EP19.01: A safety bundle for operative vaginal birth

Poor outcomes from operative vaginal birth (OVB) have been associated with failure to recognise malposition, breakdown in interdisciplinary communication and deviation from accepted guidelines. A safety bundle for OVB was implemented, including recommending routine intrapartum ultrasound, a structured time-out and procedural checklist. This study compares birth outcomes where the bundle was and was not used during the implementation period. We performed a retrospective cohort study of all attempted OVB in women with a term singleton cephalic fetus at Monash Health from August 2022 to July 2023 during bundle implementation. We compare births where the bundle was and was not used, assessing neonatal and maternal outcomes. To control confounding by indication, we estimated propensity scores (PS) for the probability of using the bundle for each case based on maternal and labour characteristics, and adjusted the effect estimates for the PS using multivariable logistic regression models. There were 996 attempted OVB in the study period. The bundle was used in 767 cases, of which 90% used the checklist, 62% the time-out and 53% intrapartum ultrasound, and in 229 cases no aspect of the bundle was used. Cases where the bundle was used were less likely to be performed in the operating theatre, have a consultant present, or to not document fetal position or station. Bundle use was associated with significantly fewer neonates delivered in an unexpected position (0.9% vs 3.5%, adjusted odds ratio [adjOR] 0.23, 95%CI 0.08-0.67, p = 0.008) and a trend to reduced composite neonatal morbidity (21.6% vs 27.6%, adjOR 0.79, 95%CI 0.55-1.13, p = 0.191). In the fifteen neonates delivered in an unexpected position, compared to those delivered in a known position, there were higher rates of unsuccessful OVB (27% vs 6.0%, p = 0.012), Caesarean for failed OVB (13% vs 2.0%, p = 0.041) and neonatal resuscitation (40% vs 15%, p = 0.016). Use of a safety bundle for OVB is associated with less infants delivered in an unexpected position and may improve perinatal outcomes.