Maternal Death Is It Preventable Slides - Mead Johnson€¦ · Maternal Death Is It Preventable? Disclaimer ... The presenter has complete and independent control over the planning

Washington C. Hill, MD, FACOGMedical Director, Labor and Delivery

Director, Maternal-Fetal Medicine Sarasota Memorial Hospital1700 South Tamiami Trail

Sarasota, Florida [email protected]

(941) 917-6260 / (800) 892-7088

Maternal DeathIs It Preventable?

DisclaimerDisclaimerMead Johnson sponsors programs such as this to give Mead Johnson sponsors programs such as this to give healthcare professionals access to scientific and educationalhealthcare professionals access to scientific and educationalinformation provided by experts. The presenter has completeinformation provided by experts. The presenter has completeand independent control over the planning and content ofand independent control over the planning and content ofthe presentation, and is not receiving any compensation the presentation, and is not receiving any compensation from Mead Johnson for this presentation. The presenterfrom Mead Johnson for this presentation. The presenter’’s s comments and opinions are not necessarily those of Meadcomments and opinions are not necessarily those of MeadJohnson.Johnson. In the event that this presentation contains In the event that this presentation contains statements about uses of drugs that are not within the drugs' statements about uses of drugs that are not within the drugs' approved indications,approved indications, Mead Johnson does not promote the Mead Johnson does not promote the use of any drug for indications outside the FDAuse of any drug for indications outside the FDA--approved approved product label.product label.


I I have nohave no ccommercial ommercial disclosures odisclosures orr

potential conflicts of potential conflicts of interestinterest


ObjectivesObjectives--At the end of this presentation the At the end of this presentation the participant will be able to:participant will be able to:

11--Understand what causes maternal death.Understand what causes maternal death.

22--Understand how maternal death can be Understand how maternal death can be prevented and when it cannot.prevented and when it cannot.

33--Understand the possible medical legal issues Understand the possible medical legal issues when maternal death occurs.when maternal death occurs.


Maternal Mortality RatioMaternal Mortality Ratio

The number of maternal deaths (direct The number of maternal deaths (direct ––hemorrhage and indirecthemorrhage and indirect--asthma) that asthma) that result from the reproductive process per result from the reproductive process per 100,000 live births.100,000 live births.Numerator=number of deaths Numerator=number of deaths regardless of pregnancy outcomeregardless of pregnancy outcomeDenominator=the number of live birthsDenominator=the number of live birthsUsed less often than maternal mortality Used less often than maternal mortality rate or maternal death raterate or maternal death rate

Maternal Mortality RateMaternal Mortality Rate(maternal deaths per 100,00 live births)(maternal deaths per 100,00 live births)

ColoradoColorado--11.011.0

CaliforniaCalifornia--11.311.3

FloridaFlorida--13.113.1

Healthy People 2010 GoalHealthy People 2010 Goal--3.33.3

Maternal Mortality RateMaternal Mortality Rate

Overall In U.S. about Overall In U.S. about 13.313.3 per 100,000per 100,000Significant racial disparitySignificant racial disparityWhites 5.3 per 100,000Whites 5.3 per 100,000African Americans 19.6 per 100.000African Americans 19.6 per 100.000Reasons are unclearReasons are unclear

Source: CDCSource: CDC--19991999

PregnancyPregnancy--Associated Associated MortalityMortality

Defined as the death of a Defined as the death of a woman from any cause while woman from any cause while she is pregnant or within one she is pregnant or within one

year of terminationyear of termination

CDC and ACOGCDC and ACOG

Known Risk Factors For Maternal DeathKnown Risk Factors For Maternal Death

Advanced maternal ageAdvanced maternal age--due to due to associated illnesses such as obesity, associated illnesses such as obesity, diabetes and hypertension. diabetes and hypertension. Increasing parityIncreasing parity--due to increased due to increased incidence of abruptio placenta, placenta incidence of abruptio placenta, placenta previa and uterine ruptureprevia and uterine ruptureHospital to large or to smallHospital to large or to smallInexperienced providersInexperienced providersNonNon--white racewhite race

Mortality RatesMortality Rates

Have decreased over the last two Have decreased over the last two decadesdecadesHighest in the Southern statesHighest in the Southern statesLowest in the Western statesLowest in the Western statesModest rise from 1987Modest rise from 1987--19901990Wide discrepancies between whites and Wide discrepancies between whites and nonnon--whiteswhites

Most Common Causes Of Most Common Causes Of Maternal Death In The NationMaternal Death In The Nation

Bleeding or hemorrhageBleeding or hemorrhageEmbolismEmbolismPreeclampsia and hypertensive diseasePreeclampsia and hypertensive diseaseInfectionInfectionCardiomyopathyCardiomyopathyAnesthesiaAnesthesiaMost causes have decreased but infection and Most causes have decreased but infection and cardiomyopathy have increased for unknown cardiomyopathy have increased for unknown reasonsreasons

Bleeding or HemorrhageBleeding or HemorrhageCauses of Maternal DeathCauses of Maternal Death

Postpartum hemorrhage/uterine Postpartum hemorrhage/uterine atonyatonyUterine ruptureUterine ruptureUterine inversionUterine inversionFibroidsFibroidsReproductive tract lacerationsReproductive tract lacerationsCoagulopathyCoagulopathy

Florida Leading Causes of DeathFlorida Leading Causes of DeathChart 2: Distribution of Pregnancy-Related Causes of

Death, Florida 1999-2005 (n=264)

8%

9%

11%

11%

12%

12%

22%

15%

0% 5% 10% 15% 20% 25% 30%

Other Cardiovascular Problems

Amniotic Fuild Embolism

Cardiomyopathy

Infection

Thrombotic Embolism

Hemorrhage

Hypertensive Disorders

Other

*The Other cause category includes deaths due to cancer, gas trointes tinal disorders , HIV/AIDS, and hem atopoietic disorders .

*

LetLet’’s Look Closer At Bleeding or Hemorrhages Look Closer At Bleeding or Hemorrhage

Bleeding or HemorrhageBleeding or HemorrhageCauses of Maternal DeathCauses of Maternal Death

Trauma: shoulder dystocia, operative Trauma: shoulder dystocia, operative deliverydeliveryPrevious tocolysisPrevious tocolysisHistory of postpartum hemorrhageHistory of postpartum hemorrhageAbruptio placenta and placenta previaAbruptio placenta and placenta previaPlacenta previa and previous C/SPlacenta previa and previous C/SPlacenta accreta which will increasePlacenta accreta which will increase

Bleeding or HemorrhageBleeding or HemorrhageClinical PearlsClinical Pearls

Hemorrhage is a sign, NOT a diagnosisHemorrhage is a sign, NOT a diagnosisThe first step is to determine the The first step is to determine the causecauseLarge bore IV accessLarge bore IV accessDonDon’’t underestimate blood losst underestimate blood lossNotify early anesthesia and blood bankNotify early anesthesia and blood bank


Act quickly in delivery roomAct quickly in delivery roomDonDon’’t get behindt get behindUterine massageUterine massageUterotonic medicationsUterotonic medications--pitocinpitocin--metherginemethergine--hemobatehemobate--misoprostolmisoprostol

What Can We Learn From This?

http://rds.yahoo.com/_ylt=A9G_bDtPU5VLG0UAlfSjzbkF/SIG=12fko32j7/EXP=1268163791/**http%3a//www.shsclassof1956.org/Images2/MiracleOnHudson01.jpg

PRACTICE, Practice, practice

http://rds.yahoo.com/_ylt=A9G_bDtPU5VLG0UAlfSjzbkF/SIG=12fko32j7/EXP=1268163791/**http%3a//www.shsclassof1956.org/Images2/MiracleOnHudson01.jpg


Repair lacerationsRepair lacerationsRemove placenta and do D and C if Remove placenta and do D and C if necessarynecessaryDiagnose and treat coagulopathyDiagnose and treat coagulopathyInitiate blood component therapy quicklyInitiate blood component therapy quicklyMove on to surgical treatmentMove on to surgical treatment


Surgical treatmentSurgical treatment--uterine packinguterine packing

--uterine artery ligationuterine artery ligation--BB--Lynch sutureLynch suture

--uteroutero--ovarian arterial anastomosis ligationovarian arterial anastomosis ligation--oversew of placental implantation siteoversew of placental implantation site--bilateral hypogastric artery ligationbilateral hypogastric artery ligation--embolizationembolization--supracervical hysterectomysupracervical hysterectomy

Bleeding or HemorrhageBleeding or HemorrhageMedical Legal IssuesMedical Legal Issues

Failure to establish differential diagnosis Failure to establish differential diagnosis and appreciate degree of blood lossand appreciate degree of blood lossLack of attention to blood lossLack of attention to blood lossDelayed or concealed bleedingDelayed or concealed bleedingSlow recognition of hemorrhageSlow recognition of hemorrhageSlow treatment of coagulopathySlow treatment of coagulopathyHysterectomy not considered or Hysterectomy not considered or performed too lateperformed too late

Bleeding or HemorrhageBleeding or HemorrhageMedical Legal IssuesMedical Legal Issues

False reliance on initial CBCFalse reliance on initial CBCGetting behind in treatmentGetting behind in treatmentNot enough blood componentsNot enough blood componentsTreating patient in the wrong locationTreating patient in the wrong locationHemorrhage could have been prevented Hemorrhage could have been prevented or predictedor predictedLack of experienced personnelLack of experienced personnel

Estate of Becky Brown v. Estate of Becky Brown v. The Medical Center The Medical Center

and Dr. K.and Dr. K.

Bleeding or HemorrhageBleeding or HemorrhageCase ReviewCase Review

Becky is a G7P6 patient of Dr. K. who had an Becky is a G7P6 patient of Dr. K. who had an uncomplicated prenatal course. Admitted in uncomplicated prenatal course. Admitted in spontaneous labor at 38 weeks. spontaneous labor at 38 weeks. Augmentation of labor was necessary because Augmentation of labor was necessary because of failure to progress. Pitocin was of failure to progress. Pitocin was administered according to the hospital administered according to the hospital protocol and she delivered without protocol and she delivered without complication, however after delivery of the complication, however after delivery of the infant there was massive vaginal bleeding. infant there was massive vaginal bleeding.


Her uterus was massaged, uterotonic Her uterus was massaged, uterotonic medication was given, and D & C was done, medication was given, and D & C was done, but hemorrhage persisted. but hemorrhage persisted. Anesthesia was in attendance and initiated Anesthesia was in attendance and initiated immediately appropriate diagnostic tests and immediately appropriate diagnostic tests and therapy. Hypotensive, Becky was taken to the therapy. Hypotensive, Becky was taken to the OR and explored, where a retroperitoneal OR and explored, where a retroperitoneal hematoma was found from a laceration of the hematoma was found from a laceration of the uterus. uterus.


A gynecological oncologist was called in and a A gynecological oncologist was called in and a Supracervical hysterectomy was performed. An Supracervical hysterectomy was performed. An attempt was made to stop bleeding into the attempt was made to stop bleeding into the retroperitoneal hematoma. During the retroperitoneal hematoma. During the procedure ,however, Becky coded and could procedure ,however, Becky coded and could not be resuscitated. The family filed a law suit not be resuscitated. The family filed a law suit against Dr. K. and the hospital.against Dr. K. and the hospital.

A Model For Reviewing Your A Model For Reviewing Your Pregnancy Associated Pregnancy Associated

Maternity MortalityMaternity Mortality

FloridaFlorida’’ssPregnancyPregnancy--AssociatedAssociated

Mortality ReviewMortality Review

Our Report Is Available Online

The InternationalExperience

WhatWhat’’s up in developing countries...s up in developing countries...

http://www.heartsafire.us/



Maternal Mortality Around The WorldMaternal Mortality Around The World1996 1996 Maternal deaths per 100,000 live birthsMaternal deaths per 100,000 live births

Afghanistan 1700Afghanistan 1700Tanzania 770Tanzania 770Ghana 740Ghana 740Kenya 650Kenya 650United States 12United States 12United Kingdom 9United Kingdom 9Norway 6Norway 6Canada 6Canada 6http://www.unicef.org/pon96/leag1wom.htmhttp://www.unicef.org/pon96/leag1wom.htm

http://www.unicef.org/pon96/wofigure.htm

The FloridaExperience19961996--PresentPresent

To reduce pregnancyTo reduce pregnancy--related deaths, related deaths, we must examine:we must examine:

Why are women dyingWhy are women dying??

What action steps can be taken What action steps can be taken to reduce these deaths?to reduce these deaths?

Components of PAMRComponents of PAMR

Case AscertainmentCase AscertainmentAbstraction TeamAbstraction TeamInterdisciplinary Case ReviewInterdisciplinary Case ReviewState Level CoordinationState Level CoordinationData Maintenance, Analysis, and Data Maintenance, Analysis, and DisseminationDissemination

OverviewOverview19991999--20052005

PAMR committee reviewed 381 PAMR committee reviewed 381 pregnancypregnancy--associated deathsassociated deaths

Identified 264 (71%) as pregnancyIdentified 264 (71%) as pregnancy--relatedrelated

Chart 1: PAMR Pregnancy-Related Mortality RatiosFlorida, 1999-2005

0.0

20.0

40.0

60.0

Dea

ths

per 1

00,0

00 li

ve b

irths All White Black

All 20.3 19.1 16.1 15.1 19.3 23.0 13.3 White 15.0 13.3 9.9 9.9 8.9 14.4 8.4Black 40.0 40.2 36.1 34.7 55.2 53.2 27.1

1999 2000 2001 2002 2003 2004 2005

Leading Causes of DeathLeading Causes of DeathChart 2: Distribution of Pregnancy-Related Causes of

Death, Florida 1999-2005 (n=264)

8%

9%

11%

11%

12%

12%

22%

15%

0% 5% 10% 15% 20% 25% 30%

Other Cardiovascular Problems

Amniotic Fuild Embolism

Cardiomyopathy

Infection

Thrombotic Embolism

Hemorrhage

Hypertensive Disorders

Other

*The Other cause category includes deaths due to cancer, gas trointes tinal disorders , HIV/AIDS, and hem atopoietic disorders .

*

Timing of DeathTiming of DeathChart 3: Timing of Death for PAMR

Pregnancy-Related Deaths, 1999-2005 (n=264)

Labor and Delivery

5%

Prenatal18%

Postpartum76%

No Source Data1%

Timing of DeathTiming of Death--RevisedRevisedTable 1: Interval Between Date of Hospital Discharge and Table 1: Interval Between Date of Hospital Discharge and

Date of Death PregnancyDate of Death Pregnancy--Related Deaths, 1999Related Deaths, 1999--2005 2005

Interval between Date of Interval between Date of Hospital Discharge and Date of Hospital Discharge and Date of

DeathDeathPregnancyPregnancy--

Related DeathsRelated Deaths PercentPercent

6 weeks or less6 weeks or less 5353 59%59%

6 weeks to 3 months6 weeks to 3 months 1313 14%14%

3 months or >3 months or > 1717 19%19%

Data Not PresentData Not Present 77 8%8%

TotalTotal 9090 100.0%100.0%

Leading Cause of Death during Leading Cause of Death during the first six weeks postpartumthe first six weeks postpartum--

Discharged HomeDischarged Home

Infection (23%)Infection (23%)

Thrombotic Embolism (21%)Thrombotic Embolism (21%)

Cardiomyopathy (20%)Cardiomyopathy (20%)

Leading Cause of DeathLeading Cause of DeathDuring the first six During the first six weeksweeks--

Remained in HospitalRemained in Hospital

Hypertension (26%)Hypertension (26%)

Amniotic Fluid Embolism (15%)Amniotic Fluid Embolism (15%)

Hemorrhage (12%)Hemorrhage (12%)

Women most at risk for pregnancyWomen most at risk for pregnancy--related death:related death:

Age 35 and older (RR=3.65)Age 35 and older (RR=3.65)Black nonBlack non--Hispanic (RR=3.32)Hispanic (RR=3.32)High school education or less (RR=1.72,1.50, High school education or less (RR=1.72,1.50, respectively)respectively)Received no prenatal care (RR=9.95)Received no prenatal care (RR=9.95)Cesarean Delivery (RR=5.09)Cesarean Delivery (RR=5.09)Overweight (OR= 2.13)Overweight (OR= 2.13)Obese Categories 1,2,or 3 (OR=3.5, 3.5, 8.0)Obese Categories 1,2,or 3 (OR=3.5, 3.5, 8.0)

What Are The Risk Factors?What Are The Risk Factors?What Are The Risk Factors?

Issues/Recommendations Issues/Recommendations or or

Why Do This Anyway?Why Do This Anyway?

Issues/RecommendationsIssues/Recommendations

The purpose of FloridaThe purpose of Florida’’s PAMR is to:s PAMR is to:Elucidate gaps in careElucidate gaps in careIdentify systemic service delivery Identify systemic service delivery issues issues Make recommendations to facilitate Make recommendations to facilitate improvements in overall systems of improvements in overall systems of care.care.

SummarySummary

Recommendations were categorized into Recommendations were categorized into 4 improvement categories:4 improvement categories:

Clinical FactorsClinical FactorsSystems FactorsSystems FactorsIndividual/Community FactorsIndividual/Community FactorsDeath Review FactorsDeath Review Factors

Issues & RecommendationsIssues & Recommendations

Clinical FactorsClinical Factors::IssuesIssues::

Incomplete assessmentsIncomplete assessmentsInadequate documentationInadequate documentationDeficient communicationDeficient communicationLack of association with change in Lack of association with change in mental status.mental status.


Clinical FactorsClinical FactorsRecommendations:Recommendations:

Care Coordination/Follow Care Coordination/Follow ––UpUpThorough AssessmentsThorough AssessmentsEducate on postpartum warning signsEducate on postpartum warning signsRaise awareness of postpartum Raise awareness of postpartum thrombotic embolism riskthrombotic embolism risk


Clinical FactorsClinical FactorsRecommendations:Recommendations:

Preconception education and counselingPreconception education and counselingFamily planningFamily planning--chronic illnesschronic illnessScreen, treat and refer for substance Screen, treat and refer for substance abuse, domestic violence and depression.abuse, domestic violence and depression.

Issues & RecommendationsIssues & RecommendationsSystem FactorsSystem FactorsIssues:Issues:

Lack of standard treatment policy for Lack of standard treatment policy for prevention of thrombotic embolismprevention of thrombotic embolismPostpartum Education not inclusive of Postpartum Education not inclusive of signs of thrombosis and cardiovascular signs of thrombosis and cardiovascular events.events.

Issues & RecommendationsIssues & RecommendationsSystem FactorsSystem FactorsRecommendations:Recommendations:

Develop standards and guidelines for Develop standards and guidelines for prevention/treatment of thrombotic embolismprevention/treatment of thrombotic embolismPostpartum education needs to be more Postpartum education needs to be more inclusive and delivered more effectively.inclusive and delivered more effectively.Establish policies regarding care coordination Establish policies regarding care coordination for high risk pregnant/postpartum women.for high risk pregnant/postpartum women.


Individual/Community FactorsIndividual/Community FactorsIssuesIssues::

PrePre--Existing Medical ConditionsExisting Medical ConditionsInformed ConsentInformed Consent

Issues & RecommendationsIssues & RecommendationsIndividual/CommunityIndividual/CommunityRecommendations:Recommendations:

Educate women with a chronic illness on risk of Educate women with a chronic illness on risk of pregnancypregnancyObtain Obtain ““informed consentinformed consent”” on all medical on all medical procedures for all women.procedures for all women.(Particularly for inductions and Cesarean delivery (Particularly for inductions and Cesarean delivery of women who are obese or have a chronic of women who are obese or have a chronic illness.)illness.)


Death Review FactorsDeath Review FactorsIssues:Issues:

Lack of autopsy on unexplained or Lack of autopsy on unexplained or inconclusive deathsinconclusive deathsInaccurate/Incomplete documentation Inaccurate/Incomplete documentation on death certificateson death certificates

SummarySummaryBlack pregnancyBlack pregnancy--related mortality ratio remains related mortality ratio remains three or more times greater than the White three or more times greater than the White ratio. ratio.

The overall leading causes of death were The overall leading causes of death were hypertension, hemorrhage and thrombotic hypertension, hemorrhage and thrombotic embolism. embolism.

Most of the pregnancyMost of the pregnancy--related deaths occurred related deaths occurred during the postpartum period with the majority during the postpartum period with the majority occurring during the first 6 weeks after occurring during the first 6 weeks after discharge. discharge.

SummarySummary

The PAMR committee recommendations The PAMR committee recommendations were categorized into 4 improvement were categorized into 4 improvement categories, 71% were classified as clinical categories, 71% were classified as clinical factors potentially modifiable by factors potentially modifiable by practitioners. practitioners.

For additional information on FloridaFor additional information on Florida’’s PAMR s PAMR project, please contact: project, please contact:

Ms. Deborah Burch, R.N., B.S., C.P.C.E. at: Ms. Deborah Burch, R.N., B.S., C.P.C.E. at: [email protected][email protected]: 850/245Telephone: 850/245--4465 x29694465 x2969

mailto:[email protected]

Finally….What Does The Joint Commission Have To Say AboutPreventing Maternal Death ?

Preventing Maternal DeathJoint Commission Sentinel Event Alert

Issue 44, January 26, 2010According to the HCA study, the most According to the HCA study, the most common preventable errors are:common preventable errors are:Failure to adequately control blood pressure Failure to adequately control blood pressure in hypertensive women in hypertensive women Failure to adequately diagnose and treat Failure to adequately diagnose and treat pulmonary edema in women with prepulmonary edema in women with pre--eclampsia eclampsia Failure to pay attention to vital signs Failure to pay attention to vital signs following Cesarean section following Cesarean section Hemorrhage following Cesarean sectionHemorrhage following Cesarean section

Clark SL, et al: Maternal Death in the 21st century:Causes, prevention, and relationship to Caesarean delivery. American Journal of Obstetrics & Gynecology, 2008, 199(1):91-92


Issue 44, January 26, 2010There Are Existing Joint Commission There Are Existing Joint Commission requirements:requirements:Have a process for recognizing and Have a process for recognizing and responding as soon as a patientresponding as soon as a patient’’s s condition appears to be worsening. condition appears to be worsening.


Issue 44, January 26, 2010There Are Existing Joint Commission There Are Existing Joint Commission requirements:requirements:Have a process for recognizing and Have a process for recognizing and responding as soon as a patientresponding as soon as a patient’’s s condition appears to be worsening. condition appears to be worsening. Develop written criteria describing early Develop written criteria describing early warning signs of a change or warning signs of a change or deterioration in a patientdeterioration in a patient’’s condition and s condition and when to seek further assistance. when to seek further assistance.


Issue 44, January 26, 2010

There Are Existing Joint Commission There Are Existing Joint Commission requirements:requirements:Based on the hospitalBased on the hospital’’s early warning s early warning criteria, have staff seek additional criteria, have staff seek additional assistance when they have concerns assistance when they have concerns about a patientabout a patient’’s condition. s condition. Inform the patient and family how to Inform the patient and family how to seek assistance when they have seek assistance when they have concerns about a patientconcerns about a patient’’s condition.s condition.



Joint Commission suggested actionsJoint Commission suggested actionsEach case of maternal death needs to be Each case of maternal death needs to be identified, reviewed, and reported in order to identified, reviewed, and reported in order to develop effective strategies for preventing develop effective strategies for preventing pregnancypregnancy--related mortality and severe related mortality and severe morbidity. To this end, The Joint Commission morbidity. To this end, The Joint Commission encourages participation by hospital physicians, encourages participation by hospital physicians, including obstetricianincluding obstetrician--gynecologists, in stategynecologists, in state--level maternal mortality review and collaboration level maternal mortality review and collaboration with such review committees in sharing data with such review committees in sharing data and records needed for review. and records needed for review.



The following The following 6 suggested actions6 suggested actions from from the Joint Commission can help hospitals the Joint Commission can help hospitals and providers (that is us) prevent and providers (that is us) prevent maternal death: maternal death:



1.1. EducateEducate physicians and other clinicians physicians and other clinicians who care for women with underlying who care for women with underlying medical conditions about the additional medical conditions about the additional risks that could be imposed if pregnancy risks that could be imposed if pregnancy were added; how to discuss these risks were added; how to discuss these risks with patients; the use of appropriate and with patients; the use of appropriate and acceptable contraception; and preacceptable contraception; and pre--conceptual care and counseling. conceptual care and counseling. CommunicateCommunicate identified pregnancy risks identified pregnancy risks to all members of the health care delivery to all members of the health care delivery teamteam



2. 2. Identify specific triggersIdentify specific triggers for for responding to changes in the motherresponding to changes in the mother’’s s vital signs and clinical condition and vital signs and clinical condition and develop and use protocols and drills for develop and use protocols and drills for responding to changes, such as responding to changes, such as hemorrhage and prehemorrhage and pre--eclampsia. eclampsia. Use the Use the drills to train staffdrills to train staff in the protocols, to in the protocols, to refine local protocols, and to identify and refine local protocols, and to identify and fix systems problems that would prevent fix systems problems that would prevent optimal care.optimal care.



3. 3. Educate emergency room personnelEducate emergency room personnelabout the possibility that a woman, whatever about the possibility that a woman, whatever her presenting symptoms, may be pregnant or her presenting symptoms, may be pregnant or may have recently been pregnant. Many may have recently been pregnant. Many maternal deaths occur before the woman is maternal deaths occur before the woman is hospitalized or after she delivers and is hospitalized or after she delivers and is discharged. These deaths may occur in another discharged. These deaths may occur in another hospital, away from the womanhospital, away from the woman’’s usual prenatal s usual prenatal or obstetric care givers. Knowledge of pregnancy or obstetric care givers. Knowledge of pregnancy may affect the diagnosis or appropriate may affect the diagnosis or appropriate treatment treatment



4. 4. Refer highRefer high--risk patientsrisk patients to the care to the care of experienced prenatal care providers of experienced prenatal care providers with access to a broad range of with access to a broad range of specialized servicesspecialized services



5. Make 5. Make pneumatic compression pneumatic compression devicesdevices available for patients undergoing available for patients undergoing Cesarean section who are at high risk for Cesarean section who are at high risk for pulmonary embolism.pulmonary embolism.



6. Evaluate patients who are at 6. Evaluate patients who are at high risk high risk for thromboembolism for low for thromboembolism for low molecular weight heparinmolecular weight heparin for for postpartum carepostpartum care

Maternal Death:Maternal Death:Is It Preventable?Is It Preventable?

Sometimes, YESSometimes, YES

Sometimes, NOSometimes, NO

However, you do not However, you do not have time to make all have time to make all

the mistakes and the mistakes and must learn from must learn from those of others!those of others!

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Maternal Death Is It Preventable Slides - Mead Johnson€¦ · Maternal Death Is It Preventable? Disclaimer ... The presenter has complete and independent control over the planning