Obstetric Operating Room Research Articles

Enhancing operating room efficiency and patient outcomes: The impact of preoperative neuraxial ultrasound in cesarean deliveries

BackgroundThe operating room (OR) is a pivotal financial hub in modern healthcare, accounting for up to 40 % of hospital costs and generating 60–70 % of revenue. Optimizing OR efficiency is crucial for financial sustainability, patient safety, OR throughput, and satisfaction among patients, surgeons, and staff. ObjectiveThis Quality Improvement (QI) project aims to evaluate whether pre-procedure neuraxial ultrasound can enhance obstetric OR efficiency by reducing the time and attempts needed for epidural placement. The secondary objective is to assess improvements in patient comfort, safety, and satisfaction. MethodsConducted at a tertiary hospital in Miami from January to March 2022, the study included 98 parturients undergoing elective cesarean delivery. Patients were randomized into two groups: one receiving preoperative ultrasound (n = 49) and the other not (n = 49). Key metrics recorded included patient demographics, procedural times, number of attempts, pain scores, and patient satisfaction. ResultsThe ultrasound group demonstrated significant improvements in OR efficiency: shorter epidural placement times (median 9 vs. 13 min, p < 0.001), fewer attempts (median 1 vs. 2, p < 0.001), reduced anesthesia ready times (median 22 vs. 31 min, p < 0.001), and decreased total OR times (median 122 vs. 140 min, p = 0.004). Patients in the ultrasound group reported less back pain (median score 0 vs. 1, p < 0.001) and higher satisfaction (median score 10 vs. 9, p < 0.001). ConclusionPreoperative neuraxial ultrasound significantly improves OR case duration and enhances patient outcomes in obstetric anesthesia. While the study's single-site data and lack of blinding are limitations, the findings support larger, multi-institutional studies to confirm these benefits and explore further efficiency improvements.

Electronic feedback alone vs. electronic feedback plus in-person debriefing, for a serious game designed to teach novice anesthesiology residents to perform general anesthesia for cesarean delivery: a randomized controlled trial.

EmergenCSimTM, is a novel researcher-developed serious game (SG) with an embedded scoring and feedback tool that reproduces an obstetric operating room environment. The learner must perform general anesthesia (GA) for emergent cesarean delivery (CD) for umbilical cord prolapse. The game was developed as an alternative teaching tool because of diminishing real-world exposure of anesthesiology trainees to this clinical scenario. Traditional debriefing (facilitator-guided reflection) is considered to be integral to experiential learning but requires the participation of an instructor. The optimal debriefing methods for SGs have not been well-studied. Electronic feedback is commonly provided at the conclusion of SGs, so we aimed to compare the effectiveness of learning when an in-person debrief is added to electronic feedback compared to using electronic feedback alone. We hypothesized that an in-person debriefing in addition to the SG-embedded electronic feedback will provide superior learning than electronic feedback alone. Novice 1st year anesthesiology residents (CA-1) (n=51) (i) watched a recorded lecture on GA for emergent CD, (ii) took a 26-item multiple-choice question (MCQ) pre-test, and (iii) played EmergenCSimTM (maximum score 196.5). They were randomized to either the control group which experienced the electronic feedback alone (Group EF, n=26) or the intervention group, which experienced the SG-embedded electronic feedback and an in-person debriefing (Group IPD+EF, n=25). All subjects played the SG a 2nd time, with instructions to try to increase their score, then they took a 26-item MCQ post-test. Pre-and post-tests (maximum score of 26 points each), were validated parallel forms. For Groups EF and IPD+EF respectively, mean pre-test scores were18.6 (SD 2.5) and 19.4 (SD 2.3), and mean post-test scores were 22.6 (SD 2.2) and 22.1 (SD 1.6); F=1.8, P =.19. SG scores for Groups EF and IPD+EF respectively were - mean 1st play SG scores of 135 (SE 4.4) and 141 (SE 4.5), and mean 2nd play SG scores were 163.1 (SE 2.9) and 173.3 (SE 2.9); F= 137.7, P < .001. Adding an in-person debriefing experience led to greater improvement in SG scores, emphasizing the learning benefits of this practice. Improved SG performance in both groups suggests that SGs have a role as independent, less resource-intensive educational tools. None.

Lower-body warming and postoperative temperature in cesarean delivery under spinal anesthesia: a randomized controlled trial

Study objective: Intraoperative warming techniques after spinal anesthesia in cesarean delivery have conflicting results. Lower body warming has not been investigated, and may be beneficial to counteract heat loss from vasodilation. We investigated a combination of intraoperative lower body forced-air warming and warmed intravenous (IV) fluids versus only warmed IV fluids alone for the primary outcome of maternal temperature in the post-anesthesia care unit (PACU) after elective cesarean delivery.Design: A single-center, single-blinded, randomized, superiority trial.Setting: Obstetric operating room and post-anesthesia care unit in a university hospital.Patients: Sixty-six healthy women undergoing elective cesarean delivery under spinal anesthesia.Interventions: After written informed consent, recruited women received intravenous (IV) co-loading of 1000 mL lactated Ringer’s solution warmed to 42°C during performance of spinal anesthesia. They were then randomized to receive intra-operative lower-body forced-air warming (warming group) or no forced-air warming (control group).Measurements: The primary outcome was maternal oral temperature upon arrival at PACU. Secondary outcome measures included the incidence of hypothermia (<36.0°C), shivering and thermal comfort scores, and the incidence of meperidine administration. In addition, umbilical cord blood gases, Apgar scores, and newborns' rectal temperature were measured after delivery. ResultsIn total, 66 women were recruited. After exclusion of 3 participants (1 missing crucial data, 2 converted to general anesthesia), 63 women remained available for analysis. The mean (Standard deviation) core temperature on arrival to PACU was 36.6°C (0.4°C) in the warming group and 36.5°C (0.3°C) in the control group (P = 0.67). There were no significant differences in shivering intensity between the groups at any time; thermal comfort scores were significantly higher for the air-warming group 30 minutes after arrival to PACU (P = 0.03), but not at any other time. There were no differences in meperidine administration or neonatal outcomes. ConclusionIn healthy women having cesarean delivery under spinal anesthesia, addition of lower body forced air warming conveyed no additional benefit beyond standard management with warmed IV fluids.

Obstetric operating room staffing and operating efficiency using queueing theory

IntroductionStrategies to achieve efficiency in non-operating room locations have been described, but emergencies and competing priorities in a birth unit can make setting optimal staffing and operation benchmarks challenging. This study used Queuing Theory Analysis (QTA) to identify optimal birth center operating room (OR) and staffing resources using real-world data.MethodsData from a Level 4 Maternity Center (9,626 births/year, cesarean delivery (CD) rate 32%) were abstracted for all labor and delivery operating room activity from July 2019—June 2020. QTA has two variables: Mean Arrival Rate, λ and Mean Service Rate µ. QTA formulas computed probabilities: P0 = 1-(λ/ µ) and Pn = P0 (λ/µ)n where n = number of patients. P0…n is the probability there are zero patients in the queue at a given time. Multiphase multichannel analysis was used to gain insights on optimal staff and space utilization assuming a priori safety parameters (i.e., 30 min decision to incision in unscheduled CD; ≤ 5 min for emergent CD; no greater than 8 h for nil per os time). To achieve these safety targets, a < 0.5% probability that a patient would need to wait was assumed.ResultsThere were 4,017 total activities in the operating room and 3,092 CD in the study period. Arrival rate λ was 0.45 (patients per hour) at peak hours 07:00–19:00 while λ was 0.34 over all 24 h. The service rate per OR team (µ) was 0.87 (patients per hour) regardless of peak or overall hours. The number of server teams (s) dedicated to OR activity was varied between two and five. Over 24 h, the probability of no patients in the system was P0 = 0.61, while the probability of 1 patient in the system was P1 = 0.23, and the probability of 2 or more patients in the system was P≥2 = 0.05 (P3 = 0.006). However, between peak hours 07:00–19:00, λ was 0.45, µ was 0.87, s was 3, P0 was 0.48; P1 was 0.25; and P≥2 was 0.07 (P3 = 0.01, P4 = 0.002, P5 = 0.0003).ConclusionQTA is a useful tool to inform birth center OR efficiency while upholding assumed safety standards and factoring peaks and troughs of daily activity. Our findings suggest QTA is feasible to guide staffing for maternity centers of all volumes through varying model parameters. QTA can inform individual hospital-level decisions in setting staffing and space requirements to achieve safe and efficient maternity perioperative care.

Effect of On -Job Training Program on Nurses' Compliance and Satisfaction with Infection Control Measures at Obstetric Operating Room

Background: The primary area of concentration in the operating room for obstetrics is infection control. Nurses engaged practise infection control diminish the probability of pathogens getting to women. Aim of the study: study intention was meet out in what way an on-the-job training program light speed nurses' compliance and satisfaction with infection control procedures inside obstetric operating apartment. Design: To conduct the study, a quasi-experimental approach was taken Setting: The study was done in the obstetrics operating room of the Benha. Sample: will involve all (70) nurses who work in the obstetric operating room. Tools: Structured interview questions, an observation checklist, and nurses' satisfaction. Results: shows that there was a highly statistically significant improvement in wearing protective clothing, surgical hand washing, gloving, gowning, masking, handling sharp instruments, cleaning, and sterilization in post-on-the-job training program compared to 28.6 percent, 31.4 percent, 54.3 percent, 28.6 percent, 40.0 percent, 31.4 percent. Conclusion: Compared to before the on-the-job training program, there was a highly statistically significant improvement in nurses' overall knowledge, compliance, and satisfaction. Recommendations: Continued on-the-job training programs should be used to update nurses' knowledge and compliance.

Strategies for Improving Anesthesia Ready Time in the Obstetric Operating Room

(J Clin Anesth. 2021;73:110302) Operating room (OR) efficiency provides many benefits to patients, surgeons, staff, and hosting organizations including increased OR capacity. A previous retrospective study identified cases performed with neuraxial anesthesia at university hospitals as having the longest mean duration for OR use. Efficiencies and quality improvements are of interest to hospital administration and obstetric OR practice optimization, particularly in large academic hospitals in cases with neuraxial anesthesia. Herein causes of inefficiency are identified, along with improvement practices, and assessment of their efficacy.

Oral Gabapentin versus Pregabalin for Postoperative Pain Relief in Elective Cesarean Section Patients under Spinal Anesthesia

Background: Pain after Cesarean delivery is the main postoperative complain in parturients, pregabalin and gabapentin have been shown to decrease acute postoperative pain in parturient. Objective: The aim of the study was to compare gabapentin and pregabalin as oral premedication in patients for elective cesarean section under spinal anesthesia for postoperative pain relief and the need to rescue analgesia. Methods: This study was carried out at Obstetric Operating Rooms, Zagazig University Surgical Hospitals. The study included 54 consenting women aging 20–40 yrs old with uncomplicated pregnancies that were scheduled to undergo elective Cesarean section delivery under spinal anesthesia. They were randomly allocated into three equal groups. Group (P) received 300 mg pregabalin, group (G) received 900 mg gabapentin, and control group (C). The study medication given orally one hour before the anticipated time of the surgical incision, and data measured included visual analogue scale (VAS), the total doses of analgesia, the incidence of post-operative nausea and vomiting (PONV) and the level of sedation. Results: The VAS was comparatively low in patients of group P as compared to G and C groups (P value < 0.05). Total analgesic requirement of pethidine in first 24 h was significantly lower in groups P as compared to groups G & C (P value < 0.001). We found that there was statistically significant increase in the sedation scores of the patients in P group as compared to G & C groups. Conclusion: Pregabalin 300 mg was more effective than gabapentin300 mg in reducing post Cesarean section pain, opioid consumption, nausea, and vomiting.

Infection Prevention and Control Practices Implemented for Congenital Measles in an Extremely Low Birth Weight Infant

Background: Measles can cause miscarriages and preterm birth in nonimmune pregnant women. During the 2018–2019 measles outbreak in New York, a woman with measles delivered an extremely low birth weight preterm infant at our Women and Children’s Hospital. We describe our measles preparedness strategies and infection prevention and control (IPC) management relevant to congenital measles. Methods: Because of the measles outbreak, in Q4 2018, IPC verified measles immunity in all obstetric and pediatric staff, per state regulations, and recommended determining the measles immune status of all pregnant women. To prevent measles exposure, visitor restrictions for the neonatal intensive care unit (NICU) were implemented (May 2019); only 3 visitors were permitted for each infant, including parents. All visitors had to provide written documentation of immunity to measles, regardless of epidemiologic risk factors or receive an MMR vaccine prior to visiting. New York state and New York City health departments performed measles diagnostic testing for maternal and infant specimens. Results: Our hospital was informed of the imminent transfer of a woman in preterm labor with suspected measles. To avoid any exposure, the mother was masked in the ambulance bay and taken by commandeered elevator to the obstetrical operating room suite, which was cleared of other patients. She delivered by C-section and was transferred to an airborne infection isolation (AII) room. The 25-week-gestation infant was transported by isolette to the NICU and was placed on AII. Testing confirmed measles in the mother (measles PCR- and IgM-positive) and congenital measles in the infant (Table 1). The mother was allowed to visit the NICU when her respiratory symptoms and rash resolved, as confirmed by her provider, ~10 days after discharge. The infant never developed a rash, pneumonia, or neurologic findings. AII was discontinued on day of life 61 in consultation with the health departments. The infant was discharged at ~36 weeks gestation. No secondary cases of measles occurred among patients, visitors, or staff. Conclusions: We safely cared for an extremely preterm infant with congenital measles. Laboratory testing suggested prolonged presence of measles virus, but it is unknown how long an infant in the NICU should remain on AII. The current Council of State and Territorial Epidemiologists case definition for measles requires the presence of rash. This case provides support to revise this case definition if laboratory findings are consistent with congenital measles.Funding: NoneDisclosures: None

Critical Obstetric Patients During the Coronavirus Disease 2019 Pandemic: Operationalizing an Obstetric Intensive Care Unit.

Critical Obstetric Patients During the Coronavirus Disease 2019 Pandemic: Operationalizing an Obstetric Intensive Care Unit.

Identified themes of interactive visualizations overlayed onto EHR data: an example of improving birth center operating room efficiency.

While electronic health record (EHR) systems store copious amounts of patient data, aggregating those data across patients can be challenging. Visual analytic tools that integrate with EHR systems allow clinicians to gain better insight and understanding into clinical care and management. We report on our experience building Tableau-based visualizations and integrating them into our EHR system. Visual analytic tools were created as part of 12 clinician-initiated quality improvement projects. We built the visual analytic tools in Tableau and linked it within our EPIC environment. We identified 5 visual themes that spanned the various projects. To illustrate these themes, we choose 1 exemplary project which aimed to improve obstetric operating room efficiency. Across our 12 projects, we identified 5 visual themes that are integral to project success: scheduling & optimization (in 11/12 projects); provider assessment (10/12); executive assessment (8/12); patient outcomes (7/12); and control and goal charts (2/12). Many visualizations share common themes. Identification of these themes has allowed our internal team to be more efficient and directed in developing visualizations for future projects. Organizing visual analytics into themes can allow informatics teams to more efficiently provide visual products to clinical collaborators.

Distractions in the Obstetric Operating Room [27F

INTRODUCTION: Distractions in the operating room are common. The frequency and impact of distractions during obstetric surgery is unknown. According to JACHO and HRO, distractions are an important cause of mistakes in medicine. Persoon et al reported distractions occurred at a rate of one event every 1.8 minutes during endo urological procedures at a teaching hospital in the Netherlands. Our goal was characterize the type and frequency of distractions in obstetric surgery at our institution. METHODS: Obstetric surgeries were observed at a community teaching hospital in suburban New Jersey. A researcher recorded all observed distractions during cesarean sections using a study design validated by Persoon et al. Distractions were categorized by severity, based on how distracting they were to the surgeons. RESULTS: 23 operations were observed. Mean operating time was 47 ±16minutes (range 32-78 minutes). Average distractions per case was 57±16 (range 21-85). Potentially distracting events occurred every 54 ± 23 seconds (range 29-113). There were 3 distracting events that caused one of the surgeons to stop what they were doing to engage entirely with the distracting stimuli — twice for phone calls, and once for conversation related to another patient. CONCLUSION: Distractions appear to be twice as common in obstetric surgery versus the rate reported during endo urologic procedures. While no obvious adverse events were observed in this small study, the frequency, characterization and impact of distractions in obstetric surgery warrant further study.

Improving Surgical and Anaesthesia Practice: Review of the Use of the WHO Safe Surgery Checklist in Felege Hiwot Referral Hospital, Ethiopia

Development of surgical and anaesthetic care globally has been consistently reported as being inadequate. The Lancet Commission on Global Surgery highlights the need for action to address this deficit. One...

Early elective delivery and vaginal birth after cesarean in rural US maternity hospitals

The purpose of this study was to describe policies on early elective delivery (EED) and vaginal birth after cesarean (VBAC) in rural US maternity hospitals and to measure whether hospital policies differ by staffing, facilities, or birth volume. Data came from a telephone survey, conducted among all rural maternity hospitals in nine US states from November 2013 to March 2014, to report on EED and VBAC at the hospital level. The associations between EED and VBAC and hospital characteristics were analyzed using χ2 and Fisher's exact tests. Most rural maternal hospitals (70.1%) had a 'hard stop' EED policy, whereby elective delivery before 39 weeks gestation was prohibited. Less than half of the rural hospitals surveyed allowed VBACs (38.1%). Rural hospitals with a higher birth volume (p=0.001), with a dedicated obstetric operating room (p<0.001), and where obstetricians and certified nurse-midwives attended deliveries (p=0.010 and p=0.030, respectively) were more likely to allow VBAC deliveries. Hospitals where family physicians and general surgeons attended deliveries were less likely to allow VBAC deliveries (p=0.002 and p=0.040, respectively). Most rural US maternity hospitals have a hard stop EED policy, consistent with evidence and guideline recommendations. Access to VBAC varies across rural settings, possibly owing to capacity limitations to provide this option. Further research is needed to determine whether and how best to safely implement national recommendations for EED and VBAC policies across a range of rural settings.

Transitioning to Blunt Suture Needles in Obstetric Operating Rooms

INTRODUCTION: Our objective was to identify impact of transition to blunt-tip suture needles in obstetric procedures on incidence of needlestick injuries (NSI) in obstetric residents and attendings. METHODS: All OBGYN residents and attending physicians in a tertiary care hospital were surveyed regarding NSI. Following this, suture needles in obstetric operating rooms were changed to blunt needles. A one-year follow-up survey was then sent. RESULTS: Prior to introduction of blunt needles, 28% of attendings had at least one NSI in previous year. Eight needlesticks were sustained in the year preceding transition to blunt needles versus 1 in the year following transition (P=.05) in attendings. Prior to their introduction, greater than 70% of attendings believed blunt needles would reduce NSI; following introduction, only 29% still felt this to be true, despite the actual reduction in NSI occurrence among attendings (P less than .01 for change). Of the responding residents, 61% had sustained at least 1 NSI in the preceding year in the initial query; 50% sustained at least 1 NSI following the introduction to blunt suture needles. At the 1-year follow-up survey, a total of 10 NSI were recalled, with a reporting rate of 50%. CONCLUSION: The introduction of blunt suture needles was associated with a decrease in total recalled needlestick injuries sustained by residents and attendings. The decrease was most notable among the attending physicians, despite their perception that blunt needles were not safer. Blunt needles are an acceptable alternative to the sharp suture needles and thus should be utilized wherever feasible.

The effects of resource improvement on decision-to-delivery times for cesarean deliveries in a Ghanaian regional hospital

ObjectiveTo evaluate the effects of having a dedicated obstetric operating room (OR) on the decision-to-delivery interval (DDI) in a large referral hospital in Ghana. MethodsAn observational study was undertaken of all patients undergoing cesarean delivery at Ridge Regional Hospital, Accra, before (pre-OR; August–September 2011) and after (post-OR; August–September 2012) introduction of an obstetric OR. The primary outcome was the DDI. ResultsIn total, 581 cesareans were performed in the pre-OR period and 574 in the post-OR period. Overall, the median DDI decreased from 259min (interquartile range [IQR] 161–432) in the pre-OR period to 195min (IQR 138–319) in the post-OR period (P<0.001). DDI was lower in the post-OR period than in the pre-OR period for both emergency (175min [IQR 126–241] vs 220min [IQR 146–315]; P<0.001) and elective (1828min [IQR 1432–2985] vs 4291min [IQR 2992–5862]; P<0.001) cesarean deliveries. Only one emergency cesarean—in the post-OR period—was conducted within the recommended 30-minute timeframe. ConclusionAn obstetric OR lowered the DDI for cesarean delivery; however, a realistic timeframe for emergency cesareans in low-income countries remains to be determined.

Birth wind and fire: raising awareness to operating room fires during delivery

Objective: We researched whether the obstetric operating room (OR) qualified as a fire-risk environment so as to take preventive measures accordingly.Methods: We analyzed a series of iatrogenic burns inflicted during birth by collecting clinical data and comparing it with known OR fire risk factors and with other factors that repeated in all cases in search of unique characteristics of the obstetric OR.Results: All three cases shared in common the same type of oxygen-rich open ventilation system, alcohol-based prepping solution, and the hastiness of cesarean delivery while spontaneous vaginal delivery was already in progress.Conclusion: The obstetric OR is, as suspected, a fire-prone zone in more ways than the regular OR. Therefore, preventive measures should be undertaken and awareness for the possibility for such occurrences should be raised.

Exploring the Impact of a Family-Centered Maternity Care Program on Staff Attitudes and Patient Satisfaction

Professional Issues Poster Presentation Purpose for the Program Our obstetric service implemented a familycentered maternity care program in 2010. Our facility was known in the region for being very high-tech and medicalized and a place where patients would want to give birth if they had high-risk pregnancies or desired induction and epidural. Families who sought a low intervention, nonmedicalized birth often went elsewhere. We simultaneously suffered a downturn in births. Some of this was attributable to the economic situation, but also we felt our patients may be going to facilities that offered a different birth experience than the one we were providing. Additionally, we were seeing an increase in emergent admissions from nearby lay midwife-run birthing centers. We wanted to offer our patients the opportunity to give birth the way they wanted to but within easy access to our obstetric operating rooms and the neonatal intensive care unit if the need arose.

LIFTS: Lowering Injuries for Transfer Safety

More than 10% of nurses have had injuries that have allowed them to file workmen's compensation claims nationally. Ceiling mounted lifts are proven to reduce staff injuries and improve patient safety. Our hospital supports the use of ceiling mounted lifts to prevent injury in inpatient and outpatient settings. To renew our commitment to both patient and staff safety, our labor and delivery unit installed ceiling mounted lifts in every labor room and obstetric operating room. Laboring patients are immobilized with regional anesthesia requiring nurses to assist with all activities.

Who's WHO in the Obstetrical Operating Room

Who's WHO in the Obstetrical Operating Room

Packed and Wearing Pink: Damage Control Surgery in the Obstetric Operating Room

Packed and Wearing Pink: Damage Control Surgery in the Obstetric Operating Room