Barbara M. Scavone

The national partnership for maternal safety

Recognition of the need to reduce maternal mortality and morbidity in the United States has led to the creation of the National Partnership for Maternal Safety. This collaborative, broad-based initiative will begin with three priority bundles for the most common preventable causes of maternal death and severe morbidity: obstetric hemorrhage, severe hypertension in pregnancy, and peripartum venous thromboembolism. In addition, three unit-improvement bundles for obstetric services were identified: a structured approach for the recognition of early warning signs and symptoms, structured internal case reviews to identify systems improvement opportunities, and support tools for patients, families, and staff that experience an adverse outcome. This article details the formation of the National Partnership for Maternal Safety and introduces the initial priorities.

National Partnership for Maternal Safety: Consensus Bundle on Obstetric Hemorrhage.

Hemorrhage is the most frequent cause of severe maternal morbidity and preventable maternal mortality and therefore is an ideal topic for the initial national maternity patient safety bundle. These safety bundles outline critical clinical practices that should be implemented in every maternity unit. They are developed by multidisciplinary work groups of the National Partnership for Maternal Safety under the guidance of the Council on Patient Safety in Womens Health Care. The safety bundle is organized into four domains: Readiness, Recognition and Prevention, Response, and Reporting and System Learning. Although the bundle components may be adapted to meet the resources available in individual facilities, standardization within an institution is strongly encouraged. References contain sample resources and “Potential Best Practices” to assist with implementation.Hemorrhage is the most frequent cause of severe maternal morbidity and preventable maternal mortality and therefore is an ideal topic for the initial national maternity patient safety bundle. These safety bundles outline critical clinical practices that should be implemented in every maternity unit. They are developed by multidisciplinary work groups of the National Partnership for Maternal Safety under the guidance of the Council on Patient Safety in Womens Health Care. The safety bundle is organized into four domains: Readiness, Recognition and Prevention, Response, and Reporting and System Learning. Although the bundle components may be adapted to meet the resources available in individual facilities, standardization within an institution is strongly encouraged. References contain sample resources and Potential Best Practices to assist with implementation.

The Use of Postpartum Hemorrhage Protocols in United States Academic Obstetric Anesthesia Units

BACKGROUND:Postpartum hemorrhage (PPH) is the leading cause of severe maternal morbidity, cardiac arrest, and death during the hospitalization for childbirth. Protocol-driven care has been associated with improved outcomes in many settings; the National Partnership for Maternal Safety now recommends that PPH protocols be implemented in every labor and delivery unit in the United States. In this study, we sought to identify the level of PPH protocol availability in academic United States obstetric units. We hypothesized that the majority (>80%) of academic obstetric anesthesia units would have a PPH protocol in place. METHODS:A survey was developed by an expert panel. Domains included hospital characteristics, availability of PPH protocol or plans to develop such a protocol, and protocol components included in the upcoming National Partnership for Maternal Safety obstetric hemorrhage safety bundle initiative. The electronic survey was emailed to the 104 directors of United States academic obstetric anesthesia units. Responses were stratified by PPH protocol availability as appropriate. Univariate statistics were used to characterize survey responses and the probability distribution for PPH protocol availability was estimated using the binomial distribution. RESULTS:The survey response rate was 58%. The percentage of responding units with a PPH protocol was lower than hypothesized (P = 0.03); there was a PPH protocol in 67% of responding units (N = 40, 95% confidence interval [CI]: 53%–78%). The median annual delivery volume for responding units with PPH protocol was 3900 vs 2300 for units without PPH protocol (P = 0.002), with no difference in cesarean delivery rate (P = 0.73) or observed PPH rate (P = 0.69). There was no difference in annual delivery volume between responding and nonresponding hospitals (P = 0.06), suggesting that academic centers with delivery volume >3200 births per year are more likely than smaller volume hospitals to have a PPH protocol in place (odds ratio 3.16 (95% CI: 1.01–9.90). Adjusting for delivery volume among nonresponding hospitals, we estimate that 67% (95% CI: 55%–77%) of all academic obstetric anesthesia units had a PPH protocol in place at the time of this survey. Institutional processes for escalation do not correlate with the presence of a PPH protocol. There was a massive transfusion protocol in 95% of units with a PPH protocol and in 90% of units without (95% CI of difference: −7% to 7%). A PPH code team or rapid response team was available in 57% of responding institutions, with no difference between units with or without a PPH protocol [mean difference 4%, 95% CI (−24% to 32%)]. CONCLUSIONS:Despite increasing emphasis on national quality improvement in patient safety, there are no PPH protocols in at least 20% of U.S. academic obstetric anesthesia units. Delivery volume is the most important variable predicting the presence of a PPH protocol. National efforts to ensure universal presence of a PPH protocol in all academic centers will achieve the greatest impact by focusing on small-volume facilities. Future work is needed to evaluate and facilitate PPH implementation in nonacademic obstetric units.

National Partnership for Maternal Safety: Consensus Bundle on Obstetric Hemorrhage

Hemorrhage is the most frequent cause of severe maternal morbidity and preventable maternal mortality and therefore is an ideal topic for the initial national maternity patient safety bundle. These safety bundles outline critical clinical practices that should be implemented in every maternity unit. They are developed by multidisciplinary work groups of the National Partnership for Maternal Safety under the guidance of the Council on Patient Safety in Women’s Health Care. The safety bundle is organized into four domains: Readiness, Recognition and Prevention, Response, and Reporting and Systems Learning. Although the bundle components may be adapted to meet the resources available in individual facilities, standardization within an institution is strongly encouraged. References contain sample resources and potential best practices to assist with implementation.

Outcomes after institution of a new oxytocin infusion protocol during the third stage of labor and immediate postpartum period

BACKGROUNDnDue to safety concerns when oxytocin is administered in an uncontrolled fashion, and recent dose-response data that indicate oxytocins effectiveness at doses lower than those traditionally used, we instituted a new protocol for the infusion of oxytocin during the third stage of labor and in the immediate postpartum period. We undertook this study to confirm that this change in practice did not have untoward effects on postpartum hemorrhage rates.nnnMETHODSnIn this retrospective review, patients who delivered in the six months before (PRE group) and patients who delivered in the six months after (POST group) the new protocol had been introduced were identified through an institutional database and their medical records were reviewed. The primary outcome variable was the postpartum hemorrhage rate. Secondary outcomes included maternal and fetal co-morbidities, protocol compliance, administration of other uterotonic agents, use of Bakri balloons and B-Lynch sutures, rate of uterine artery embolization and peripartum hysterectomy, need for red blood cell transfusion, and drop in hemoglobin after delivery. Categorical data were analyzed using Chi-squared or Fishers Exact test, as appropriate. Continuous data were analyzed using a Mann-Whitney U test. A P value <0.05 was required to reject the null hypothesis.nnnRESULTSnA total of 1572 medical records were reviewed. Postpartum hemorrhage occurred in 9.0% of PRE patients and 7.1% of POST patients, and was not different between groups (P=0.17). Carboprost use was lower in the POST group, but no other differences were noted.nnnCONCLUSIONnAdoption of a protocol to infuse oxytocin in a controlled manner at a lower dose than that historically used was not associated with an increased incidence of postpartum hemorrhage.

The effect of intravenous magnesium therapy on the duration of intrathecal fentanyl labor analgesia

BACKGROUNDnMagnesium has been reported to augment the analgesic effects of opioids when co-administered into the cerebrospinal fluid. The purpose of this study was to determine the influence of intravenous magnesium therapy administered for preeclampsia on the duration of intrathecal fentanyl analgesia for labor.nnnMETHODSnThirty-four nulliparous parturients having labor induced for preeclampsia and receiving intravenous magnesium therapy were recruited. Thirty-four nulliparous patients having labor induced for elective or medical reasons were recruited as controls. At request for analgesia, baseline serum magnesium levels were obtained and combined spinal-epidural analgesia was initiated with intrathecal fentanyl 25μg. Before injection of fentanyl, a sample of cerebrospinal fluid was obtained for magnesium assay. An epidural catheter was sited but no additional medications were administered until the second request for analgesia. The primary outcome was duration of intrathecal fentanyl analgesia.nnnRESULTSnThere was no difference in the median duration of analgesia between the magnesium [79min (95% CI 76 to 82)] and control groups [69min (95% CI 56 to 82)] (difference between medians: 10min (95% CI -4 to 21min; P=0.16). There was neither a relationship between the serum and cerebrospinal fluid magnesium concentrations nor the cerebrospinal magnesium concentration and duration of intrathecal fentanyl analgesia.nnnCONCLUSIONSnIntravenous magnesium therapy at doses typically used for seizure prophylaxis in preeclampsia did not influence the duration of intrathecal fentanyl labor analgesia. However, this study may have been underpowered to detect a difference and future study is warranted.

National Partnership for Maternal Safety Consensus Bundle on Obstetric Hemorrhage

Hemorrhage is the most frequent cause of severe maternal morbidity and preventable maternal mortality and therefore is an ideal topic for the initial national maternity patient safety bundle. These safety bundles outline critical clinical practices that should be implemented in every maternity unit. They are developed by multidisciplinary work groups of the National Partnership for Maternal Safety under the guidance of the Council on Patient Safety in Womens Health Care. The safety bundle is organized into 4 domains: Readiness, Recognition and Prevention, Response, and Reporting and Systems Learning. Although the bundle components may be adapted to meet the resources available in individual facilities, standardization within an institution is strongly encouraged. References contain sample resources and Potential Best Practices to assist with implementation.

Consensus Bundle on Severe Hypertension During Pregnancy and the Postpartum Period

Complications arising from hypertensive disorders of pregnancy are among the leading causes of preventable severe maternal morbidity and mortality. Timely and appropriate treatment has the potential to significantly reduce hypertension-related complications. To assist health care providers in achieving this goal, this patient safety bundle provides guidance to coordinate and standardize the care provided to women with severe hypertension during pregnancy and the postpartum period. This is one of several patient safety bundles developed by multidisciplinary work groups of the National Partnership for Maternal Safety under the guidance of the Council on Patient Safety in Womens Health Care. These safety bundles outline critical clinical practices that should be implemented in every maternity care setting. Similar to other bundles that have been developed and promoted by the Partnership, the hypertension safety bundle is organized into four domains: Readiness, Recognition and Prevention, Response, and Reporting and Systems Learning. Although the bundle components may be adapted to meet the resources available in individual facilities, standardization within an institution is strongly encouraged. This commentary provides information to assist with bundle implementation.

Cardiogenic shock in pregnancy: Analysis from the National Inpatient Sample

ABSTRACT Objective: Cardiogenic shock (CS) may occur during pregnancy and dramatically worsen peripartum outcomes. Methods: We analyzed the National Inpatient Sample from 2002 to 2013 to describe the incidence of, risk factors for and outcomes of CS during pregnancy. Results: Of the 53,794,192 hospitalizations analyzed, 2044 were complicated by CS. The mortality rate in peripartum women with CS was 18.81% versus 0.02% without. It occurs more often during postpartum (58.83%) as compared with delivery (23.47%) or antepartum (17.70%) hospitalizations. Factors associated with CS -related death included cardiac arrest, renal failure, and sepsis. Conclusions: CS during pregnancy occurs more commonly in the postpartum period and is associated with a high mortality.

Outcomes and mortality in parturient and non-parturient patients with peripartum cardiomyopathy: A national readmission database study

BACKGROUNDnPeripartum cardiomyopathy (PPCM) affects young females and mortality occurs after the peripartum period. Hospital readmissions for patients discharged with PPCM are poorly understood. The aim of this study was to evaluate differences in readmission rates, risk factors, and mortality in women with PPCM.nnnMETHODSnWe conducted a retrospective cohort analysis using the Healthcare Cost and Utilization Project 2013 National Readmissions Database. From the database, we selected patients with PPCM to include patients discharged between January and November 2013. Readmission rate, mortality rate and risk factors were analyzed. In our cohort of 3800 patients, we found a readmission rate of 15.1% and a mortality rate of 1.6%. Comorbidities associated with readmission were pulmonary hypertension, obesity, renal failure, and drug abuse. Mortality on initial admission was associated with coagulation disorders and respiratory failure. Women who delivered on initial admission had a statistically lower rate of readmission than women who did not deliver on initial admission.nnnCONCLUSIONSnIn a large retrospective nationwide analysis of PPCM patients, we found associated conditions that may help predict which patients will have a higher risk for readmission and mortality.