///2010 Abstract Details
2010 Abstract Details2018-05-01T17:52:49+00:00

The Utility of a Pre-procedure Briefing to Facilitate Emergent Cesarean Delivery After Attempted Version

Abstract Number: 182
Abstract Type: Case Report/Case Series

Jordan A Stabinski MD1 ; Jordan A Stabinski MD2; Amar Parikh MD3; Stephen D Pratt MD4

Introduction: External cephalic version (ECV) can cause placental abruption or umbilical cord compromise requiring emergent cesarean delivery.A coordinated team approach may help improve outcomes after an attempted version.Safety literature has cited the benefit of a briefing prior to surgical procedures, however no literature currently demonstrates this in obstetrics. We present a case of a pre-procedure briefing to facilitate an emergency cesarean delivery after an ECV.

Case Review: The patient was a 41 year old G6P2 healthy parturient who had a scheduled attempted version and possible c-section for a breech presentation after a benign antepartum history.Prior to the procedure, a multi-disciplinary briefing was held outside the holding area. Staff taking part in the briefing included the obstetric attending and resident, anesthesia attending and resident, and nurse. Decisions made at the briefing included: 1) use of the largest OR, 2) epidural use for the attempted version, 3) use of nitroglycerin for uterine relaxation, 4) team situational awareness for a possible c-section, 5) immediate availability of a scrub tech, and 6) two obstetric attendings present.

The patient was examined, consent obtained, and an intravenous catheter placed. The patient was brought to the OR, standard ASA monitors placed and an epidural inserted at L3-4. The patient was placed supine with left uterine displacement. After a negative test dose, 20 mL of chloroprocaine 3% were given in incremental doses.The patient had a dense T4 sensory level.Two nitroglycerin boluses of 40 mcg were administered for uterine relaxation. The version was successful, but the fetal heart rate monitor demonstrated recurrent bradycardia which necessitated an emergent cesarean delivery. The final bradycardia to delivery time was six minutes. The infant was born with APGARs of 7 and 9. NICU staff was present for the emergent c-section, but the infant was stable and brought to the regular nursery.

Discussion: Multiple authors have demonstrated the benefit of a briefing prior to general surgical procedures.The implementation of a 19-item safety checklist decreased post-op mortality from 1.5% to 0.8%, and complications from 11.0% to 7.0% (1). Pre-op briefings have also been shown to reduce intra-operative communication failures (2), and improve the administration of DVT prophylaxis and pre-op antibiotics (3). This is the first report of the beneficial effect of a briefing in obstetrics. The decisions made at the briefing ensured a shared mental model among the team members and facilitated the safe and rapid delivery after ECV complicated by fetal bradycardia. This type of briefing has been our standard for more than 5 years and our hope would be for this to become the national standard of care.


References:


1) Haynes AB, et al. N Engl J Med. 2009 Jan 29;360(5):491-9.

2) Lingard L et al. Arch Surg.2008 Jan;143(1):12-7.


3) Awad SS, et al Am J Surg. 2005; 190:770-4.

SOAP 2010