting the elusive teamwork skills that cannot be taught in a didactic setting. Multidisciplinary simulation-based team training is also being used to detect latent system errors in existing or new units, to rehearse complicated procedures (surgical dress rehearsal), and to identify knowledge gaps of labor and delivery teams. Multidisciplinary simulation-based team training should be an integral component of ongoing quality-improvement efforts to ultimately produce teams of experts that perform proficiently.
View details for DOI 10.1053/j.semperi.2013.02.004
View details for PubMedID 23721769
Response times for emergency cesarean delivery: use of simulation drills to assess and improve obstetric team performance
JOURNAL OF PERINATOLOGY
2013; 33 (4): 259-263
We documented time to key milestones and determined reasons for transport-related delays during simulated emergency cesarean.Prospective, observational investigation of delivery of care processes by multidisciplinary teams of obstetric providers on the labor and delivery unit at Lucile Packard Children's Hospital, Stanford, CA, USA, during 14 simulated uterine rupture scenarios. The primary outcome measure was the total time from recognition of the emergency (time zero) to that of surgical incision.The median (interquartile range) from time zero until incision was 9 min 27 s (8:55 to 10:27 min:s).In this series of emergency cesarean drills, our teams required approximately nine and a half minutes to move from the labor room to the nearby operating room (OR) and make the surgical incision. Multiple barriers to efficient transport were identified. This study demonstrates the utility of simulation to identify and correct institution-specific barriers that delay transport to the OR and initiation of emergency cesarean delivery.
View details for DOI 10.1038/jp.2012.98
View details for Web of Science ID 000316833300002
View details for PubMedID 22858890
Oral misoprostol vs vaginal dinoprostone for labor induction in nulliparous women at term
MOSBY-ELSEVIER. 2013: S53
View details for DOI 10.1016/j.ajog.2012.10.255
View details for Web of Science ID 000313393500093
Rectus muscle and visceral peritoneum closure at cesarean delivery and intraabdominal adhesions
78th Annual Meeting of the Pacific-Coast-Obstetrical-and-Gynecological-Society
The purpose of this study was to evaluate the effect of the rectus muscle and visceral peritoneum closure at cesarean delivery on adhesions.We performed a secondary analysis of a prospective cohort study of women who underwent first repeat cesarean delivery. Surgeons scored the severity and location of adhesions. Records were abstracted to assess previous surgical techniques.The original cohort included 173 patients. Rectus muscle closure was associated with fewer combined filmy and dense adhesions overall (27.5% vs 46%; P = .04) and fewer dense adhesions overall (17.5% vs 46%; P = .001; adjusted odds ratio, [aOR], 0.24; 95% confidence interval [CI], 0.09-0.65), particularly from fascia to omentum (aOR, 0.08; 95% CI, 0.007-0.82). Visceral peritoneum closure was associated with increased dense fascia-to-omentum adhesions (aOR, 15.78; 95% CI, 1.81-137.24).Closure of the rectus muscles at cesarean delivery may reduce adhesions, and visceral peritoneum closure may increase them. Surgical techniques at cesarean delivery should be assessed independently, because they may have opposite effects on adhesion formation.
View details for DOI 10.1016/j.ajog.2012.02.033
View details for Web of Science ID 000304442900029
View details for PubMedID 22463952
How we treat: transfusion medicine support of obstetric services
2011; 51 (12): 2540-2548
Obstetric services depend on the transfusion service (TS) to provide diagnostic testing and blood component therapy for clinical care pathways.We describe three quality improvement (QI) initiatives implemented to improve TS support of obstetric services.We implemented a pathway for patients requiring an ABO/Rh order for every admission to obstetric services, along with reconciliation of the daily hospital birth manifest and TS umbilical cord log to identify every woman eligible for RhIG. After assessment over 6 months, 21 (1%) of 2041 women lacked an admission ABO/Rh; all subsequently had ABO/Rh determinations. Umbilical cords were missing for eight (0.4%) mothers; four were D- and received RhIG. We developed algorithms for diagnostic blood ordering for patients deemed at "low,"moderate," or "high" risk of blood transfusion. A 27% reduction in total diagnostic test volumes and 24% reduction in charges was documented after compared to before implementation. We analyzed the impact of our massive transfusion protocol (MTP) on blood inventory management for 31 (0.25%) women undergoing 12,945 deliveries, representing 11% of 286 MTPs for all clinical services over a 32-month interval. O- uncrossmatched red blood cells (RBCs) represented 103 (24%) of 421 RBC units issued. Wastage rates of RBCs, plasma, and platelets ordered and issued in the MTPs were 0.7, 16, and 3%, respectively.QI initiatives for RhIG prophylaxis, diagnostic blood test ordering, and MTP improve TS support of obstetric services.
View details for DOI 10.1111/j.1537-2995.2011.03152.x
View details for PubMedID 21542850
Labor Room Setting Compared With the Operating Room for Simulated Perimortem Cesarean Delivery A Randomized Controlled Trial
OBSTETRICS AND GYNECOLOGY
2011; 118 (5): 1090-1094
To compare the labor room and operating room for perimortem cesarean delivery during simulated maternal arrests occurring outside the operating room. We hypothesized transport to the operating room for perimortem cesarean delivery would delay incision and other important resuscitation milestones.We randomized 15 teams composed of obstetricians, nurses, anesthesiologists, and neonatal staff to perform perimortem cesarean delivery in the labor room or operating room. A manikin with an abdominal model overlay was used for simulated cesarean delivery. The scenario began in the labor room with maternal cardiopulmonary arrest and fetal bradycardia. The primary outcome was time to incision. Secondary outcomes included times to important milestones, percentage of tasks completed, and type of incision.The median (interquartile range) times from time zero to incision were 4:25 (3:59-4:50) and 7:53 (7:18-8:57) minutes in the labor room and operating room groups, respectively (P=.004). Fifty-seven percent of labor room teams and 14% of operating room teams achieved delivery within 5 minutes. Contacting the neonatal team, placing the defibrillator, resuming compressions after analysis, and endotracheal intubation all occurred more rapidly in the labor room group.Perimortem cesarean delivery performed in the labor room was significantly faster than perimortem cesarean delivery performed after moving to the operating room. Delivery within 5 minutes was challenging in either location despite optimal study conditions (eg, the manikin was light and easily moved; teams knew the scenario mandated perimortem cesarean delivery and were aware of being timed). Our findings imply that perimortem cesarean delivery during actual arrest would require more than 5 minutes and should be performed in the labor room rather than relocating to the operating room.
View details for DOI 10.1097/AOG.0b013e3182319a08
View details for Web of Science ID 000296292600017
View details for PubMedID 22015877
Do adhesions at repeat cesarean delay delivery of the newborn?
31st Annual Scientific Meeting of the Society-of-Maternal-Fetal-Medicine (SMFM)
We sought to assess whether the presence and severity of adhesions at first repeat cesarean delivery are associated with delayed delivery of the newborn.We conducted secondary analysis of a prospective cohort of women undergoing first repeat cesarean. Severity and location of adhesions were reported by surgeons immediately postoperatively. We compared adhesion density scores with delivery data.Of 145 women analyzed, 92 (63.5%) had adhesions and 53 (36.5%) did not. Mean incision to delivery time in women with adhesion scores >3 was 19.8 minutes, compared to 15.6 minutes with scores ≤ 3 (P = .04). More women with adhesion scores >3 remained undelivered at 30 minutes after incision compared to scores ≤ 3 (17.9% vs 5.1%; odds ratio, 7.6; 95% confidence interval, 1.6-34.5), after controlling for potential confounders.Among women undergoing first repeat cesarean, severity of adhesions may delay delivery of the newborn. Study of techniques to reduce adhesions may be warranted to prevent delayed delivery at repeat cesarean.
View details for DOI 10.1016/j.ajog.2011.06.088
View details for Web of Science ID 000296084600050
View details for PubMedID 21864825
The Case for OBLS: A Simulation-based Obstetric Life Support Program
SEMINARS IN PERINATOLOGY
2011; 35 (2): 74-79
Errors by health care professionals result in significant patient morbidity and mortality, and the labor and delivery ward is one of the highest risk areas in the hospital. Parturients today are of higher acuity than anytime previously, and maternal mortality is increasing. Obstetrical staff must therefore be familiar with emergency protocols geared to the maternal-fetal dyad. However, the medical literature suggests that obstetrical providers are not optimally trained to render care during maternal cardiopulmonary arrest. We describe the evolution of immersive learning and simulation in the Neonatal Resuscitation Program, and suggest the development of a multidisciplinary team, simulation-enhanced obstetric crisis training program (OBLS) may likewise benefit obstetrical health care professionals. OBLS would emphasize high quality basic life support, uterine displacement, use of an automatic external defibrillator, and delivery of the fetus within 5 minutes of maternal arrest should resuscitative efforts prove ineffective.
View details for DOI 10.1053/j.semperi.2011.01.006
View details for PubMedID 21440814
Introduction: Simulation in the Perinatal Environment
SEMINARS IN PERINATOLOGY
2011; 35 (2): 45–46
View details for DOI 10.1053/j.semperi.2011.01.001
View details for Web of Science ID 000289600200001
View details for PubMedID 21440809
Do adhesions at repeat cesarean delay delivery of the newborn?
MOSBY-ELSEVIER. 2011: S267–S268
View details for Web of Science ID 000285927500675
Deficits in the provision of cardiopulmonary resuscitation during simulated obstetric crises
AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY
2010; 203 (2)
Previous work suggests the potential for suboptimal cardiopulmonary resuscitation (CPR) in the parturient but did not directly assess actual performance.We evaluated 18 videotaped simulations of maternal amniotic fluid embolus and resultant cardiac arrest. A checklist containing 10 current American Heart Association recommendations for advanced cardiac life support (ACLS) in obstetric patients was utilized. We evaluated which tasks were completed correctly and the time required to perform key actions.Proper compressions were delivered by our teams 56% of the time and ventilations 50% of the time. Critical interventions such as left uterine displacement and placing a firm back support prior to compressions were frequently neglected (in 44% and 22% of cases, respectively). The mean +/- SD overall composite score for the tasks was 45 +/- 12% (range, 20-60%). The neonatal team was called in a median (interquartile range) of 1:42 (0:44-2:18) minutes:seconds; 15 of 18 (83%) teams called only after the patient was completely unresponsive. Fifty percent of teams did not provide basic information to the neonatal teams as required by neonatal resuscitation provider guidelines.Multiple deficits were noted in the provision of CPR to parturients during simulated arrests, despite current ACLS certification for all participants. Current requirements for ACLS certification and training for obstetric staff may require revision.
View details for DOI 10.1016/j.ajog.2010.02.022
View details for Web of Science ID 000280234500037
View details for PubMedID 20417476
Single- versus double-layer hysterotomy closure at primary caesarean delivery and bladder adhesions
BJOG-AN INTERNATIONAL JOURNAL OF OBSTETRICS AND GYNAECOLOGY
2010; 117 (6): 690-694
To determine the association between single-layer (one running suture) and double-layer (second layer or imbricating suture) hysterotomy closure at primary caesarean delivery and subsequent adhesion formation.A secondary analysis from a prospective cohort study of women undergoing first repeat caesarean section.Department of Obstetrics and Gynecology, Stanford University, Stanford, CA, USA.One hundred and twenty-seven pregnant women undergoing first repeat caesarean section.Patient records were reviewed to identify whether primary caesarean hysterotomies were closed with a single or double layer. Data were analysed by Fisher's exact tests and multivariable logistic regression.Prevalence rate of pelvic and abdominal adhesions.Of the 127 women, primary hysterotomy closure was single layer in 56 and double layer in 71. Single-layer hysterotomy closure was associated with bladder adhesions at the time of repeat caesarean (24% versus 7%, P = 0.01). Single-layer closure was associated in this study with a seven-fold increase in the odds of developing bladder adhesions (odds ratio, 6.96; 95% confidence interval, 1.72-28.1), regardless of other surgical techniques, previous labour, infection and age over 35 years. There was no association between single-layer closure and other pelvic or abdominal adhesions.Primary single-layer hysterotomy closure may be associated with more frequent bladder adhesions during repeat caesarean deliveries. The severity and clinical implications of these adhesions should be assessed in large prospective trials.
View details for DOI 10.1111/j.1471-0528.2010.02529.x
View details for Web of Science ID 000276509100007
View details for PubMedID 20236104
Prospective Randomized Trial of Simulation Versus Didactic Teaching for Obstetrical Emergencies
Joint Annual Meeting of the Association-of-Professors-of-Gynecology-and-Obstetrics/Council-on-Resident-Education-in-Obstetrics-and-Gynecology
LIPPINCOTT WILLIAMS & WILKINS. 2010: 40–45
The objective of this study was to determine whether simulation was more effective than traditional didactic instruction to train crisis management skills to labor and delivery teams.Participants were nurses and obstetric residents (<5 years experience). Both groups were taught management for shoulder dystocia and eclampsia. The simulation group received 3 hours of training in a simulation laboratory, the didactic group received 3 hours of lectures/video and hands-on demonstration. Subjects completed a multiple-choice questionnaire before training and before testing. After 1 month, all teams underwent performance testing as a labor and delivery drill. All drills were video recorded. Team performances were scored by a blinded reviewer using the video recordings and an expert-developed checklist. The data were analyzed using independent samples Student t test and analysis of variance (one way). P value of < or =0.05 was considered to be statistically significant.There was no statistical difference found between the groups on the pretraining and pretesting multiple-choice questionnaire scores. Performance testing performed as a labor and delivery drill showed statistically significant higher scores for the simulation-trained group for both shoulder dystocia (Sim = 11.75, Did = 6.88, P = 0.002) and eclampsia management (Sim = 13.25, Did = 11.38, P = 0.032).In an academic training program, didactic and simulation-trained groups showed equal results on written test scores. Simulation-trained teams had superior performance scores when tested in a labor and delivery drill. Simulation should be used to enhance obstetrical emergency training in resident education.
View details for DOI 10.1097/SIH.0b013e3181b65f22
View details for Web of Science ID 000276077900009
View details for PubMedID 20383090
Use of Simulation Based Team Training for Obstetric Crises in Resident Education
SIMULATION IN HEALTHCARE
2008; 3 (3): 154-160
Obstetric crises are unexpected and random. Traditionally, medical training for these acute events has included lectures combined with arbitrary clinical experiences. This educational paradigm has inherent limitations. During actual crises insufficient time exists for discussion and analysis of patient care. Our objective was to create a simulation program to fill this experiential gap.Ten L&D teams participated in high fidelity simulation training. A team consisted of two or three nurses, one anesthesia resident and one or two obstetric residents. Each team participated in two scenarios; epidural-induced hypotension followed by an amniotic fluid embolism. Each simulation was followed by a facilitated debriefing. All simulations were videotaped. Clinical performances of the obstetric residents were graded by two reviewers using the videotapes and a faculty-developed checklist. Recurrent errors were analyzed and graded using Health Failure Modes Effects Analysis. All team members completed a course evaluation.Performance deficiencies of the obstetric residents were identified by an expert team of reviewers. From this list of errors, the "most valuable lessons" requiring further focused teaching were identified and included 1) Poor communication with the pediatric team, 2) Not assuming a leadership role during the code, 3) Poor distribution of workload, and 4) Lack of proper use of low/outlet forceps. Participants reported the simulation course allowed them to learn new skills needed by teams during a crisis.Simulated obstetric crises training offers the opportunity for educators to identify specific performance deficits of their residents and the subsequent development of teaching modules to address these weaknesses.
View details for DOI 10.1097/SIH.0b013e31818187d9
View details for Web of Science ID 000207536200005
View details for PubMedID 19088659
Antibiotic prophylaxis for prevention of postpartum perineal wound complications - A randomized controlled trial
27th Annual Meeting of the Society-of-Maternal-Fetal-Medicine
LIPPINCOTT WILLIAMS & WILKINS. 2008: 1268–73
To estimate whether prophylactic antibiotics at the time of repair of third- or fourth-degree perineal tears after vaginal delivery prevent wound infection and breakdown.This was a prospective, randomized, placebo-controlled study. Patients who sustained third- or fourth-degree perineal tears after a vaginal delivery were recruited for the study. Each patient was given a single intravenous dose of a second-generation cephalosporin (cefotetan or cefoxitin) or placebo before repair of third- or fourth-degree perineal tears. Obstetricians and patients were blinded to study drug. The perineum was inspected for evidence of infection or breakdown at discharge from the hospital and at 2 weeks postpartum. Primary end points were gross disruption or purulent discharge at site of perineal repair by 2 weeks postpartum.One hundred forty-seven patients were recruited for the study. Of these, 83 patients received placebo and 64 patients received antibiotics. Forty patients (27.2%) did not return for their 2-week appointment. Of the patients seen at 2 weeks postpartum, 4 of 49 (8.2%) patients who received antibiotics and 14 of 58 (24.1%) patients who received placebo developed a perineal wound complication (P=.037). There were no differences between groups in parity, incidence of diabetes, operative delivery, or third-degree compared with fourth-degree lacerations.By 2 weeks postpartum, patients who received prophylactic antibiotics at the time of third- or fourth-degree laceration repair had a lower rate of perineal wound complications than patients who received placebo.ClinicalTrials.gov, www.clincaltrials.gov, NCT00186082.I.
View details for Web of Science ID 000256191400003
View details for PubMedID 18515507
Single- vs. double-layer uterine incision closure at primary cesarean section and adhesion formation
MOSBY-ELSEVIER. 2007: S77
View details for DOI 10.1016/a.ajog.2007.10.249
View details for Web of Science ID 000251708500235
Cesarean delivery outcomes after a prolonged second stage of labor
27th Annual Meeting of the Society-of-Maternal-Fetal-Medicine
We hypothesized that prolonged second stage of labor increases the incidence of unintentional hysterotomy extensions at cesarean delivery.A retrospective cohort of term pregnant women who underwent primary cesarean delivery after failed second stage of labor at Stanford University was assessed for hysterotomy extensions and other maternal and neonatal morbidities. Groups included second stage length of 1-3 hours and >4 hours. Data were analyzed with the use of chi-square and Fisher's exact tests.Of the 239 women who were studied, the second stage of labor lasted 1-3 hours in 82 patients and >4 hours in 157 patients. Prolonged second stage of labor was associated with unintentional hysterotomy extensions (40% vs 26%; P = .03), particularly to the cervix (29% vs 5%; P = .005), and with surgery that lasted >90 minutes (9% vs 1%; P = .01). The incidence of hysterotomy extensions was associated positively with the length of the second stage. Other maternal and neonatal morbidities were similar between groups.Prolonged second stage of labor is associated with an increase in unintentional hysterotomy extensions at cesarean delivery and prolonged operative time. The future risk of hysterotomy extensions merits further investigation.
View details for DOI 10.1016/j.ajog.2007.07.005
View details for PubMedID 17826431
Use of a community mobile health van to increase early access to prenatal care
MATERNAL AND CHILD HEALTH JOURNAL
2007; 11 (3): 235-239
To examine whether the use of a community mobile health van (the Lucile Packard Childrens Hospital Women's Health Van) in an underserved population allows for earlier access to prenatal care and increased rate of adequate prenatal care, as compared to prenatal care initiated in community clinics.We studied 108 patients who initiated prenatal care on the van and delivered their babies at our University Hospital from September 1999 to July 2004. One hundred and twenty-seven patients who initiated prenatal care in sites other than the Women's Health Van, had the same city of residence and source of payment as the study group, and also delivered their babies at our hospital during the same time period, were selected as the comparison group. Gestational age at which prenatal care was initiated and the adequacy of prenatal care - as defined by Revised Graduated Index of Prenatal Care Utilization (RGINDEX) - were compared between cases and comparisons.Underserved women utilizing the van services for prenatal care initiated care three weeks earlier than women using other services (10.2 +/- 6.9 weeks vs. 13.2 +/- 6.9 weeks, P = 0.001). In addition, the data showed that van patients and non-van patients were equally likely to receive adequate prenatal care as defined by R-GINDEX (P = 0.125).Women who initiated prenatal care on the Women's Health Van achieved earlier access to prenatal care when compared to women initiating care at other community health clinics.
View details for DOI 10.1007/s10995-006-0174-z
View details for Web of Science ID 000246578900005
View details for PubMedID 17243022
Maximized learning in limited time: Using health failure modes effects analysis (HFMEA) in simulated obstetric crisis drills poor communication is the highest ranking team deficiency
39th Annual Meeting of the Society-for-Obstetric-Anesthesia-and-Perinatology
LIPPINCOTT WILLIAMS & WILKINS. 2007: B13–B13
View details for Web of Science ID 000246032500049
Cesarean delivery outcomes following prolonged second stage
27th Annual Meeting of the Society-of-Maternal-Fetal-Medicine
MOSBY-ELSEVIER. 2006: S101–S101
View details for DOI 10.1016/j.ajog.2006.10.333
View details for Web of Science ID 000242834500304
Prophylactic antibiotics for prevention of postpartum perineal wound complications
MOSBY-ELSEVIER. 2006: S49
View details for DOI 10.1016/j.ajog.2006.10.141
View details for Web of Science ID 000242834500126
Perinatal outcomes among Asian American and Pacific Islander women
26th Annual Meeting of the Society-for-Maternal-Fetal-Medicine
MOSBY-ELSEVIER. 2006: 834–38
The purpose of this study was to examine perinatal outcomes between Asian American and Pacific Islander subgroups.This is a retrospective study of all Asian American/Pacific Islander women who were delivered at Stanford University Medical Center from 1998 to 2003. Asian American women were subdivided into the following groups: Indian/Pakistani, Chinese, Filipino, Japanese, Korean, Pacific Islanders (individuals from Tonga, Samoa, Guam, or Polynesia), and Vietnamese. Perinatal outcomes included gestational hypertension/preeclampsia, gestational diabetes mellitus, preterm delivery, cesarean delivery, birthweight <2500 g, and birthweight >4000 g.In the study population of 3779 Asian American women, there were statistically significant differences (P < .01) between most of the outcomes that were examined. Filipina women had the highest risk of gestational hypertension/preeclampsia (adjusted odds ratio, 2.21); Indian/Pakistani women had the highest risk of preterm delivery (adjusted odds ratio, 1.67), gestational diabetes mellitus (adjusted odds ratio, 1.39), and low birthweight at term (adjusted odds ratio, 2.30); and Pacific Islander women had the highest risk of macrosomia (adjusted odds ratio, 3.67).Significant differences in perinatal outcomes exist between subgroups of the Asian American and Pacific Islander community. Future research on race/ethnicity and perinatal outcomes should examine heterogeneity among these groups before collapsing these individual subgroups into the larger group "Asian." Individuals should be counseled regarding perinatal risk according to their specific Asian subgroup.
View details for DOI 10.1016/j.ajog.2006.06.079
View details for Web of Science ID 000240473500031
View details for PubMedID 16949421
Perinatal outcomes among Asian Americans/Pacific islanders
26th Annual Meeting of the Society-for-Maternal-Fetal-Medicine
MOSBY-ELSEVIER. 2005: S182–S182
View details for Web of Science ID 000233947800639
Peritoneal closure at primary cesarean delivery and adhesions
24th Annual Meeting of the Society-for-Maternal-Fetal-Medicine
LIPPINCOTT WILLIAMS & WILKINS. 2005: 275–80
To evaluate the effect of parietal peritoneal closure at cesarean delivery on adhesion formation.A prospective cohort study of women undergoing first repeat cesarean delivery was designed. All surgeons were asked immediately after surgery to score the severity and location of adhesions. Patient records were then abstracted to assess prior surgical technique, including parietal peritoneal closure, other attributes of first surgery, and patient characteristics. Exclusion criteria included adhesions, other surgery, or use of permanent suture at the first cesarean, unavailable first postoperative note and course, wound infection or breakdown following first surgery, intervening pelvic surgery, insulin-dependent diabetes mellitus, and steroid-dependent disease. The chi2 test and multivariable logistic regression were used for statistical comparison and analysis. A total of 128 patients was required to have 80% power to detect a 50% reduction in adhesions when the parietal peritoneum was left open.One hundred seventy-three patients were enrolled. Prior parietal peritoneal closure was associated with significantly fewer dense and filmy adhesions (52% versus 73%, P = .006) and significantly fewer dense adhesions (30% versus 45%, P = .043). When controlling for potential confounding variables, including prior infection, visceral peritoneal closure, rectus muscle closure, payor status, ethnicity, maternal age, gestational diabetes, and labor, parietal peritoneal closure at primary cesarean delivery was 5-fold protective against all adhesions (odds ratio 0.20, 95% confidence interval 0.08-0.49), and 3-fold protective against dense adhesions (odds ratio 0.32, 95% confidence interval 0.13-0.79). Omental-fascial adhesions were decreased most consistently.Parietal peritoneal closure at primary cesarean delivery was associated with significantly fewer dense and filmy adhesions. The practice of nonclosure of the parietal peritoneum at cesarean delivery should be questioned.
View details for Web of Science ID 000230717800010
View details for PubMedID 16055575
Peritoneal closure at primary cesarean section decreases adhesion formation
MOSBY, INC. 2003: S61
View details for DOI 10.1016/j.ajog.2003.10.016
View details for Web of Science ID 000187910500018