Abstract
Résumé
Key Words
- Calder L
- Bowman C
- De Gorter R
- et al.
Knowledge gaps | Promising interventions | Barriers to spread | Opportunities for spread |
---|---|---|---|
• Lack of national and provincial-level data • Lack of high-level evidence for which aspects of processes are most closely linked to morbidity or mortality | • Standardized booking processes • Evidence-based oxytocin protocols and checklists • Checklist and protocol adherence audits and feedback relating to quality clinical and process outcomes | • Perceived wide variation in practice across and within institutions • Lack of appropriate standardization, including appropriate incentives, could affect success • Lack of a network within and between provinces to facilitate uptake of accepted national protocols | • SOGC could coordinate a national approach for protocols to standardize booking processes and oxytocin usage • Regional best practices exist for standardized oxytocin protocols and checklists |
Knowledge gaps | Promising interventions | Barriers to spread | Opportunities for spread |
---|---|---|---|
• Lack of clear evidence on when to use vacuum versus forceps • Lack of standardized protocols for the “double set-up” allowing access to prompt Caesarean section | • Procedural and team checklists • Simulation of assisted vaginal delivery technical and non-technical skills • Checklist and protocol adherence audits and feedback relating to quality clinical and process outcomes • Mentoring and coaching of less experienced providers | • Regional variation in uptake of MOREOB and ALARM • Lack of consistent training on vacuum and forceps across health care providers | • Competence by Design could evaluate the adequacy of current training and create continuing professional development curricula for infrequently performed skills beyond residency |
Knowledge gaps | Promising interventions | Barriers to spread | Opportunities for spread |
---|---|---|---|
• Lack of standard definition of shoulder dystocia • Lack of common language to identify priorities and urgency of Caesarean section • Lack of consistent anticipation and management of this clinical event • Lack of consistent documentation • Lack of national clinical practice guidelines | • Simulation of shoulder dystocia management including emergency team responses • Procedural and team communication checklists • Debriefing skills for use in clinical practice • Antenatal patient education tools and shared decision-making guides | • Lack of mechanisms such as communities of practice to enable high-level knowledge sharing • Lack of appropriate incentives for broad interprofessional participation in training and/or drills • Variable access to effective simulation models that provide real-time skills feedback • Lack of consistent learning culture to facilitate knowledge sharing, reflective practice, and critical incident debriefing | • SOGC could facilitate broader acceptance of national clinical practice guidelines |
Knowledge gaps | Promising interventions | Barriers to spread | Opportunities for spread |
---|---|---|---|
• Lack of standardized terminology for processes and outcomes • Lack of communication protocols clearly identifying the level of urgency of Caesarean section to the necessary physician, staff, and support teams • Lack of meaningful measures | • Structured emergency team response systems • Interprofessional communication training • Standardizing nomenclature, measuring and reporting on process adherence | • Perceived lack of trust among disciplines • Lack of effective structured communication mechanisms • Conflicting priorities for management of urgent surgical cases in each institution | • Best practices currently existfor operating room prioritization and team communication |
Knowledge gaps | Promising interventions | Barriers to spread | Opportunities for spread |
---|---|---|---|
• Lack of appropriate definitions • Lack of meaningful measures | • Interprofessional team communication simulation training • Structured handover communication processes • Shared care roles including most responsible provider clearly defined and documented • Structured morbidity and mortality rounds and/or patient safety rounds • Team communication audit and feedback | • Electronic and paper health record hybrids can impede effective collaborative care • Workplace culture issues affecting shared team situational awareness and speaking up • Current privacy legislation can inhibit information sharing across teams | • Best practices currently exist for structured handover tools • Experienced sites could share positive implementation experiences |
Topic | Recommendations and strategies |
---|---|
Induction and augmentation of labour | • Regional health systems should enable the collection of data on current practices to identify the most impactful parts of induction processes on the quality of care. • Create a national oxytocin protocol and implementation package to ensure appropriate patients are induced and appropriate oxytocin doses are used. Implementation should include education of patients, families, and providers. • Link implementation efforts in this area to quality improvement initiatives targeting fetal health surveillance training, labour support, and structured handover processes. • Use audit and feedback to measure impact of implementation at local and regional levels. |
Assisted vaginal delivery | • Standardize continuing professional development goals beyond residency at a national level. • Encourage implementation of assisted vaginal delivery checklists and use of simulation to practise technical and non-technical skills, including acquisition and maintenance of situational awareness. • Implement plans with attention to workplace culture, engagement of opinion leaders, and appropriate incentives. • Develop mentorship models to facilitate consistency in approaches to assisted vaginal delivery. • Develop benchmarking tools to measure impact of implementation of assisted vaginal delivery checklists. |
Shoulder dystocia | • Develop a clear definition of shoulder dystocia and consensus on unsafe acts. • Emphasize consistent drills, especially in the first 5years of practice. • Engage in simulation as a tool to clarify team roles and responsibilities when managing shoulder dystocia. • Develop methods of creating mobile simulation units that can facilitate shoulder dystocia training by sharing tools and scenarios. |
Decision to delivery time for Caesarean section | • Develop standardized terminology and measures for high quality decisions to delivery time for Caesarean section. • Set a national standard that all institutions have a plan and policy for emergency response to Caesarean section. • Incorporate structured team communication tools into implementation plans to enhance team situational awareness for improving decisions to delivery time for Caesarean section (e.g., team huddles, structured handover). |
Collaborative care | • Create national guidelines on a clearly defined most responsible provider role, consultation standards, and structured team communication tools to support collaborative care in obstetrics. • Engage in shared interprofessional fetal health surveillance training, and use the opportunity to address safety culture issues and practise speaking up. |
INTRAPARTUM FETAL SURVEILLANCE
OVERARCHING THEMES

CONCLUSION
Acknowledgements
REFERENCES
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- A systematic review of quality improvement interventions in labour and delivery.PROSPERO. 2016; (CRD42016052118Available at:)http://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD42016052118Date accessed: November 8, 2018
- Perinatal death and hypoxic injury in Canada: can we reduce the incidence?.J Obstet Gynaecol Can. 2017; 39: 965-967
Each baby counts: 2015 full report. London: Royal College of Obstetricians and Gynaecologists; 2017.
Delivery in focus: strengthening obstetrical care in Canada. Ottawa: Healthcare Insurance Reciprocal of Canada and the Canadian Medical Protective Association; 2018.
- Practice feedback interventions: 15 suggestions for optimizing effectiveness.Ann Intern Med. 2016; 164: 435-441
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Competing interests: The authors declare that they have no competing interests. Each author has indicated that they meet the journal's requirements for authorship.
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