Addressing Maternal Mortality

Courtney Furrow-White, RN, MPM

In January, the Centers for Disease Control and Prevention’s (CDC’s) National Vital Statistics System released its report on maternal mortality rates in the US. There were 17.4 maternal deaths per 100,000 live births in 2018. That is roughly 700 lives lost during pregnancy, at birth, or within 42 days of birth. When compared to other countries in the World Health Organization’s (WHO’s) maternal mortality ranking, the U.S. is 55th, just behind Russia and slightly ahead of Ukraine.

The death of a mother during pregnancy, childbirth, or soon after delivery is a tragedy. To help address this issue, Vizient organized a performance improvement collaborative with 32 member hospitals. The team’s focus was to develop and share leading practices, protocols, and tools to manage obstetric patients who experienced postpartum hemorrhage (PPH) and preeclampsia/eclampsia, the 2 main preventable causes of maternal mortality.

Subject matter expert Karen E. Harris, MD, MPH, obstetrics/gynecology program director at the HCA Healthcare/University of Central Florida Consortium, provided educational presentations on leading practices, protocols, and tools to manage this patient population. Participants who submitted both baseline and re-measured data showed an aggregated reduction of roughly 6% in readmission/revisit rates due to PPH or preeclampsia/eclampsia.

Assessing maternal risk

Work by the collaborative participants showed proactively assessing a patient’s risk for experiencing an obstetric hemorrhage after delivery was the first step to being prepared to quickly and effectively manage a hemorrhage event.

Conditions that may increase the risk for PPH include placental abruption, placenta previa, obesity, prolonged labor, multiple pregnancies, preeclampsia, medications to induce labor, or stop contractions, to just name a few. Other factors that may increase the potential for PPH included a tear in the cervix, vaginal tissues or a uterine blood vessel, blood clotting disorders and placenta accreta, increta or percreta. The most common symptoms of a PPH are uncontrolled bleeding, decreased blood pressure, elevated heart rate, decreased red blood cell count, and swelling and pain in tissues in the vaginal and perineal area. These symptoms may resemble other conditions or medical problems and each woman may experience them differently.

For patients experiencing postpartum hemorrhage, it is critically important that providers have protocols in place for measuring quantified blood loss for both vaginal and cesarean section deliveries, along with having hemorrhage carts available on the unit for staff to utilize quickly when necessary.

Risk factors for preeclampsia include first pregnancy, history of preeclampsia, high blood pressure, diabetes, kidney disease, multiple gestation, age, and obesity. Providers should also monitor their pregnant patients for sudden weight gain as that may be due to a large increase in bodily fluid, upper right-side belly pain, severe headaches, urinating less, dizziness, severe vomiting or nausea, and vision changes.

For preeclampsia/eclampsia, collaborative participants focused on reviewing staff training and protocols for blood pressure measurement. This included utilizing the correct blood pressure cuff, identification of urine protein, awareness of signs and symptoms of risk, and taking quick action in response to elevated blood pressures.

Commitment to continuous learning

The collaborative work also uncovered another opportunity to identify patients at risk: the electronic health record (EHR). Participants partnered with their IT departments to include best practice advisories, quantitative blood loss calculators, risk assessments, algorithms, and order sets in their EHRs. One participant set up their EHR so when the patient arrives, the nurse completes the OB risk assessment, which assigns a level of risk to the patient. Based on the patient's risk level, the nurse may receive a notification reminding them the patient is at risk, and when specific, stage-based physician orders should be placed. As the old adage says, “practice makes perfect.” A vital step in improving the identification and management of serious obstetric events is to conduct routine simulation drills of different emergency scenarios. While a majority of the same providers work on a given unit, the team that comes together at the moment to care for a patient experiencing a serious event is unique each time. Practicing clinical skills and teamwork among all staff involved is crucial to improving patient outcomes. Providing an immediate debrief afterward with the participants allows leaders and team members to discuss what went well and opportunities for improvement. Hardwiring protocols and what to do in an emergency through simulation education presents an opportunity to practice teamwork between providers and nurses and improve the clinical skills and knowledge of the staff in attendance.

Maintaining awareness of the signs of postpartum hemorrhage and preeclampsia/eclampsia is a fundamental step toward lowering the rate of maternal mortality in our country. It is the foundation for preparing staff to appropriately assess patients, treat, and monitor this patient population. It will also be critical to partner with other providers in our communities to identify obstetric patients who are the most vulnerable and provide access to the care they need.

Courtney Furrow-White, RN, MPM, is a program director on the Vizient Performance Improvement Collaboratives team. The presented analysis reflects her views, not necessarily those of the publication.

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