|Jennifer Doyle Biography & Abstract|
Jennifer Doyle, MSN, WHNP-BC
Summa Health System - Akron City Hospital
Jennifer Doyle, MSN, WHNP-BC is the perinatal outreach educator/APN for the Women's Service line at Summa Health System's Akron City Hospital in Ohio. Jennifer leads multiple research and quality improvement projects within her facility and across the state of Ohio. Many of her projects focus on intrapartum safety. As a participating site in Premier's Perinatal Safety Initiative, Summa, ACH demonstrated the highest scoring outcomes in conjunction with sustainability, and "Tackling Tachysystole" earned 'Article of the Year' for JOGNN in 2011. She has led antenatal projects such as Progesterone and Antenatal Corticosteroid Administration to improve birth outcomes. Finally, she is now studying low-risk intrapartum interventions such as use of birthing mirrors and upright positioning via the Relaxbirth device. Mrs. Doyle's passion is maximizing safety through evidence-based intrapartum nursing care. 1 of her 4 current projects is examining the effects of a postpartum standardized oxytocin administration protocol to reduce postpartum hemorrhage (PPH). A preliminary 6 month pre-and-post examination of outcomes revealed a statistically significant decrease in treatment of PPH for vaginal deliveries. This grant award will allow for a full 2 year pre/post implementation evaluation to hopefully establish evidence regarding standardization of postpartum oxytocin to reduce PPH, thereby improving maternal safety and outcomes.
Postpartum hemorrhage (PPH) is the leading cause of maternal mortality both in the developing and developed world. In the United States, 12% of pregnancy-related mortality is attributed to postpartum hemorrhage. In addition to death, other poor health outcomes related to PPH include: adult respiratory distress syndrome, coagulopathy, shock, loss of fertility, and pituitary necrosis. Any delay in the management of postpartum hemorrhage may increase the risk of maternal morbidity and mortality. Oxytocin administration for all women has been recommended to reduce the incidence of postpartum hemorrhage. Oxytocin is routinely used to prevent postpartum hemorrhage in the United States, but dosing is based on limited evidence and no standard policy has been introduced. Standardized postpartum oxytocin administration is lacking in many facilities.
Our multidisciplinary team developed a standardized postpartum oxytocin administration protocol to prevent PPH based on limited evidence ranging from 10 -80 or more units of oxytocin with administration times from <1 to 12 hours postpartum. Our protocol was a 'middle of the road' approach in which a total of 60 units of oxytocin is administered intravenously postdelivery over a 5 hour period.
A retrospective quality improvement assessment has compared PPH rates at our level three urban perinatal center for 6 months pre- and 6 months post-protocol implementation (60 units of oxytocin over 5 hours). PPH was defined as PPH treatment by pharmaceutical, mechanical or surgical methods. Inclusion criteria included all deliveries > 23 weeks' gestation April 2012 to March 2013. RESULTS: The Pre-protocol group (n=1267) and post-protocol group (n=1440) were similar for race, age, parity, gestational age, delivery type and neonatal weights. The PPH rate decreased 37% after protocol implementation (Adjusted Relative Risk=0.63, 95% CI: 0.46-0.91). Administration of misoprostol, carboprost, methylergonovine maleate and blood products decreased post-protocol implementation by 36%, 38%, 32% and 22% respectively. The PPH rate for women with a vaginal delivery lowered significantly after protocol implementation (5.9% versus 3.8%, P= 0.03). The PPH rate for women with a cesarean delivery increased but not significantly after protocol implementation (6.9% vs. 8.6%, P= 0.34).
Implementation of our standardized oxytocin administration protocol was promising, reducing the overall incidence of PPH. While we did not control for some PPH risk factors, our PPH rate for women delivered by cesarean remains lower than other published rates. This protocol warrants further study. The proposed study will further evaluate the effectiveness of the current protocol using a larger sample size pre- and post-implementation. We will also control for some additional PPH risk factors.
The clinical goal is to establish an evidence-based, standardized protocol for oxytocin administration to prevent postpartum hemorrhage. We hope to thereby decrease maternal morbidity and mortality and related liability, and meet the Healthy People 2010 goals for maternal mortality. We will disseminate findings widely through various academic and lay sources such as presentations, publications, media outlets, Facebook, Twitter, blogging, and a toolkit package available as an iBook. We anticipate this project could also contribute tools to AWHONN's national project to reduce postpartum hemorrhage.