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Active plan betters hospitals' ob. care.

A multifacted education program both significantly increased the use of oxytocin in the third stage of labor and decreased episiotomy rates in a randomized, controlled trial in 19 hospitals in South America.

In the United States in general, average episiotomy rates at hospitals hover around 20%, Dr. Pierre Buekens said in a press conference with several of his coinvestigators. "There's still improvement to be done." Rates of prophylactic oxytocin use in the United States are unknown, "but we know that it's not done universally," said Dr. Buekens, professor and dean of the School of Public Health and Tropical Medicine at Tulane University, New Orleans.

The changes didn't come easily, but they were associated with significant improvements in maternal outcomes, lead author Dr. Fernando Althabe and his associates noted.

The results of the program were associated with a median 45% reduction in mild postpartum hemorrhages (500-1,000 mL blood loss), a 70% reduction in severe postpartum hemorrhages (1,000 mL or greater), a median 122-mL decrease in postpartum blood loss, and a 20% decrease in second-degree perineal tears and episiotomies in the hospitals randomized to the intervention, compared with the control hospitals, Dr. Althabe of the Institute of Clinical Effectiveness and Health Policy, Buenos Aires, reported (N. Engl. J. Med. 2008; 358:1929-40).

That translates into prevention of 100 mild and 13 severe postpartum hemorrhages and 109 episiotomies averted for every 1,000 vaginal deliveries at the hospitals, they concluded.

The investigators designed the labor-intensive intervention used to educate clinicians at the 17 public hospitals in Argentina and 2 in Uruguay in order to overcome the slow rate of change in clinical practice that results from more passive approaches such as publishing practice guidelines or holding educational seminars.

"You have to do more than that. You need to spend money and time and effort to have very active programs in our hospitals to make sure that what we do meets what we know, " Dr. Buekens said.

The program for the intervention group started with a survey of birth attendants (physicians, residents, or midwives) to indentify three to six "opinion leaders" at each hospital whom others turn to for professional guidance. The teams of opinion leaders attended a 5-day workshop on how to find and evaluate scientific evidence, then create and disseminate guidelines. They developed guidelines for their institutions recommending giving oxytocin to all women just after vaginal birth to prevent postpartum hemorrhage and recommending against the routine use of episiotomy.

Back at their hospitals, they attended a 1-day workshop to develop their training skills, and then set about disseminating their guidelines by training and visiting birth attendants; placing reminders in labor-and-delivery wards, inside surgical packages, and on clinical records; and producing monthly reports on rates of episiotomy and oxytocin use.

At the control hospitals, birth attendants received no special training. During the study, one control hospital independently adopted a policy of active management of the third stage of labor that included oxytocin use. After 18 months, records showed that oxytocin use increased from 2% at the start of the study to 84% in the intervention group and from 3% to 12% in the control group.

In addition, episiotomies decreased from 41% to 30% in the intervention group and increased from 44% to 45% in the control group.

One year after the end of the follow-up period, the rate of oxytocin use remained high in the intervention group (73%) and low in the control group (7%), and the rate of episiotomies changed little compared with the end of the study--45% in the intervention group and 28% in the control group.

The results suggest that old habits die hard--like the use of episiotomies--and that it may be easier for clinicians to adopt new habits, like prophylactic oxytocin use, Dr. Buekens said.

Less than 15% of deliveries in the United States and Latin America include active management of the third stage of labor, consisting of use of a prophylactic uterotonic such as oxytocin, controlled traction of the umbillical cord, and uterine massage, previous data show. The current study assessed changes only in oxytocin use because the other two elements could not be measured reliably and are not evidence based, the investigators said.

The only previous randomized, controlled trial of an intensive, multifacted educational intervention in obstetrics used local opinion leaders, grand rounds, chart reminders, group discussions, audits, and feedback to successfully increase the use of antenatal corticosteroids for fetal maturation, based on guidelines from a National Institutes of Health consensus conference (JAMA 1999; 281: 46-52).

The current study solidifies the success of the multifaceted, evidence-based approach to changing clinical behaviors, said coauthor Dr. Linda L. Wright, a neonatologist and director of the Global Network for Women's and Children's Health Research, a public-private partnership between the National Institute of Child Health and Human Development, Bethesda, Md., and the Bill and Melinda Gates Foundation. The Global Network funded the study.

"We're talking about dissemination" of this approach, "not replication, because we feel that this is the definitive trial," she said. "I don't think we need a consensus development conference on this."

Details on the components of the intervention are available in a supplementary appendix to the article on, and could be used by clinicians anywhere to design similar programs for change at their own hospitals. Dr. Wright and her associates suggested.

The investigators stated that they had no potential conflicts of interest related to the study.


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Author:Boschert, Sherry
Publication:OB GYN News
Date:May 15, 2008
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