In this blog, I’ll be reviewing the national, and New York State statistics related to maternal mortality associated with obstetrical hemorrhage. I’ll also highlight one of the risk factors associated with obstetrical hemorrhage, and discuss the standards of care that should be employed to mitigate the risk of maternal morbidity and mortality.
Statistics: Obstetrical hemorrhage is a preventable cause of maternal morbidity and mortality and continues to be one of the leading causes of maternal death in the U.S.
How the U.S. compares to 10 other developed countries:
In New York State, postpartum hemorrhage is the 2nd most frequently reported postpartum complication, and accounted for 29% (18) of maternal deaths between 2012-2013 according to the NYS Maternal Morbidity and Mortality Review Report (2017).
Prolonged oxytocin exposure as a risk factor: In a recent (published May, 2022) retrospective cohort study performed by Boston University School of Medicine, prolonged (greater than or equal to 12 hours) oxytocin exposure for induction of labor increased the risk of obstetrical hemorrhage by 52% compared to those women exposed for less than 12 hours. Use of obstetrical risk assessment tools alert the perinatal team to the risk of obstetrical hemorrhage and prompts evidence-based interventions.
The importance of standardized safety bundles: The American College of Obstetricians and Gynecologists (ACOG) recommends the use of the Obstetrical Safety Bundle as a means to guide standardized management of obstetrical emergencies associated with maternal morbidity and mortality in accordance to evidence-based practice. ACOG’s Safe Motherhood Initiative (SMI) focuses on the four leading causes of maternal death: maternal sepsis, obstetric hemorrhage (severe bleeding), venous thromboembolism (blood clots), and severe hypertension in pregnancy (high blood pressure).
The Obstetrical Hemorrhage Safety Bundle includes:
Risk assessments: prenatal, antepartum, labor & delivery, and postpartum.
Use of a staged obstetrical hemorrhage checklist to guide interventions in real-time.
Team debriefing recommendations and a standardized debriefing form.
Recommendation to perform quantitative blood loss assessment (QBL) with every delivery.
The Joint Commission Perinatal Safety Standards: Effective January 1, 2021, the Joint Commission implemented new perinatal safety standards required of all Joint Commission accredited hospitals. One of the new standards aims to improve care for women experiencing maternal hemorrhage. The Joint Commission requirements focus on evidence-based written procedures, education, training, and drills for staff and providers, education for patients and families, and quality review. The requirement also focuses on evidence-based risk assessments and hemorrhage supply kits.
NYS Department of Health. 2017. NYS Morbidity and Mortality Review Report
OECD Health Data. 2020
P.S. Comment and share your experience with a maternal death case associated with obstetrical hemorrhage. What were the deviations in the standards of care?
In this blog, I’ll be reviewing the U.S. maternal morbidity statistics associated with hypertensive disorders of pregnancy. Additionally, I’ll be highlighting the elements of performance, specific to severe hypertension and preeclampsia, Joint Commission accredited hospitals are required to be in compliance with. Lastly, I will offer risk mitigation strategies specific to care delivery, risk assessment, prevention, documentation, consultation, and referral.
Statistics: Hypertensive disorders of pregnancy (chronic hypertension, gestational hypertension, severe hypertensive crisis, preeclampsia, eclampsia, HELLP Syndrome) continue to be the leading cause of maternal and infant death. Preeclampsia specifically, complicates 8% of pregnancies globally. It is estimated that 60% of maternal deaths from preeclampsia may be preventable. In the U.S., hypertensive disorders of pregnancy account for 6.8% of pregnancy related deaths. For women who had a hypertensive disorder of pregnancy cause of death, 12.2% had a stillbirth (fetal demise). Almost all (96.8%) pregnancy related deaths occurred by 42 days postpartum (CDC, 2018).
The Joint Commissions Perinatal Safety Standards: In response to the worsening maternal morbidity and mortality in the U.S. associated with severe hypertension and preeclampsia, The Joint Commission has identified clinical areas of greatest potential impact based on review of maternal mortality reports, and evidence-based practice recommendations.
The literature review performed revealed that prevention, early recognition of signs and symptoms, and timely treatment for severe hypertension, and preeclampsia had the highest impact on maternal, fetal, and neonatal outcomes.
Joint Commission accredited hospitals are now required to conform to the six new elements of performance (EPs) as identified below:
GOAL: PC.06.03.01 – Reduce the likelihood of harm related to maternal severe hypertension/preeclampsia
Requirement EP 1: Develop written evidence-based procedures for measuring and remeasuring blood pressure. These procedures include criteria that identify patients with severely elevated blood pressure.
Rationale: Procedures should address appropriate blood pressure measurement, including cuff size, proper patient positioning, and frequency of measurement. Inaccurate measurement can lead to a mother not receiving proper treatment and being discharged with elevated blood pressure. Untreated hypertension can lead to morbidities or even death. Criteria for what constitutes a severely elevated blood pressure should be established by the organization utilizing current recommendations from national organizations.
Requirement EP 2: Develop written evidence-based procedures for managing pregnant and postpartum patients with severe hypertension/preeclampsia that includes the following:
• The use of an evidence-based set of emergency response medications that are stocked and immediately available on the obstetric unit
• The use of seizure prophylaxis
• Guidance on when to consult additional experts and consider transfer to a higher level of care • Guidance on when to use continuous fetal monitoring
• Guidance on when to consider emergent delivery
• Criteria for when a team debrief is required
Note: The written procedures should be developed by a multidisciplinary team that includes representation from obstetrics, emergency department, anesthesiology, nursing, laboratory, and pharmacy.
Rationale: Studies have shown that delays in the diagnosis and treatment of severe hypertension/preeclampsia and receipt of suboptimal treatment of severe hypertension/preeclampsia are linked with adverse maternal outcomes. Having clear procedures in place and educating staff around these procedures should decrease failures to recognize and treat severe hypertension/preeclampsia
Requirement EP 3: Provide role-specific education to all staff and providers who treat pregnant/ postpartum patients about the hospital’s evidence-based severe hypertension/preeclampsia procedure. At a minimum, education occurs at orientation, whenever changes to the procedure occur, or every two years.
Note: The emergency department is often where patients with symptoms or signs of severe hypertension present for care after delivery. For this reason, education should be provided to staff and providers in emergency departments regardless of the hospital’s ability to provide labor and delivery services.
Rationale: Decreasing the blood pressure through rapid recognition and treatment has been shown to decrease maternal morbidity and mortality. It is imperative to provide education for staff and providers on how to measure accurate blood pressures, recognize severe hypertension/ preeclampsia, and provide evidence-based treatments to lower blood pressure in a safe and timely manner. Although not required, in situ simulations that allow staff to practice organizational procedures in actual clinical settings are encouraged.
Requirement EP 4: Conduct drills at least annually to determine system issues as part of ongoing quality improvement efforts. Severe hypertension/preeclampsia drills include a team debrief.
Rationale: Multidisciplinary drills give an organization the opportunity to practice skills and identify system issues in a controlled environment. It is crucial to have members from as many disciplines as possible available during drills to truly be able to test each level of the emergency and identify areas of improvement. Organizations should assess their level of proficiency to determine the frequency drills should be performed; organizations that have reached a high level of mastery may need less frequent drills.
Requirement EP 5: Review severe hypertension/preeclampsia cases that meet criteria established by the hospital to evaluate the effectiveness of the care, treatment, and services provided to the patient during the event.
Rationale: Continuous feedback loops are imperative for organizations to find errors and improve skills to ensure that patients are receiving the highest level of care. Root cause analysis, apparent-cause analysis, or similar tools to review the care in a rigorous, psychologically safe environment is critical to identify successes and opportunities for improvement in a way that creates a culture of safety and empowers staff to design safe and effective procedures and processes.
Requirement EP 6: Provide printed education to patients (and their families including the designated support person whenever possible). At a minimum, education includes:
• Signs and symptoms of severe hypertension/preeclampsia during hospitalization that alert the patient to seek immediate care
• Signs and symptoms of severe hypertension/preeclampsia after discharge that alert the patient to seek immediate care
• When to schedule a post-discharge follow-up appointment
Rationale: Maternal mortality reviews have shown that some patients with severe hypertension/ preeclampsia due after discharge because they were unaware of which symptoms to watch for and when to seek care urgently. Women should understand their severe hypertension/ preeclampsia diagnosis and inform healthcare providers of their pregnancy history when the seek care after discharge to ensure correct diagnosis and treatment.
How to Mitigate Medicolegal Risk & Increase Defensibility:
Confirm that your organization is conforming to the six elements of performance (EPs) that is now required for Joint Commission accredited hospitals. Become an active provider leader in implementing and educating staff/providers on the above (EPs). Render care according to the above (EPs). Consider implementing re-credentialing requirements to support required simulation drills and debriefings.
Identify women at risk: first pregnancy, new genetic makeup, pregnancy of artificial reproductive technology, multiple pregnancy, gestational diabetes, preexisting medical history: diabetes, chronic hypertension, renal disease, lupus, older maternal age, African American race, obesity, personal or family history of preeclampsia (list is not inclusive)
Document risks, and plan of care for surveillance and prevention strategies in pregnancy within the medical record.
Implement prevention strategies in plan of care, and document in medical record: exercise, low dose aspirin therapy, dietary supplementation
Diagnose and initiate timely management according to evidence-based practice criteria, and organizational policy: document diagnosis and management plan in the medical record.
Consider referral to Maternal Fetal Medicine, or higher level of care delivery based on organizational level of care, and maternal consultation and transfer agreement with Regional Perinatal Center.
Consultation/collaboration: ensure patient assessment is complete within the time frame designated within organizational by-laws, rules and regulations. Ensure timely entry of consultation / progress note as the consulting, or collaborating provider.
References:
Association of Women’s Health, Obstetric, and Neonatal Nurses. 2021.
CDC. 2018. Pregnancy mortality surveillance system
The Joint Commission. 2019. Provision of care, treatment, and services standards for maternal safety. Issue 24
P.S. Comment and Share: Do you have experience with a maternal hypertensive case that resulted in a maternal death. Did this case impact policy, procedure, process, or system changes as a result?
