Documents

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Expert Team Resources

Dextrose gel for neonatal hypoglycaemia (the Sugar Babies Study): a randomised, double-blind, placebo-controlled trial - This seminal article has shaped the management of neonatal hypoglycemia. This study out of New Zealand recommends treatment with dextrose gel be considered the first-line treatment to manage hypoglycemia in late preterm and term babies in the first 48 hours after birth.  The authors concluded dextrose gel is inexpensive, simple to administer and can successfully reverse newborn hypoglycemia. 

Neonatal hypoglycemia, defined as a plasma glucose level of less than 30 mg/dL (1.65 mmol/L) in the first 24 hours of life and less than 45 mg/dL (2.5 mmol/L) thereafter, is the most common metabolic problem in newborns. Major long-term sequelae include neurologic damage resulting in mental retardation, recurrent seizure activity, developmental delay, and personality disorders. Some evidence suggests that severe hypoglycemia may impair cardiovascular function.

Outcome at two years after dextrose gel treatment for neonatal hypoglycemia; Follow up of a randomized trial -  This follow up study to the Sugar Babies paper confirms that treatment with dextrose gel is not associated with additional risks or benefits at two years of age.  The authors claim that clinicians and families can be reassured that the advantages of treatment with dextrose gel soon after birth are not counterbalanced by increased risk of poor neurodevelopmental outcomes at two years’ corrected age. 

Clinical Report—Postnatal Glucose Homeostasis in Late-Preterm and Term Infants - Published in Pediatrics, this report provides a practical guide and algorithm for the screening and subsequent management of neonatal hypoglycemia. Highlighting the fact that no rigorous scientific definition has been reached, this influential article from 2011, continues to be endorsed today as the guidelines to manage neonatal hypoglycemia by the American Academy of Pediatrics.

Early skin-to-skin contact for mothers and their healthy newborn infants. - This extensive Cochrane review discusses the general consensus that “minimally, skin to skin contact should continue until the end of the first successful breastfeeding in order to show an effect and to enhance early infant self-regulation.”  Cited in this article as one of the common reasons for separation is hypoglycemia.  The review highlights evidence for a clinically meaningful increase in blood glucose in infants who received skin to skin contact and goes on to say that even if practiced for a “short time at birth [skin to skin contact] should have measurable breastfeeding effects one to four months’ post birth.”

New approaches to management of neonatal hypoglycemia. - This very informative article focuses on the role of buccal dextrose gel in the management of asymptomatic neonatal hypoglycemia and encourages the use of dextrose gel as part of a treatment protocol.  Additionally, the authors support the abandonment of the intravenous dextrose bolus for the treatment of asymptomatic, hypoglycemic late preterm, LGA, SGA/IUGR, and IDM newborns.

READINESS:

The National Partnership for Maternal Safety Hemorrhage Bundle - This patient safety bundle created by The National Partnership for Maternal Safety, outlines what every unit can do to be ready, recognize and prevent, respond to and report on when working toward improving outcomes related to Obstetric hemorrhage.  We encourage you to adapt the bundle to complement the work within your hospital setting. 

 

ACOG Practice Bulletin PP Hemorrhage - This ACOG practice bulletin reviews the etiology, evaluation, and management of postpartum hemorrhage.  The information is designed to aid practitioners in making decisions about appropriate obstetric and gynecologic care as it relates to hemorrhage.

 

CMQCC Obstetric Hemmorhage ToolKit - The California Maternal Quality Care Collaborative (CMQCC) released this document in 2015 aligning with the National Partnership for Maternal Safety Hemorrhage Bundle.  Following the structure of readiness, recognition, response and reporting, CMQCC digs deeper at each level and provides an extensive toolkit packed with a myriad of resources for hospitals to utilize.

CMQCC Obstetric Hemorrhage Hospital Level Implementation Guide - This article provides a framework and step-by-step guidance on how to utilize quality improvement methods to assist healthcare leaders with implementing best practices and tools for obstetric hemorrhage. 

Preparing for Clinical Emergencies in Obstetrics and Gynecology - This ACOG committee opinion paper outlines several vital tools inpatient units should have in place when responding to obstetric emergencies such as hemorrhage.

Massive Transfusion Protocols: The Role of Aggressive Resuscitation Versus Product Ratio in Mortality Reduction - This study looked at the impact of developing a massive transfusion protocol (MTP) and its association with better outcomes and improved mortality rates in the trauma patient population. The most important finding was the development of a protocol to improve communication with the blood bank and decrease the time needed to have components available for transfusion. 

AWHONN postpartum hemorrhage project - This website outlines the postpartum hemorrhage project spearheaded by AWHONN and offers several resources such as articles, videos, and a poster on recognition, readiness and response related to hemorrhage.

Severe Maternal Morbidity: Screening and Review - Identifying severe morbidity is important for preventing injuries that lead to mortality and for highlighting opportunities to avoid repeat injuries. A two-step screen and review process described in this document is intended to efficiently detect severe maternal morbidity in women and to ensure that each case undergoes a review to determine whether there were opportunities for improvement in care.  

American College of Obstetricians and Gynecologists: Safe motherhood initiative - In 2013, ACOG district II kicked off their Safe Motherhood Initiative (SMI).  They set out to develop and implement standard approaches for handling obstetric emergencies associated with maternal mortality and morbidly; obstetric hemorrhage was one of them. Visit this website to access multiple resources related to improving maternal outcomes of those who may experience postpartum hemorrhage.  

Agency for Healthcare Quality and Research. Team Stepps: National Implementation - Focused on improving patient safety within organizations, Team Stepps offers a plethora of information designed to build teamwork, improve communication and integrate successful principles that optimize safe clinical care.  Specifically, as it relates to obstetric hemorrhage, the concepts of briefing and debriefing should be reviewed and integrated into practice.

 

RECOGNITION

An AWHONN Practice Brief on the Clinical Management Guidelines for the use of oxytocin in management of the third stage of labor.  Specific guidance is provided regarding oxytocin use, including dosing and administration.

Postpartum Hemorrhage - This is a chapter from the Advanced Life Support in Obstetrics providing detailed information regarding the causes and methods of preventing postpartum hemorrhage.  The need for early recognition and quick response to postpartum hemorrhage are also discussed, as well as, treatments for hemorrhage.

WHO recommendations for the prevention and treatment of postpartum haemorrhage - This document contains 32 recommendations for prevention and treatment of postpartum hemorrhage; 7 are new recommendations and others have been revised based on new evidence.  All recommendations have been evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology and are presented with the associated GRADE recommendation and the quality of supporting evidence.  The primary source of evidence for all recommendations was Cochrane systematic reviews of randomized controlled trials.  Consideration is given to who would be in attendance at the birth: skilled birth attendant, non-skilled birth attendant or only the delivering mother.  These guidelines were published in 2012 and are scheduled for review in 2017.

 

RESPONSE

Florida Perinatal Collaborative. Obstetric hemorrhage initiative (OHI) tool kit for hospital implementation - This toolkit will provide obstetric care providers, hospital personnel and the collaborating services with the resources to develop their own obstetric hemorrhage policies and protocols.  This document is divided into three sections with recommendations for the providers, the hospital and appendices with supplemental information and resources. This toolkit does utilize portions of the CMQCC toolkit and includes some updated and revised elements as well.

Preparing for Clinical Emergencies in Obstetrics and Gynecology - This ACOG committee opinion paper outlines several vital tools inpatient units should have in place when responding to obstetric emergencies such as hemorrhage.

LEND Support to a Patient or Family Member Impacted by an Adverse Medical Event - Using the acronym L.E.N.D., this quick resource helps clinical staff understand how to be supportive to patient and families when dealing with an adverse medical event such as obstetric hemorrhage. 

AWHONN postpartum hemorrhage project - This website outlines the postpartum hemorrhage project spearheaded by AWHONN and offers several resources such as articles, videos, and a poster on recognition, readiness and response related to hemorrhage.

 

REPORTING

Standardized Severe Maternal Morbidity Review - This article provides guidance in standardizing terminology and definitions for severe maternal morbidity.  It emphasizes the need for standard terminology so that cases of severe maternal morbidity can be reviewed and tenets of quality improvement can be applied.  The case is made that tenets of quality improvement should be applied not only to care processes but also to identification, analysis and review of severe maternal morbidity cases.

Severe Maternal Morbidity: Screening and Review - This article is the current guidance supporting the retired Joint Commission Sentinel Event Alert 44.  The article outlines the importance of identifying and screening cases of severe maternal morbidity.  It highlights that the American College of Obstetricians and Gynecologists and the Society for Maternal and Fetal Medicine have not created or come to consensus on a comprehensive definition of severe maternal morbidity.  The article suggests that in the absence of a comprehensive definition, institutions should utilize existing screening criteria or create a list of their own.  A screening tool with high probability to detect severe maternal morbidity is proposed. 

 

 

 

 

 

 

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