Recognition of Deterioration of Maternal Status

Julie Arafeh MSN, RN

Faculty Disclosure

Julie Arafeh has no disclosures to announce

Objectives

Discuss key assessments warning of deterioration of maternal status

List risk factors for maternal morbidity and mortality

Review recommendations to address issues surrounding rising maternal mortality rates

The Scope of the Problem…. In the World ~600,000 women die

each year as a result of pregnancy and childbirth

1600 women die each day

One woman dies every minute

In the U.S……

The Scope of the Problem….

In the US ~6 million US women become

pregnant/year, >10,000 give birth/day 2-3 die of pregnancy related causes/day Risk of death varies greatly in different racial

and ethnic groups

CA-PAMR

California Pregnancy-Associated California Pregnancy-Associated Mortality Review (CA-PAMR)Mortality Review (CA-PAMR)

Report from 2002 and 2003 Maternal Report from 2002 and 2003 Maternal Death Reviews Death Reviews

Released April 2011Released April 2011 LinkLinkhttp://cmqcc.org/maternal_mortality/california_maternal_mortality/http://cmqcc.org/maternal_mortality/california_maternal_mortality/

california_pregnancy_associated_mortality_review california_pregnancy_associated_mortality_review

“More than a third of the pregnancy-related deaths were determined to

have had a good-to-strong chance of being prevented.”

CA-PAMR, 2011

Leading Causes of Maternal Death: CA-PAMR

Cardiovascular disease, including Cardiovascular disease, including cardiomyopathy (20%) cardiomyopathy (20%)

Pre-eclampsia/eclampsia (15%) Pre-eclampsia/eclampsia (15%) Amniotic fluid embolism (14%) Amniotic fluid embolism (14%) Obstetrical hemorrhage (10%) Obstetrical hemorrhage (10%) Sepsis/infection (8%) Sepsis/infection (8%)

Risk Factors

Advanced maternal age: ≥35Advanced maternal age: ≥35 Parity: Five or more birthsParity: Five or more births Multiple birthsMultiple births Prior cesarean sectionPrior cesarean section ObesityObesity

CA-PAMR 2011CA-PAMR 2011

Risk Factor: Obesity

“Obese women with body mass index (BMI) > 30 far more likely to die during pregnancy”

Parameters for BMI of 30 5’4” 175 # 5’5’’ 180 # 5’6’’ 186 # 5’7’’ 191.5 # 5’8’’ 197 # 5’9’’ 203 #

http://www.cemach.org.uk/Home.aspx

Sentinel Event Alert Issue 44: Preventing Maternal DeathJanuary 26, 2010

…the most common preventable errors are: Failure to adequately control blood pressure in

hypertensive women Failure to adequately diagnose and treat

pulmonary edema in women with pre-eclampsia Failure to pay attention to vital signs following

Cesarean section Hemorrhage following Cesarean section

Sentinel Event Alert Issue 44: Preventing Maternal DeathJanuary 26, 2010

2010 Standards for Hospitals Recognize and respond as soon as

condition worsens Written criteria: early warning signs,

when to seek help Staff seek assistance when concerned Family seek assistance when concerned

Key Assessments

What Are The Signs of Maternal Deterioration?

KEY ASSESSMENTS Heart rate over 100 beats/min Systolic BP over 160 mmHg or

under 90 mmHg Diastolic BP over 80 mmHg Temperature over 38°C (100.4° F) Respiratory rate over 21 breaths/min

Over 30 breaths/min indicates serious illness

KEY ASSESSMENT: Heart Rate

Count HR for 1 minute with stethoscope at apex of heart for high risk patient

Investigate cause of tachycardia: Pain, stress, fever, medication including recreational drugs, CV/pulmonary compromise

For patients with a history of cardiac disease: Report irregular rate (rule out arrhythmia) Report if consistently above 100 (may interfere

with cardiac output)

KEY ASSESSMENT: Blood Pressure Measurement

Most accurate position for BP is sitting or semi-sitting

May be 10-12 mmHg difference in superior and inferior arm when pt side-lying

KEY ASSESSMENT: Respiratory Rate

Count rate for 1 minute with stethoscope for high risk patients

Other assessments: Breath sounds, SaO2, dyspnea (speech pattern), pt posture,cough

Sustained RR of 35-40, indication for evaluation for intubation

KEY ASSESSMENT: Pulse Pressure

Pulse pressure (PP) = difference between systolic and diastolic BP

in PP seen with exercise, anxiety, bradycardia, anemia, fever, HTN, pulmonary edema, aortic coarctation

↓ in PP seen with hemorrhage Narrowing PP occurs with rising diastolic BP

KEY ASSESSMENT: The Fetus

Fetus = the “miner’s canary” Fetal tachycardia may indicate early fetal

hypoxemia, late decelerations indicate uteroplacental insufficiency

FHR accelerations and/or moderate variabilityadequate cerebral oxygenationadequate placental perfusion = maternal perfusion

KEY ASSESSMENT: Neurologic Assessment

Glasgow Coma Scale: Objective assessment of level of consciousness 7 points or less found in comatose pt

Use scale for neurologic assessment that is used by local ICU

““The weakest link in patient care is the tendency The weakest link in patient care is the tendency of the clinician to convince himself or herself of the clinician to convince himself or herself that somehow everything will be alright”that somehow everything will be alright”

Stephen Ayres, MDStephen Ayres, MD

Recognition of life threatening illness can be challenging

Physiologic changes of pregnancy can mask development of serious illness

Early Warning System

Assessment of: Mental status Heart rate Respiratory rate Systolic blood pressure Temperature

Documentation strategy that assists in alerting the bedside provider to changes in patient status

Modified Early Obstetric Warning System = MEOWS

CEMACH – Confidential Enquiry into Maternal and Child Health, Dec 2007

Adapted from other Early Warning Systems

http://www.cemach.org.uk/http://www.cemach.org.uk/

MEOWS

Documentation system with yellow and red highlights

Respiratory rate 21-30 <10 or >30 Temperature <36°C >38°C or <35°C Heart rate 100-120 <40 or >120 Systolic BP 90-100 or 150-160 <90 Diastolic BP 90-100 >100

MEOWS

Other parameters highlighted: SaO2 < 95% Neuro responds to voice

responds to pain only or is unresponsive

Appearance looks unwell

‘MEOWS’ Monitors

Mechanism for comparison of variability

96 hours of VS data stored to allow discovery of trends in patients that decompensate

Early warning systems embedded into monitor based on data that alert staff

Case Study

32-year-old, G 2 P 1001, received prenatal care

OB Hx: Previous LTCS for failure of fetus to descend (7 lbs, 6 ozs)

Presents to L&D at 37 weeks with c/o N&V, denies fever, chills, diarrhea or abdominal pain, blurred vision, headache

Admission

Placed on EFM Labwork: Creatinine 1.25, AST 220,

ALT 326, uric acid 8.8, UA neg, 24 hour urine started

Plan: Delivery, patient desires VBAC, Epidural for pain management

0650: Adm to L&D, 117/43, 92, SaO2 97%, Cx: 4/80%/-2

1000: 126/84, 113, 95%, Cx: C/-1

1015: 15 minutes later, 116/93, 127, SaO2 87%

1020: 116/93, 131, 93%, Pitocin off, Cx: C/+1

1025: MDs in room, O2@ 10L, L side, IV bolus

1035: 123/83, 141, SaO2 94%

1040: Pt pushing, no descent noted

1056: Immediately following, In OR

Outcome

Viable male infant, 2832 grams, Apgars 2, 7

Uterus ruptured along previous incision, 1500 cc of blood in peritoneal cavity

EBL 2500 cc, 2 units FFP, 2 units cryoprecipitate, 1 unit PRBCs given

Both mother and baby to ICU, both discharged in stable condition on PPD #5

Case Study

44 y.o. G12, P0-1-10-1@ 28 4/7 weeks Diagnosis: PTL, reduced cervical

competence - cerclage placed Prev. adm. 2 days ago for PTL; placed on

terbutaline, indocin, BMZ, abx for UTI Current meds: terbutaline and abx

Update

1630: 128/62, 115, 24,

99.5 MD Orders: Admit,

Mag SO4 infusion, Terb SQ q 4 hr

1840: 130/54, 125, 28 UC’s q 2-3 min FHRB 140-150, no accels

or decels UOP 40 cc/2 hrs MD Orders: MgSO4 at 2

gm/hr, Indocin 50 mg

Update

2130: 136/46, 140, 32 SaO2 95% on room

air MD Orders: DC

terbutaline, MgSO4 to 3 gm/hr

0130: 123/48, 119, 32 UOP 30 cc/hr Late decels on EFM MD Orders:

Observe

Update

0200: 126/44, 128, 35 SaO2 90% with O2 per

mask, C/O SOB Crackles heard in lung

bases MD Orders: MgSO4 at 2

gm/hr

0600: 126/44, 120, 32 SaO2 90% UOP < 30 cc/hr MD Orders: DC MgSO4,

wean O2, transfer to antepartum unit

Update

0730: 122/50, 140, 40 SaO2 87% FHRB 160-170 To L&D CXR Incentive spirometry q hr

0920: 96/38, 132, 36 SaO2 89% on O2 per mask UC mild intensity MD Orders: CXR – Pulm Edema Lasix 40 mg IV, ✔ cervix,

Observe

Outcome:

Cerclage clipped SVD: male infant with Apgars of 4 & 6 CBG’s: 7.01/ 54/ 8/ -13.6 Mother to ICU for intubation

Selected Recommendations

“….detection of life threatening illness alone is of little value. It is the subsequent management that will alter the outcome.”

http://www.cemach.org.uk/

Selected Recommendations

Preconception care for women with pre-existing serious medical or mental health condition or obesity

Treatment of systolic BP of 160 or greater with anti-hypertensive, possibly earlier if clinical picture suggests rapid deterioration

Cesarean may be the safest birth for some but is not risk free

Selected Recommendations

All clinical staff need to learn from critical events or serious untoward incidents

All clinical staff need to have regular information and training on identification, management and referral of serious conditions

Early warning scoring systems should be adapted and used to alert staff to worsening clinical condition

Selected Recommendations

Identification and management of hemorrhage should be reviewed with staff including use of in-situ drills

Encourage and practice open communication between all staff

Standardize and centralize documentation Develop guidelines or algorithms to guide

management of serious conditions

Selected Recommendations

Guidelines/best practices for preconception management of obese women established

Promote attainment of healthy pre-pregnancy weight, appropriate weight gain during pregnancy through better nutrition and increased activity

CA-PAMR 2011

Selected Recommendations

Measures to prevent blood clots for all women undergoing cesarean delivery

Education - health risks of primary and subsequent cesarean birth

Causes of death found more preventable: obstetric hemorrhage, sepsis/infection, and preeclampsia/eclampsia

Direct, set priorities for statewide quality improvement efforts

Selected Recommendations

Help health care providers recognize and respond to critical clinical obstetric events

Identify and manage maternal risk factors, including obesity, hypertension and underlying heart disease

Improve the ability of health care facilities to respond to obstetric emergencies

References

http://www.cmqcc.org/ http://www.cmqcc.org/resources/maternal_

morbidity (MEOWS form)

Darovic, GO. Hemodynamic Monitoring: Invasive and NonInvasive Clinical Applications, 3rd Ed.

DeVita MA et al. Identifying the hospitalised patient in crisis. Resuscitation 2010;81:375-382.

References

Eighth Report of the Confidential Enquiries into Maternal Deaths in the UK. :2006-2008. BJOG, March 2011;Vol 118 Suppl 1:1-203

The Joint Commission. Sentinel Event Alert Issue 44: Preventing Maternal Death, January 26, 2010.

Troiano NH et al. High-Risk and Critical Care Obstetrics, 3rd Ed. 2013.

jarafeh@stanford.edu