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

Abstract

Background: 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.

Objective: 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.

Study design: 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.

Conclusion: 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.

Keywords: adverse perinatal outcomes; obstetrical interventions; provider fatigue; quality improvement; quality of care; shift change.

Figure 1.

Distribution of deliveries across shifts

Figure 2.

Histogram of total shift time across all eligible deliveries

Figure 3.

Frequency of outcomes by amount of attending shift completed 3a. Cesarean delivery 3b. Episiotomy 3c. Major perineal laceration 3d. 5-minute Apgar score <4 3e. Neonatal intensive care unit admission Blue line represents smoothed frequency of the outcome by proportion of attending physician’s time completed in the working shift. The shaded area represents 95% confidence band. The probabilities and confidence limits were calculated by generalized additive models. P-value represents probability value for unadjusted models.

Figure 4.

Frequency of outcomes by amount of attending shift completed in the sensitivity analysis cohort of obstetricians working 12-hour shifts 4a. Cesarean delivery 4b. Episiotomy 4c. Major perineal laceration 4d. 5-minute Apgar score <4 4e. Neonatal intensive care unit admission Sensitivity analysis is restricted to patients delivered by attending obstetricians working 12-hour shifts. Blue line represents smoothed frequency of the outcome by proportion of attending physician’s time completed in the working shift. The shaded area represents 95% confidence band. The probabilities and confidence limits were calculated by generalized additive models. P-value represents probability value for unadjusted models.