Improving Second Stage Safety: IHI Perinatal Community Supports Hospitals in Evidence-Based Improvement Efforts

I know when I set out to change something about my health, a few things make the process much easier and, for that matter, more likely to yield the benefits I’m after. I’m particularly aware of this these days as I’ve recently (successfully!) changed some health habits that put me at risk for heart disease, which, with my family history, really needed to be addressed. In making these changes, I realized that my success reflected the body of literature that tells us that change is easiest and more likely to stick when you:

  • know what you need to change and why
  • start with small, feasible objectives that move you toward a larger goal
  • have support, especially from others who are also trying to change or who have done so successfully already
  • track your progress and adjust your approach as needed
  • measure and celebrate your results

Large organizations, such as hospitals or healthcare systems, are capable of change, too, and there’s another body of literature on how effective organizational changes unfold. But knowledge of the problem, peer support, and tracking and measuring against feasible objectives are no less important. That’s why I’m excited about the Institute for Healthcare Improvement (IHI) Perinatal Improvement Community. Any hospital interested in improving perinatal care and outcomes can enroll in the community and take advantage of their measurement tools as well as support from IHI experts and other participating hospitals. IHI organizes its improvement efforts around “bundles” so that hospitals can work toward change in one focus area at a time, with the overarching goals of reducing harm through better communication and teamwork, patient-centered care, and less unwarranted variation in care practices. Hospitals that participated in the first round of the Perinatal Improvement Community worked on safe use of induction and augmentation, including eliminating elective inductions prior to 39 weeks. The next round of participation will focus on Second Stage Safety, and hospitals must enroll by next Wednesday, September 1. Check out IHI’s web site to learn about the results of participating hospitals’ improvement efforts and to find out how your hospital can enroll.


  1. avatar
    Christie B
    August 24th, 2010 at 23:47 | #1

    Thanks for this post – this certainly seems to be an exciting set of initiatives. There is definitely room for improvement in second stage management!

  2. August 25th, 2010 at 09:57 | #2

    I’m curious to know what improvements will be part of the “second-stage safety” package. Do you know?

    And I must say I am less than impressed that the “induction safety” package stopped at eliminating elective induction before 39 weeks instead of eliminating elective induction, or at the very least, eliminating it, period, in first-time mothers and in women with an unfavorable cervix. Electively inducing labor in these subgroups increases the risk of cesarean surgery, and the use of cervical ripening agents does not do away with the excess, so it is far from safe.

  3. August 25th, 2010 at 14:23 | #3

    Thank you for your on target comments. In the current obstetrical environment, we decided to start where we were which meant that we focused on the safe use of oxytocin first, knowing that changing the current practice of elective inductions would require cultural and practice changes that involve not only health care providers, but women as well. As the organizations learn at a different level what is happening to all patients in their care, it becomes more evident and intuitive that the next focus is why is this patient here to begin with? In the work, we all agree with the outcomes associated with elective induction. As part of the second stage safety work, we began with understanding the current patient populations in individual organizations using the NQF, now JCT endorsed measure for Cesarean Section (Nulliparous women with a term, singleton baby in a vertex position delivered by cesarean section). The first surprise in the data was the actual number of women who did NOT make it to second stage, and I encourage all to study this group to understand how our systems and processes contribute to the outcomes. We all may know what we should do, the truth is unless we change our systems we will not change our outcomes and the cesarean rate will continue to increase. Thank you for all your work in this area.
    My question- How can we mobilize women to partner with us to make this shift in care? Social movements are needed and many leaders have done this- you, Polly Perez, Penny Simpkin, and others. Is it time again?

  4. avatar
    Cathy Greene
    August 27th, 2010 at 14:31 | #4

    I would like a good video to help teach nurses and/or parents about techniques to help open glottis pushing/non-directed pushing during second stage. I saw the webinar on AWHONN and would like a different option and have it discuss more about prevention of tears.

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