Differences in obstetrical care and outcomes associated with the proportion of the obstetrician's shift completed

Lynn M Yee; Paula McGee; Jennifer L Bailit; Ronald J Wapner; Michael W Varner; John M Thorp Jr; Steve N Caritis; Mona Prasad; Alan T N Tita; George R Saade; Yoram Sorokin; Dwight J Rouse; Sean C Blackwell; Jorge E Tolosa; Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Maternal-Fetal Medicine Units (MFMU) Network

doi:10.1016/j.ajog.2021.03.033

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Differences in obstetrical care and outcomes associated with the proportion of the obstetrician's shift completed

Journal article

Open access

Peer reviewed

Differences in obstetrical care and outcomes associated with the proportion of the obstetrician's shift completed

Lynn M Yee, Paula McGee, Jennifer L Bailit, Ronald J Wapner, Michael W Varner, John M Thorp Jr, Steve N Caritis, Mona Prasad, Alan T N Tita, George R Saade, …

American journal of obstetrics and gynecology, Vol.225(4), pp.430.e1-430.e11

10/2021

DOI: 10.1016/j.ajog.2021.03.033

PMCID: PMC8486887

PMID: 33812810

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https://www.ncbi.nlm.nih.gov/pmc/articles/8486887View

Open Access

Abstract

Understanding and improving obstetrical quality and safety is an important goal of professional societies, and many interventions such as checklists, safety bundles, educational interventions, or other culture changes have been implemented to improve the quality of care provided to obstetrical patients. Although many factors contribute to delivery decisions, a reduced workload has addressed how provider issues such as fatigue or behaviors surrounding impending shift changes may influence the delivery mode and outcomes. The objective was to assess whether intrapartum obstetrical interventions and adverse outcomes differ based on the temporal proximity of the delivery to the attending's shift change. This was a secondary analysis from a multicenter obstetrical cohort in which all patients with cephalic, singleton gestations who attempted vaginal birth were eligible for inclusion. The primary exposure used to quantify the relationship between the proximity of the provider to their shift change and a delivery intervention was the ratio of time from the most recent attending shift change to vaginal delivery or decision for cesarean delivery to the total length of the shift. Ratios were used to represent the proportion of time completed in the shift by normalizing for varying shift lengths. A sensitivity analysis restricted to patients who were delivered by physicians working 12-hour shifts was performed. Outcomes chosen included cesarean delivery, episiotomy, third- or fourth-degree perineal laceration, 5-minute Apgar score of <4, and neonatal intensive care unit admission. Chi-squared tests were used to evaluate outcomes based on the proportion of the attending's shift completed. Adjusted and unadjusted logistic models fitting a cubic spline (when indicated) were used to determine whether the frequency of outcomes throughout the shift occurred in a statistically significant, nonlinear pattern RESULTS: Of the 82,851 patients eligible for inclusion, 47,262 (57%) had ratio data available and constituted the analyzable sample. Deliveries were evenly distributed throughout shifts, with 50.6% taking place in the first half of shifts. There were no statistically significant differences in the frequency of cesarean delivery, episiotomy, third- or fourth-degree perineal lacerations, or 5-minute Apgar scores of <4 based on the proportion of the shift completed. The findings were unchanged when evaluated with a cubic spline in unadjusted and adjusted logistic models. Sensitivity analyses performed on the 22.2% of patients who were delivered by a physician completing a 12-hour shift showed similar findings. There was a small increase in the frequency of neonatal intensive care unit admissions with a greater proportion of the shift completed (adjusted P=.009), but the findings did not persist in the sensitivity analysis. Clinically significant differences in obstetrical interventions and outcomes do not seem to exist based on the temporal proximity to the attending physician's shift change. Future work should attempt to directly study unit culture and provider fatigue to further investigate opportunities to improve obstetrical quality of care, and additional studies are needed to corroborate these findings in community settings.

Pregnancy

Adult

Apgar Score

Cesarean Section - statistics & numerical data

Episiotomy - statistics & numerical data

Female

Humans

Intensive Care Units, Neonatal - statistics & numerical data

Lacerations - epidemiology

Logistic Models

Obstetric Labor Complications - epidemiology

Obstetrics

Perineum - injuries

Personnel Staffing and Scheduling - statistics & numerical data

Physicians

Quality of Health Care

Young Adult

Details

Title: Subtitle: Differences in obstetrical care and outcomes associated with the proportion of the obstetrician's shift completed
Creators: Lynn M Yee - Departments of Obstetrics and Gynecology of Northwestern University, Chicago, IL.
Paula McGee - Biostatistics Center, Department of Biostatistics and Bioinformatics Associations, Milken Institute School of Public Health, The George Washington University, Washington, DC.
Jennifer L Bailit - MetroHealth Medical Center
Ronald J Wapner - Columbia University Medical Center
Michael W Varner - University of Utah
John M Thorp Jr - Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC
Steve N Caritis - University of Pittsburgh
Mona Prasad - The Ohio State University
Alan T N Tita - University of Alabama at Birmingham
George R Saade - The University of Texas Medical Branch at Galveston
Yoram Sorokin - Wayne State University
Dwight J Rouse - Brown University
Sean C Blackwell - Memorial Hermann
Jorge E Tolosa - Oregon Health & Science University
Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Maternal-Fetal Medicine Units (MFMU) Network
Contributors: Mark K Santillan (Contributor) - University of Iowa, Obstetrics and Gynecology
Resource Type: Journal article
Publication Details: American journal of obstetrics and gynecology, Vol.225(4), pp.430.e1-430.e11
DOI: 10.1016/j.ajog.2021.03.033
PMID: 33812810
PMCID: PMC8486887
NLM abbreviation: Am J Obstet Gynecol
ISSN: 0002-9378
eISSN: 1097-6868
Grant note: U10 HD027915 / NICHD NIH HHS UG1 HD040545 / NICHD NIH HHS U10 HD021410 / NICHD NIH HHS UG1 HD027915 / NICHD NIH HHS U10 HD040500 / NICHD NIH HHS UL1 RR025764 / NCRR NIH HHS UG1 HD053097 / NICHD NIH HHS UG1 HD034116 / NICHD NIH HHS U10 HD034116 / NICHD NIH HHS UG1 HD040500 / NICHD NIH HHS U10 HD053097 / NICHD NIH HHS U10 HD036801 / NICHD NIH HHS U10 HD053118 / NICHD NIH HHS U10 HD040545 / NICHD NIH HHS K12 HD050121 / NICHD NIH HHS UL1 RR024989 / NCRR NIH HHS U10 HD040544 / NICHD NIH HHS U10 HD040512 / NICHD NIH HHS U10 HD034208 / NICHD NIH HHS UG1 HD040485 / NICHD NIH HHS U10 HD027869 / NICHD NIH HHS U10 HD040560 / NICHD NIH HHS U10 HD027917 / NICHD NIH HHS UG1 HD034208 / NICHD NIH HHS UG1 HD040560 / NICHD NIH HHS UG1 HD040544 / NICHD NIH HHS UG1 HD040512 / NICHD NIH HHS UG1 HD027869 / NICHD NIH HHS U24 HD036801 / NICHD NIH HHS U10 HD040485 / NICHD NIH HHS UL1 TR002548 / NCATS NIH HHS
Language: English
Date published: 10/2021
Academic Unit: Obstetrics and Gynecology
Record Identifier: 9984318224502771

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