INTRODUCTION:: Hypertensive disorders of pregnancy are a leading cause of maternal and neonatal morbidity and mortality. Timeliness of treatment improves maternal and neonatal outcomes. This study assesses the impact of implementing a program for severe range blood pressure (SRBP) management during inpatient obstetrical care. METHODS:: We prospectively collected data from a single academic center during 2015-2016 comparing outcomes before and after a system change. The changes included 1) an algorithm to improve blood pressure (BP) recheck times (for validating SRBP) and time to intravenous medication when indicated; 2) improved medication access making all medications equally available; and 3) multidisciplinary training including simulation sessions. All patients with ICD-10 codes of pregnancy-related hypertensive disorders who had SRBP were evaluated over a three-month period before and after program implementation. SRBP treatment included intravenous labetalol or hydralazine or oral nifedipine. Primary endpoints compared time to BP recheck, time to medication when indicated and type of medication. RESULTS:: More women had a BP recheck within one hour post-implementation (330/344, 95.9%) vs. pre-implementation (390/425, 91.7%) (P=.0025). A similar improvement occurred when evaluating BP recheck within 10 minutes (60.5% vs. 40.0%, respectively, P=.0001). For the 113 post-implementation and 89 pre-implementation SRBP events requiring treatment, time to medication did not improve (median 13 and 14 minutes, respectively, P=.40). Use of labetalol vs. hydralazine post-implementation increased from 13.3% to 38.1% (P=.0001); nifedipine was rarely used (1 and 3 patients, respectively). CONCLUSION:: Implementation of an algorithm to treat SRBP can improve BP recheck rates and impact choice of intravenous medications.

Objective

To describe sterilization completion rates after vaginal delivery and indications for unfulfilled procedures.

Study design

We used labor and delivery operating room and delivery logs to identify all women over 20years of age with a completed live vaginal birth beyond 24weeks gestation over a 33-month period (March 1, 2012 to November 30, 2014). We reviewed the electronic medical records of all of these patients and identified those who requested a sterilization procedure as indicated in a physician's admission note or antenatal record.

Results

We identified 3514 live vaginal births beyond 24weeks gestation during the study period of which 219 requested postpartum sterilization. Sterilization occurred in 114 (52%). The most common reason for unfulfilled procedures was lack of valid federally mandated consent (n=46 [44%]). Fifty-nine percent (27 of 46) of these women had little or no prenatal care. Only one (0.5%) woman had documented completion of consent with the required time elapsed prior to delivery and no consent form available. Of the women with valid consent documentation, the most common indication for an unfulfilled procedure was patient refusal (n=30 [51%]). Body mass index was an independent predictor of an unfulfilled procedure (p<.001) among women with adequate consent.

Conclusions

Inability to complete federally mandated consent is a principal cause of unfulfilled postpartum sterilization and primarily affects women desiring sterilization who lack sufficient prenatal care. Of women who meet consent criteria, the primary reason women eligible for sterilization did not undergo the procedure was due to withdrawing their request.

Implications

Because women commonly do not undergo a requested sterilization after vaginal deliveries, antepartum counseling should include alternate contraception choices. Documented consent that fulfills all federally mandated criteria remains the most common barrier to requested sterilization after vaginal delivery; providers and policymakers should work together to help unburden women from this mandate.