Transcript: Who, What ,Why? When, How, Where Who Actually Mandates these Core Measures? Purpose of Core Measure THANK YOU! Martin McCaffrey, MD Associate Professor Division of Neonatal-Perinatal Medicine UNC North Carolina Children’s Hospital Newborn Critical Care Center Janet H. Muri, MBA President National Perinatal Information Center/ Quality Analytic Services Patrick Romano, MD, MPH, FACP, FAAP Professor of Medicine and Pediatrics UC Davis School of Medicine, center for healthcare Policy Research Mark Tomlinson, MD Regional Obstetric Medical Director Providence Health System -The data is collected every time there is a live nulliparous term singleton vertex delivery (first time moms with single baby who is head down at term). -Indicator= Nulliparous, term singleton vertex cesarean births / All live nulliparous term singleton vertex delieveries WHERE these measure(s) must be in place In 2008 the National Quality Forum launched a perinatal care project in which incuded the "National Voluntary Consensus Standards for Perinatal Care." This Consensus listed 17 measures which included Cesarean section's rates in low-risk mothers. These measures were reviewed by the Joint Commision the same year and 5 of the measures were adopted as Core measures including the C-section rates. Those core measures were ready for hospital use by late 2009 and data was collected by early 2010. By late 2012 the Joint Commission made that set of perinatal core measures mandatory for hospitals. Dekker, R. (2013, January 23). U.S. Hospitals Held Accountable for C-Section Rates ImprovingBirth. Retrieved November 4, 2015. First-Birth Term Cesareans. (n.d.). Retrieved November 3, 2015. from http://health.usf.edu/Nr/rdoniyres/7D7FD0FF. Lennon, J., & Seaver, D. (2014). A Collaborative Practice Initiative to Reduce the Rate of Cesarean Deliveries: The Vaginal Delivery Optimization Team. JOGNN: Journal Of Obstetric, Gynecologic & Neonatal Nursing, 43(Supp 1), S20-1 1p. doi:10.1111/1552-6909.12413 Lowdermilk, D. (n.d.). Maternity & women's health care (11th ed.). National Voluntary Consensus Standards for Perinatal Care 2008. (2009). Vi-1. from http://www.qualityforum.org/Publications/2009/05/National_Voluntary_Consensus_Standards_for_Perinatal_Care_2008.aspx Packer-Tursman, J. (2015). What's working to lower the primary cesarean rate?. Contemporary OB/GYN, 60(4), 36-39 4p QUESTIONS AND ANSWERS: The Perinatal Care Core Measure Set. (2013). How Does The Joint Commission Use Information about Accountability Measures?, 33(11), 12-14. Retrieved November 4, 2015, from http://www.jointcommission.org/assets/1/6/S11.pdf To decrease the skyrocketing rates To improve performance To decrease adverse outcomes associated with cesarian delivery such as: Infection Longer Hospital Stay Increased Maternal Morbidity Prolonged Pain Blood Clots Adhesions Hemorrhage Emergency Hysterectomy (rare) Increase in ceasearean deliveries caused an increase in accreta. Placenta accreta- placenta grows too deeply into uterine wall, therefore it may not all come out after delivery. It is the primary cause of emergency hysterectomy Placenta accreta may cause: Massive Hemmorhage Heavy Bleeding Premature Birth C-Section rates have increased due to induction of labor. South Carolina BlueSheild BlueCross focus: Education Practice guidelines Safe ways to manage births -Exclusion: Multiple gestations, less than 8 years of age, greater than or equal to 65 years of age, length of stay > than 120 days, enrolled in clinical trial, and gestational age less than 37 weeks or unable to determine (First-Birth). There is no true "punishment" if the core measurement is not met. The hospital will not loose it's accreditation because there is no specific set rate that every hospital has to reduce their number of cesarean sections too. The goal of the cesarean section core measurement is to reduce the number of c-section rates according to what the hospitals rates are normally for c-sections. This core measure is a way to put pressure on the hospitals and encourage them to monitor, report, and evaluate their cesarean section rates. In late 2007, The Joint Commission’s Board of Commissioners recommended retiring and replacing the Pregnancy and Related Conditions (PR) measure set with an expanded set of evidenced-based measures (PC). Such as the one we are looking at today! "Perinatal Care- 02 - Cesarian section" or (pc-02) Was started and first researched by the the "California Maternal Quality Care Collabrative". Cesarean Section by: Kristen Balboni, Kayla Blackmon, Elliott Corder, Mallory Morrison, Nancy Vega Michael Ross, MD, MPH (Chair) Professor of Ob/Gyn and Public Health Geffen School of Medicine at UCLA and UCLA School of Public Health Debra Bingham, DrPH, RN, LCCE Vice President of Research, Education, and Publications Association of Women's Health, Obstetric & Neonatal Nurses (AWHONN) Steven L. Clark, MD Professor Baylor College of Medicine, Texas Children’s Hospital James T. Christmas, MD Medical
Transcript: Risks (cont.) recovery takes longer than natural birth may cause problems with future pregnancies infant may acquire breathing problems increased chance of infection in mother possible anesthetic complications may delay initiation of breast feeding increased risk of hemorrhage and hysterectomy What makes a candidate? What is it? commonly known as C-Section fetus is delivered through an incision in the mother's abdomen and uterus 33% of births are C-sections more than one child labor complications health of infant is in danger fetus is too large breech birth mother has HIV, herpes, or infection problems with placenta Pre-eclampsia gets the baby out of the mother The Nitty Gritties Jacqueline Kennedy What does it do/ fix? Barrier, Breton. "Basic Primary Cesarean Delivery Video." Vimeo. 2012. Web. 11 May 2016. "Caesarean Birth: What Are the Risks and Benefits?" BabyCentre. Web. 11 May 2016. "C-Sections: Recovery, Risks, Benefits, Pain, and More." WebMD. WebMD. Web. 11 May 2016. "The Advantages of Caesarean Sections." Mail Online. Associated Newspapers. Web. 11 May 2016. "Vaginal Birth vs. C-Section: Pros & Cons." LiveScience. TechMedia Network. Web. 11 May 2016. "What Is a Cesarean Delivery?" What Is a Cesarean Delivery? Web. 11 May 2016. knowledge of the birth date no contractions or pain between vagina and back passage reduces stress of vaginal birth reduces birth trauma to baby health care providers encourage C-Section because of the fewer complications than during a natural birth Benefits of a C-Section: Citations may become harder to get pregnant again damage to surrounding organs after first C-Section, all other births will most likely be C-Sections mother cannot drive for 2 weeks, exercise for 4-6 weeks, have sex for 6 weeks, or carry anything heavier than baby blood clots adhesion that makes organs in the stomach stick Type of Doctor: Obstetrician or family doctor Location: Emergency room or surgical room After procedure: 3 days in hospital, perfect posture, rest, pain medication Cesarean Section Risks
Transcript: Cesarean Section Surgical delivery of a baby through an incision into the abdominal and uterine walls. Also called a C-Section Legend says that it was named after the Roman emperor, Julius Caesar because he was the first person born this way. Another theory on how it came to be called this is coming from the Latin word Caedere meaning "to cut" The most common reasons for getting C-Sections are: routine repeat cesareans; dystocia; breech presentation; and fetal distress. There are many medical risks to mothers when they get C-Sections. http://www.childbirth.org/section/CSFact.html http://www.natural-pregnancy-mentor.com/history-of-cesarean-section.html http://www.aurorahealthcare.org/yourhealth/healthgate/getcontent.asp?URLhealthgate=%2214798.html%22 From 1970 to today the percentage has increased in women getting a C-Section from 5% to 28%
Transcript: Left Paralumbar Fossa Procedure Vertical skin incision made in middle of left flank between lignocaine block 30-40 cm long Muscle layers incised: Cutaneous External abdominal oblique Sharply incised with scalpel in same direction Internal abdominal oblique Sharply incised with scalpel in same direction Hemorrhage is minimal; however, ligate vessel with hemostats if necessary Transverse abdominal Split vertically with blunt scissors Peritoneum cut at dorsal aspect of incision using blunt-tipped scissors Reduces risk of cutting abdominal organs Hind limbs situated in tip of pregnant horn One or both hind limbs anchored in incision Holds uterine horn outside the abdomen Located digits, then move to hocks on both limbs Grasp digits whilst holding onto hocks then pull digits into incision Uterine horn should not be grasped without including calfs limbs May tear uterus Expose the uterus before incising the wall Infection Tocolytic used to help with myometrium contractions Left Paralumbar Fossa Procedure Real Life Case THANK YOU! Incise over calf's legs Greater curvature of uterine horn Fewest large blood vessels Large enough to remove calf Don't get too close to cervix Don't make it too small Be careful of caruncles Hemorrhage Amnion & allantochorion ruptured manually Fetlocks grasped and exteriorised Rope and chains attached to hind limbs Tech with help pull out Dorsolateral direction Uterus still held out by surgeon Live calf attended by tech Surgeon examines uterus Lacerations repaired Tech will dry calf and naval dress with antiseptic immediately 2-3 L colostrum fed if necessary Dam should be introduced properly Care for calf as normally would be cared for It is also important to consider... Equipment Preparation Abdominal cavity is explored to identify uterus Uterine tone and position of calf noted Tip of pregnant horn is located Lower left quadrant of abdomen Close to flank incision Sterile drapes applied Large single drape with window Alternative would be a plastic film Ideally, surgeons and assistants wear scrub suits Clean and disinfected apron If not, arms should be scrubbed Up to arm pit There are several ways to do a cesarean section. I will be discussing how to do a standing left paralumbar approach. Teats inspected Oxytocin IM Stimulate uterine contractions to expel placenta if not done already Calcium borogluconate IV to mature dairy cows Prevent hypocalcaemia Facilitate uterine involution Indications Cesarean Section on a Cow The Dam Aftercare Pre-operative antibiotics recommended Line block of 2% lignocaine Various points Dirt and dust brushed away from incision site Left paralumbar region is clipped Scrubbed 4% chlorhexidene gluconate solution Followed by surgical spirit Name: Alexandria Glass Works Cited Turner and Mcllwraith's Techniques in Large Animal Surgery. "Cesarean Section in the Cow." Page 258-265. January 2015. Supplement for the 2nd ISVS & 7th ISVSAR. 2008. "Cesarean Section." Page 4-17. February 2015. ACVS. "Cesarean Section in Cattle." https://www.acvs.org/large-animal/cesarean-section-cattle February 2015. "Cesarean Section in Cow." URL imbedded. GOAL 2% Lignocaine 18 gauge needle 2.5 inches Suture Tapered needle General surgery pack Clippers Surgical Scrub Long sleeved plastic gloves Calf in Anterior Presentation Closing Flank Incision Fetal oversize Pelvic inlet too small Deformities of maternal pelvis Fetal monsters Hardening of fibrous tissue of the cervix Allantois Outgrowth of embryos guts Uterine torsion Pregnancy toxemia Depression Lethargy Fetal malposition Live calf not delivered 15-20 mins of manipulation Skin closed with simple interrupted horizontal mattress or cruciate pattern Cutting needle and non-absorbable suture Moderate tension applied to bring together Continuous suture pattern not recommended Entire suture line could come undone Preparation The Calf Degree varies Depends on surgery Dam confined for several days Close observation Peritonitis Reduce chance of trauma Wound dehiscence NSAID for cows with pain Fluid therapy if shock indicated Systemic antimicrobial therapy Most common bacteria present in post-partum uterus 3-5 days Re-examined 24-48 hrs after surgery Temperature, demeanor, appetite, and fecal consistency Feces often dry and mildly constipated after surgery Watch for signs of peritonitis Skin sutures removed no sooner than 3 weeks after Post-natal examination of genital tract Insemination delayed for no less than 60 days post-partum -Value of the cow -Value of the calf -Importance of future cow's fertility -Most common technique -Most appropriate for standing animal Left Paralumbar Fossa Approach Closing Flank Incision Calf in Anterior Presentation 1. Limit contamination of the peritoneal cavity Better chance of cows survival Better chance of being rebred 2. Exteriorize the uterus Limits peritoneal contamination Prevents peritonitis Should be closed as quickly as possible Reduces chance of bacterial contamination Discretion of surgeon Abdominal
Transcript: Use of daytime services when hospital resources are optimal The ability to plan and prepare for the event. LUSCS Relative: “Non-Absolute” Fetal death Major malformations Maternal cardiac diseases Coagulapathy Scheduled too early resulting in premature or compromised delivery. Prenatal testing mitigates this risk. Recently: the rate has risen to a record level of 46% in China and to levels of 25% and above in many Asian, European and Latin American countries. In 2007, in the United States, the Caesarean section rate was 31.8%. Across Europe, there are significant differences between countries: in Italy the Caesarean section rate is 40%, while in the Nordic countries it is only 14%. Eslam Samy Zaki Eslam Farid Abo Shady Eslam Magdy Eslam Fayez Eslam Habeeb Eslam Mohamed Mahmoud Eman Elsayed Eman Helmy Eman Gamal Eman Khaled Eman Reyad Eman Talaat Eman Adel Eman Ali Eman Abdelaaty Eman Fathy Eman Magdy Eman Mohammed Technique Elective Caesarean sections Indications A surgical procedure in which one or more incisions are made through abdominal incision (laparotomy) and uterus (hysterotomy) to deliver one or more babies, or, rarely, to remove a dead fetus. Before fetal viability (28 weeks) : hysterotomy Abdominal pregnancy or after rupture of uterus: Laparotmy Timing: Classical type May be: Absolute: (No other alternative) severe CPD, Placenta Praevia centralis. Relative: (Vaginal delivery may take place but CS is safer) An ''emergency Caesarean!!! A ''crash Caesarean section'‘!!! A ''Caesarean hysterectomy'‘!!! Technique Incidence 1. Scar on the uterus can lead to rupture during next pregnancy 2. If placenta is implanted on scar the risk of rupture is increased 3. Abdominal scar leads to incisional hernia Technique Cesarean Section Others Placenta and umbilical cord: placenta previa, vasa previa, placental abruption with fetal compromise, umbilical cord prolapse, umbilical cord presenting Pelvic: anatomic abnormality preventing vaginal delivery, pelvic mass obstructing the birth canal (e.g., adnexal mass, uterine myoma), history of complicated maternal birth injury (e.g., fourth-degree laceration, rectovaginal fistula), history of pelvic reconstructive surgery Uterine: previously scarred uterus (e.g., vertical uterine incision, prior myomectomy involving the uterine cavity) Advantages Such planned caesarean sections are performed for many reasons Including history of previous caesarean section. Placenta previa. Abnormal presentations. Multiple pregnancy. known obstructions of labor. Medical conditions (such as heart disease& pre-eclampsia). Advantages of LSCS over classical caesarean section: 1)Stronger scar ( ruptures only in 0.2 % ) . 2) Less haemorrhage . 3)Less infection . 4) Less abdominal distension and ileus . 5)Less adhesions and intestinal obstruction . 6) Less mortality rate . Late Complications: Disadvantages Disadvantages of LSCS: Technique Indications Contraindications: Technique Elective (planned) :before onset of labor pains. Selective (emergency) :during labor. Other Types Complication of LSCS Technique Types Presented By Def: Indications This incidence is increasing due to: Repeated CS (malpractice) CPD (more diagnosed by partogram Breech delivery 1. Injury to bladder or ureter 2. Profuse bleeding due to lateral extension of incision 3. Time consuming and difficult 4. In case of a large fetus and limited space, delivery may be difficult
Transcript: Cesarean Section Click to edit text Analysis of Health Problem Topic 1 you would need this procedure to prevent health problems that the mother might carry Why would you need this procedure? It may prevent the baby to carry on diseases that the mother might carry like high blood pressure or diabetes What health problem does is solve or prevent? A women with a child would get this procedure Who usually get this procedure? It is recommended if the mother has any disease that can be passed on threw the procedure Is it the procedure preventable or is it used to fix a problem? Description of the procedure Topic 2 It is preformed in a hospital Where is it performed An obstetrician-gynecologist (Ob/Gyn) is a doctor who specializes in the medical and surgical care of women's health and pregnancy. Who preforms it They would have to tell the nurse or doctor any medicines they take or things they are allergic to. What preparations are needed by the patient Some risk that you might injure your bladder or you might get an infection in the uterus. you may have trouble urinating or some blood clot. What are some risk of this procedure Personal Accounts Topic 3 you won't feel any pain because you will be numbed from the waist down. They will just feel pulling or pressure. How does it feel to get this done? not eating anything or drinking anything 6-8 hours before and get a good night sleep What can make the procedure easier ? yes cause it can prevent any diseases that the mother might carry Will this procedure improve the persons life?
Transcript: My sister is now 3 years old and perfectly healthy. My mom is also fully recovered and I also have a 8 month old baby brother. What is a c-section? A c-section is what some doctors recommend for expecting mothers to do when they are going to have a baby. By that I mean, that they don't have the baby naturally. When a woman has a c-section, the doctors make a cut on the lower stomach of the mother to pull the baby out. Choices My Baby Sister's Birth The History of a C-Section 33 percent of American women who gave birth in 2011 had a cesarean delivery. The c-section rate in the United States has risen nearly 60 percent since 1996. Back then they say that they had a low population and women were having trouble being in labor. They declared that if women were having trouble with their delivery of their babies, they would cut them open. So, the women bled to death most of the time because they didn't have the right materials to stop the bleeding. Most of the time it is up to the parents of the child to have a c-section. Unless it's an emergency and there is something wrong with the baby or the mother and the baby needs to be born as soon as possible The reason I chose to present about C- Sections is because my mom had a baby three years ago. She and my step dad went to the hospital, and my sister and I went with my grandma. They went in so my mom could be induced. My mom and my step dad were at the hospital all day and all night. My grandma got us up in the middle of the night and we went to the hospital. Once we got there, my new little baby sister Julia was there but not my mom. She had an emergency c-section because she was bleeding non-stop. One of the nurses ruptured her placenta. The placenta is what feeds the baby inside the mom. If the doctor couldn't find where she was bleeding from, she could have died. Why I chose to present about a C-Section The doctor finally found where my mom was bleeding from, after an hour in surgery. Unfortunately, my mom had to be cut up and down instead of side to side like a normal c-section. So the doctors could get in quicker to deliver my sister. She also had to have staples instead of stitches. My mom had to have 3 blood transfusions to get her blood count up because she had lost so much. She was at the hospital for 5 days before she could come home with my sister. My sister was perfectly fine during and after birth. Once my mom came home she had to have a lot of help from me and my family to get around and help to take care of the baby. Afterwards Cesarean Section (C-section birth)
Transcript: Delivery? How? Emergency cesarean delivery, When? Fetus: lower respiratory problem receive protective bacteria infant bonding - breast feeding 증가 Mother: quick recovery thromboembolism 2-4 배 감소 severe morbidity 3배 감소 mortality 5 - 7배 감소 no uterine scar risk in future births Benefits of vaginal delivery prior section no cephalic presention placenta previa obstructed labor canal Elective cesarean section, when? Emergency cesarean delivery, When? Dystocia Nonreassuring fetal heart rate
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