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



Recent reports suggest a rising awareness of sudden unexpected postnatal collapse (SUPC).

Local problem

Five SUPC events during a 17-month period.


A 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.


A 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.


Pre-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.


A bundled approach to monitoring during skin-to-skin care, including measurement of oxygen saturation, was associated with no additional cases of SUPC.

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The project was completed with no specific financial support.

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Correspondence to David A. Paul.

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Paul, D.A., Johnson, D., Goldstein, N.D. et al. Development of a single-center quality bundle to prevent sudden unexpected postnatal collapse. J Perinatol 39, 1008–1013 (2019).

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