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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 - PowerPoint PPT Presentation
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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
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