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?
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Maternal DeathIs It Preventable?
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Maternal DeathIs It Preventable?
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 DeathIs It Preventable?
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
Bleeding or HemorrhageBleeding or HemorrhageClinical PearlsClinical Pearls
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?
PRACTICE, Practice, practice
Bleeding or HemorrhageBleeding or HemorrhageClinical PearlsClinical Pearls
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
Bleeding or HemorrhageBleeding or HemorrhageClinical PearlsClinical Pearls
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.
Bleeding or HemorrhageBleeding or HemorrhageCase ReviewCase Review
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.
Bleeding or HemorrhageBleeding or HemorrhageCase ReviewCase Review
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/
http://www.heartsafire.us/
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
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.
Issues & RecommendationsIssues & Recommendations
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
Issues & RecommendationsIssues & Recommendations
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.
Issues & RecommendationsIssues & Recommendations
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.)
Issues & RecommendationsIssues & Recommendations
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
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
Preventing Maternal DeathJoint Commission Sentinel Event Alert
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.
Preventing Maternal DeathJoint Commission Sentinel Event Alert
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.
Preventing Maternal DeathJoint Commission Sentinel Event Alert
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.
Preventing Maternal DeathJoint Commission Sentinel Event Alert
Issue 44, January 26, 2010
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.
Preventing Maternal DeathJoint Commission Sentinel Event Alert
Issue 44, January 26, 2010
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:
Preventing Maternal DeathJoint Commission Sentinel Event Alert
Issue 44, January 26, 2010
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
Preventing Maternal DeathJoint Commission Sentinel Event Alert
Issue 44, January 26, 2010
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.
Preventing Maternal DeathJoint Commission Sentinel Event Alert
Issue 44, January 26, 2010
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
Preventing Maternal DeathJoint Commission Sentinel Event Alert
Issue 44, January 26, 2010
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
Preventing Maternal DeathJoint Commission Sentinel Event Alert
Issue 44, January 26, 2010
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.
Preventing Maternal DeathJoint Commission Sentinel Event Alert
Issue 44, January 26, 2010
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!