Development of a single-center quality bundle to prevent sudden unexpected postnatal collapse

Abstract

Background: Recent reports suggest a rising awareness of sudden unexpected postnatal collapse (SUPC). Local problem: Five SUPC events during a 17-month period. Methods: A multidisciplinary team used a quality-improvement approach to develop the intervention. The smart aim was to develop a bundled intervention to eliminate SUPC from occurring in the delivery room during skin-to-skin care. Intervention: A bundled intervention included a standardized assessment tool and measurement of oxygen saturation levels, with prescribed responses to abnormal values, during skin-to-skin care in the delivery room. Results: Pre-intervention, there were five SUPC events/9143 live births (incidence 0.54/1000 live births) compared with 0 SUPC events/13,964 live births post intervention, p = 0.011. Special cause variation was achieved after implementation when the number of deliveries between SUPC events exceeded 3-sigma. Conclusion: A bundled approach to monitoring during skin-to-skin care, including measurement of oxygen saturation, was associated with no additional cases of SUPC.