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

Backgroundrecent reports suggest a rising awareness of sudden unexpected postnatal collapse (supc).local problemfive supc events during a 17-month period.methodsa 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.interventiona 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.resultspre-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.conclusiona bundled approach to monitoring during skin-to-skin care, including measurement of oxygen saturation, was associated with no additional cases of supc.