Dr. Wendy Wilcox (center back) and the multi-disciplinary L&D team at North Bronx Healthcare Network.

Baby Cassandra* was born at a large, private, teaching hospital following a long and difficult labor. She appeared healthy, but shortly after birth, her parents noticed that she couldn’t move her left arm.

Physicians explained that the baby had sustained an injury as a result shoulder dystocia, a common occurrence affecting nearly two of every 1,000 deliveries.

During birth, Cassandra’s head emerged from the birth canal, but her shoulder became stuck behind her mother’s pubic bone. In these cases, the baby’s neck becomes stretched to the side and as a result, damage to the brachial plexus -- a network of nerves near the neck controlling movement of the arm --can occur. With considerable treatment, some babies recover movement over time. But for many, paralysis -- termed Erb’s Palsy-- is permanent.

For Cassandra, rigorous, ongoing physical therapy would be required and maybe even surgery. But physicians could not say for certain if the damage would be permanent. Cassandra’s parents took their baby home with heads reeling, hearts grieving, and thoughts filled with anxiety.

Real life cases like baby Cassandra’s were the inspiration behind an award winning patient safety program that has dramatically reduced adverse labor and delivery (L&D) outcomes for the 4,000 deliveries performed every year at the HHC North Bronx Health Network, which includes Jacobi Medical Center and the North Central Bronx (NCB) Hospitals.

“When we embarked on this quest, we simply wanted to provide the safest environment in which women would deliver their babies,” explained Dr. Wendy Wilcox, Vice Chair of the Women’s Health Service at Jacobi and NCB. “When we saw how much our outcomes had improved, and how many babies would be spared a potentially devastating condition, we were thrilled. We are one of the safest L&D services in the entire country, and we could not be more proud.”

The Women’s Health Service teams from both hospitals joined the Perinatal Collaborative of the Institute for Healthcare Improvement (IHI) and first developed a process to identify certain risk factors associated with the incidence of shoulder dystocia, such as the prevalence of obesity and diabetes in the Bronx which predisposes babies to fetal macrosomia (excessive birth weight), and puts them at higher risk. Identifying these risk factors led to a number of interventions to help prevent such occurrences.

“We adopted a customized version of the IHI’s Oxytocin Bundle. Oxytocin is a drug used to induce labor, but it is also a high alert medication linked to adverse perinatal outcomes. The Bundle is a safety protocol that ensures strict guidelines and standardized methods are followed every time we use the drug,” explains Dr. Wilcox.

The Jacobi/NCB team also adopted other components, such as testing for changes and monitoring Bundle compliance, staff education, and improving communication through TeamSTEPPS, which trains healthcare providers to use standardized communication proven to improve information sharing and teamwork skills, which ultimately helps to provide better, safer care.

The interventions had hugely successful results. Last year, the hospitals’ combined rate of deliveries complicated by shoulder dystocia dropped to 1.4% from 4% in 2008. The rate of severe Erb’s Palsy was negligible at 0.08 percent from 0.4% in 2008. And the number of adverse occurrences overall dropped by almost half to about 35 per month in July 2010 from approximately 80 per month in January 2009.

The Jacobi/NCB team’s success in reducing adverse L&D outcomes has already earned some well-deserved honors, including the 2011 HHC Safety Expo Award, the HANYS Pinnacle Award for Quality and Patient Safety presented by the Healthcare Association of New York State, and the prestigious 2011 Safety Net Award from the National Association of Public Hospitals.

“Outcomes like Baby Cassandra’s do not have to repeat themselves. We are committed to do everything we can to prevent them, so that our babies are born safely,” added Dr. Wilcox.

* Not her actual name

August 2011