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Recognition of Deterioration of Maternal Status

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

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Recognition of Deterioration of Maternal Status

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  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. 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 The Scope of the Problem….

  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

  7. CA-PAMR • California Pregnancy-Associated Mortality Review (CA-PAMR) • Report from 2002 and 2003 Maternal Death Reviews • Released April 2011 • Link http://cmqcc.org/maternal_mortality/california_maternal_mortality/california_pregnancy_associated_mortality_review

  8. “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

  9. Leading Causes of Maternal Death: CA-PAMR • Cardiovascular disease, including cardiomyopathy (20%) • Pre-eclampsia/eclampsia (15%) • Amniotic fluid embolism (14%) • Obstetrical hemorrhage (10%) • Sepsis/infection (8%)

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

  11. 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

  12. 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

  13. 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

  14. Key Assessments

  15. 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

  16. 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)

  17. 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

  18. 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

  19. 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

  20. 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

  21. 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

  22. “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

  23. Recognition of life threatening illness can be challengingPhysiologic changes of pregnancy can mask development of serious illness

  24. 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

  25. 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/

  26. MEOWS • Documentation system with yellow and red highlights • Respiratory rate21-30<10 or >30 • Temperature<36°C>38°C or <35°C • Heart rate100-120<40 or >120 • Systolic BP90-100 or 150-160<90 • Diastolic BP90-100>100

  27. MEOWS • Other parameters highlighted: • SaO2< 95% • Neuroresponds to voice responds to pain only or is unresponsive • Appearancelooks unwell

  28. ‘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

  29. 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

  30. 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

  31. 0650: Adm to L&D, 117/43, 92, SaO2 97%, Cx: 4/80%/-2

  32. 1000: 126/84, 113, 95%, Cx: C/-1

  33. 1015: 15 minutes later, 116/93, 127, SaO2 87%

  34. 1020: 116/93, 131, 93%, Pitocin off, Cx: C/+1

  35. 1025: MDs in room, O2@ 10L, L side, IV bolus

  36. 1035: 123/83, 141, SaO2 94%

  37. 1040: Pt pushing, no descent noted

  38. 1056: Immediately following, In OR

  39. 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

  40. 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

  41. 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

  42. 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

  43. 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

  44. 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 Update

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

  46. “….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

  47. 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

  48. 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

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