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Recognition of Deterioration of Maternal Status Julie Arafeh MSN, RN.

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Presentation on theme: "Recognition of Deterioration of Maternal Status Julie Arafeh MSN, RN."— Presentation transcript:

1 Recognition of Deterioration of Maternal Status Julie Arafeh MSN, RN

2 Faculty Disclosure Julie Arafeh has no disclosures to announce

3 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

4 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

5 In the U.S……

6 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


8 CA-PAMR California Pregnancy-Associated Mortality Review (CA-PAMR) California Pregnancy-Associated Mortality Review (CA-PAMR) Report from 2002 and 2003 Maternal Death Reviews Report from 2002 and 2003 Maternal Death Reviews Released April 2011 Released April 2011 Link Link a_pregnancy_associated_mortality_review

9 “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

10 Leading Causes of Maternal Death: CA-PAMR Cardiovascular disease, including cardiomyopathy (20%) Cardiovascular disease, including 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%)

11 Risk Factors Advanced maternal age: ≥35 Advanced maternal age: ≥35 Parity: Five or more births Parity: Five or more births Multiple births Multiple births Prior cesarean section Prior cesarean section Obesity Obesity CA-PAMR 2011

12 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 #

13 Sentinel Event Alert Issue 44: Preventing Maternal Death January 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

14 Sentinel Event Alert Issue 44: Preventing Maternal Death January 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

15 Key Assessments

16 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

17 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)

18 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

19 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

20 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

21 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 variability  adequate cerebral oxygenation  adequate placental perfusion = maternal perfusion

22 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

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

24 Recognition of life threatening illness can be challenging Physiologic changes of pregnancy can mask development of serious illness

25 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

26 Modified Early Obstetric Warning System = MEOWS CEMACH – Confidential Enquiry into Maternal and Child Health, Dec 2007 Adapted from other Early Warning Systems


28 MEOWS Documentation system with yellow and red highlights Respiratory rate 21-30 30 Temperature 38°C or <35°C Heart rate 100-120 120 Systolic BP 90-100 or 150-160 <90 Diastolic BP 90-100 >100

29 MEOWS Other parameters highlighted: SaO2 < 95% Neuro responds to voice responds to pain only or is unresponsive Appearance looks unwell

30 ‘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

31 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

32 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

33 0650: Adm to L&D, 117/43, 92, SaO2 97%, Cx: 4/80%/-2

34 1000: 126/84, 113, 95%, Cx: C/-1

35 1015: 15 minutes later, 116/93, 127, SaO2 87%

36 1020: 116/93, 131, 93%, Pitocin off, Cx: C/+1

37 1025: MDs in room, O2@ 10L, L side, IV bolus

38 1035: 123/83, 141, SaO2 94%

39 1040: Pt pushing, no descent noted

40 1056: Immediately following, In OR

41 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

42 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

43 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

44 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

45 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

46 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

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

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

49 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

50 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

51 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

52 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

53 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

54 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

55 References morbidity (MEOWS form) morbidity Darovic, GO. Hemodynamic Monitoring: Invasive and NonInvasive Clinical Applications, 3 rd Ed. DeVita MA et al. Identifying the hospitalised patient in crisis. Resuscitation 2010;81:375- 382.

56 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, 3 rd Ed. 2013.


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