Steven L. Clark

Maternal death in the 21st century: causes, prevention, and relationship to cesarean delivery.

OBJECTIVE We sought to examine etiology and preventability of maternal death and the causal relationship of cesarean delivery to maternal death in a series of approximately 1.5 million deliveries between 2000 and 2006. STUDY DESIGN This was a retrospective medical records extraction of data from all maternal deaths in this time period, augmented when necessary by interviews with involved health care providers. Cause of death, preventability, and causal relationship to mode of delivery were examined. RESULTS Ninety-five maternal deaths occurred in 1,461,270 pregnancies (6.5 per 100,000 pregnancies.) Leading causes of death were complications of preeclampsia, pulmonary thromboembolism, amniotic fluid embolism, obstetric hemorrhage, and cardiac disease. Only 1 death was seen from placenta accreta. Twenty-seven deaths (28%) were deemed preventable (17 by actions of health care personnel and 10 by actions of non-health care personnel). The rate of maternal death causally related to mode of delivery was 0.2 per 100,000 for vaginal birth and 2.2 per 100,0000 for cesarean delivery, suggesting that the number of annual deaths resulting causally from cesarean delivery in the United States is about 20. CONCLUSION Most maternal deaths are not preventable. Preventable deaths are equally likely to result from actions by nonmedical persons as from provider error. Given the diversity of causes of maternal death, no systematic reduction in maternal death rate in the United States can be expected unless all women undergoing cesarean delivery receive thromboembolism prophylaxis. Such a policy would be expected to eliminate any statistical difference in death rates caused by cesarean and vaginal delivery.

Visually estimated and calculated blood loss in vaginal and cesarean delivery

OBJECTIVE The objective of the study was to compare visually estimated blood loss (vEBL) with calculated estimated blood loss (cEBL) according to mode of delivery and degree of perineal laceration. STUDY DESIGN Pre- and postdelivery hematocrit (HCT) and other variables including vEBL were prospectively recorded into an obstetrical database between January and September 2005. The cEBL was derived by multiplying the calculated pregnancy blood volume (0.75 x {[maternal height (inches) x 50] + [maternal weight in pounds x 25]}) by percent of blood volume lost ({predelivery HCT - postdelivery HCT}/predelivery HCT). cEBL and vEBL were compared according to mode of delivery and degree of perineal laceration. RESULTS There were 677 subjects with complete data. vEBL was statistically different from cEBL between each degree of laceration and between all modes of delivery, demonstrating an underestimation of vEBL with increasing cEBL. CONCLUSION Improved methods for calculating blood loss include the use of a modified version of the formula used for pregnancy blood volume calculation.

Improved outcomes, fewer cesarean deliveries, and reduced litigation: results of a new paradigm in patient safety

In a health care delivery system with an annual delivery rate of approximately 220,000, a comprehensive redesign of patient safety process was undertaken based on the following principles: (1) uniform processes and procedure result in an improved quality; (2) every member of the obstetric team should be required to halt any process that is deemed to be dangerous; (3) cesarean delivery is best viewed as a process alternative, not an outcome or quality endpoint; (4) malpractice loss is best avoided by reduction in adverse outcomes and the development of unambiguous practice guidelines; and (5) effective peer review is essential to quality medical practice yet may be impossible to achieve at a local level in some departments. Since the inception of this program, we have seen improvements in patient outcomes, a dramatic decline in litigation claims, and a reduction in the primary cesarean delivery rate.

Clinical indications for pulmonary artery catheterization in the patient with severe preeclampsia

The obstetric literature reflects an increased interest in invasive hemodynamic monitoring during the past decade. While much of this interest has focused on research applications, the patient with severe preeclampsia may benefit clinically from pulmonary artery catheterization under several circumstances. These conditions include severe hypertension unresponsive to conventional antihypertensive therapy, pulmonary edema, persistent oliguria unresponsive to fluid challenge, and in induction of conduction anesthesia in select patients. Theoretical and clinical evidence to support this contention is presented.

Maternal mortality in the United States: predictability and the impact of protocols on fatal postcesarean pulmonary embolism and hypertension-related intracranial hemorrhage.

OBJECTIVE The purpose of this study was to examine the efficacy of specific protocols that have been developed in response to a previous analysis of maternal deaths in a large hospital system. We also analyzed the theoretic impact of an ideal system of maternal triage and transport on maternal deaths and the relative performance of cause of death determination from chart review compared with a review of discharge coding data. STUDY DESIGN We conducted a retrospective evaluation of maternal deaths from 2007-2012 after the introduction of disease-specific protocols that were based on 2000-2006 data. RESULTS Our maternal mortality rate was 6.4 of 100,000 births in just >1.2 million deliveries. A policy of universal use of pneumatic compression devices for all women who underwent cesarean delivery resulted in a decrease in postoperative pulmonary embolism deaths from 7 of 458,097 cesarean births to 1 of 465,880 births (P = .038). A policy that involved automatic and rapid antihypertensive therapy for defined blood pressure thresholds eliminated deaths from in-hospital intracranial hemorrhage and reduced overall deaths from preeclampsia from 15-3 (P = .02.) From 1-3 deaths were related causally to cesarean delivery. Only 7% of deaths were potentially preventable with an ideal system of admission triage and transport. Cause of death analysis with the use of discharge coding data was correct in 52% of cases. CONCLUSION Disease-specific protocols are beneficial in the reduction of maternal death because of hypertensive disease and postoperative pulmonary embolism. From 2-6 women die annually in the United States because of cesarean delivery itself. A reduction in deaths from postpartum hemorrhage should be the priority for maternal death prevention efforts in coming years in the United States.

Intrapartum management of category II fetal heart rate tracings: towards standardization of care

There is currently no standard national approach to the management of category II fetal heart rate (FHR) patterns, yet such patterns occur in the majority of fetuses in labor. Under such circumstances, it would be difficult to demonstrate the clinical efficacy of FHR monitoring even if this technique had immense intrinsic value, since there has never been a standard hypothesis to test dealing with interpretation and management of these abnormal patterns. We present an algorithm for the management of category II FHR patterns that reflects a synthesis of available evidence and current scientific thought. Use of this algorithm represents one way for the clinician to comply with the standard of care, and may enhance our overall ability to define the benefits of intrapartum FHR monitoring.

Strategies for Reducing Maternal Mortality

The maternal death rate in the United States has shown no improvement in several decades and may be increasing. On the other hand, hospital systems that have instituted comprehensive programs directed at the prevention of maternal mortality have demonstrated rates that are half of the national average. These programs have emphasized the reduction of variability in the provision of care through the use of standard protocols, reliance on checklists instead of memory for critical processes, and an approach to peer review that emphasizes systems change. In addition, elimination of a small number of repetitive errors in the management of hypertension, postpartum hemorrhage, pulmonary embolism, and cardiac disease will contribute significantly to a reduction in maternal mortality. Attention to these general principles and specific error reduction strategies will be of benefit to every practitioner and more importantly to the patients we serve.

Preventing maternal death: 10 clinical diamonds.

The death of a mother during or after childbirth is one of the most tragic events in medicine. We have identified 10 specific recurrent errors that account for a disproportionate share of maternal deaths, primarily related to pulmonary embolism, severe preeclampsia, cardiac disease, and postpartum hemorrhage. Attention to these principles and the development and adoption of local or regional clinical protocols that address these issues will help reduce the likelihood and effect of error and of maternal mortality.

Hospital readmission after delivery: evidence for an increased incidence of nonurogenital infection in the immediate postpartum period

OBJECTIVE The purpose of this study was to analyze reasons for postpartum readmission. STUDY DESIGN We conducted a database analysis of readmissions within 6 weeks after delivery during 2007, with extended (180 day) analysis for pneumonia, appendicitis, and cholecystitis. Linear regression analysis, survival curve fitting, and Gehan-Breslow statistic with Holm-Sidak all-pairwise analysis for multiple comparisons were used. Probability values of < .05 were considered significant. RESULTS Of 222,751 women delivered, 2655 women (1.2%) were readmitted within 6 weeks (0.83% vaginal delivery and 1.8% cesarean section delivery; P < .001). A high percentage of these readmittances occurred within the first 6 weeks: pneumonia (84%), appendicitis (43%), or cholecystitis (46%). Cumulative readmission rates were higher in the first 6 weeks after delivery than in the next 20 weeks (pneumonia curve gradient, 3.7 vs 0.11; appendicitis curve gradient, 1.1 vs 0.36; cholecystitis curve gradient, 6.6 vs 1.7). CONCLUSION The cause of postpartum readmission is primarily infectious in origin. A recent pregnancy appears to increase the risk of pneumonia, appendicitis, and cholecystitis.

Emergency department use during the postpartum period: implications for current management of the puerperium.

OBJECTIVE The purpose of this study was to define patterns of morbidity that are experienced by women in the postpartum period who seek care in the emergency department within 42 and 100 days of discharge. STUDY DESIGN We conducted a retrospective examination of discharge diagnosis codes and descriptions for emergency department visits and analyzed temporal patterns of both emergency department visits and hospital readmissions. RESULTS During 2007, 222,084 patients delivered in Hospital Corporation of America facilities in the United States. Among these women, there were 10,751 emergency department visits within 42 days of delivery (4.8%). Fifty-eight percent of the patients were seen for conditions that were related to pregnancy; 42% of the patients were seen for conditions unrelated to pregnancy. Fifty percent of patients in the postpartum period who were seen either in the emergency department (21,833 patients) or readmitted (5190 patients) during both 2007 and 2008 had this encounter within 10 days of discharge. CONCLUSION The scheduling and content of traditional postpartum education and clinical visits appear poorly suited to the prevention of puerperal morbidity.