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Hemodynamic Monitoring for Intrapartum Cesarean Delivery
Abstract Number: T3B-2
Abstract Type: Original Research
Many parturients with labor epidural analgesia (LEA) are delivered by intrapartum cesarean delivery (CD).1,2 In late 2016, a QA review of an adverse event unrelated to anesthesia care identified a lapse in maternal blood pressure (BP) monitoring (25 min between BPs) during initiation of surgical epidural anesthesia, during dosing for surgery and transport from labor room (LDR) to OR. Review of additional cases revealed that this was not uncommon. An educational practice outline with instructions for epidural catheter dosing, BP monitoring, anesthetic assessment, and transport to the OR was created (Figure). The primary aim of this study was to investigate whether the intervention shortened the mean maximum time gap for maternal BP measurements to a target of less than 10 minutes.
Starting July 1, 2017, all residents received the outline at the start of their OB anesthesia rotation. Intrapartum CDs from Jan 2016-Dec 2017 were identified (N=682). EMR were used to obtain maternal and fetal data. A before/after comparison was conducted, with the primary outcome defined as ∆T=“time between last BP value recorded in labor room and 1st BP value in OR”, or “between 1st local anesthesia bolus to 1st BP value in OR,” whichever was shorter. Data included maternal BP, HR, FHR category, urgency of CD and Apgar scores. Categorical data was compared using X2 test and continuous outcomes using t-test; p<0.05 considered significant.
∆T range was 0-42min pre- (N=551) and 2-22min (N=131) post-implementation. Mean ∆T was 11min pre-, 9min post-implementation (p<0.01); percentage of cases with ∆T < 10min was 44% pre-, 68% post-implementation (p<0.01). There were no significant changes in maternal BP (nadir <90mmHg for SBP was 6.9% pre vs 7.6% post; p=0.09), cases with conversion from non-urgent to STAT CD (0.4% pre vs 0.8% post; p=0.4), or Apgar scores <7 at 1 min (14.3% pre vs 12.2% post; p=0.4).
After a sentinel event, we identified concerning time gaps in hemodynamic monitoring during the initiation of surgical anesthesia for CD, likely due to the hectic setting and events of intrapartum CD. While the number of cases needed to identify meaningful differences in secondary outcomes is high, a implementation of an educational outline for our residents resulted in improved hemodynamic monitoring during a crucial time.
1. Gambling D, et al. Anesth Analg 2013; 116: 636-43
2. Philip J, et al. Anesth Analg 2018; 126: 537-544