cesarean birth complications - mercyhealth

4/2/2019

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Cesarean Birth Complications

Carol Burke MSN, APRN/CNS, RNC‐OB, CEFM

April 8, 2019

Disclosures• No FDA “off label” pharmaceutical or medical devices will be discussed in today’s presentation.

• No commercial support was received for this presentation.

• No conflict of interest

Objectives

1. Review assessments and interventions for complications of hemorrhage, surgical site infection and venous thromboembolism following cesarean birth

2. Compare early warning systems to identify maternal deterioration.

3. Discuss use of evidence‐based bundles in management of cesarean birth complications.

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Barber et. al, 2011

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Why us rate at 32%?

• EFM• Without any evidence at all to suggest continuous fetal monitoring improves outcomes, it has become a standard of care. False positive outcome

•Macrosomia• There’s no simple test to determine a baby’s size

•Duration second stage• Varied opinion on how long a woman should spend pushing before a C‐section is called

•Defensive medicine• If a baby is born via C‐section and there’s a bad outcome, you can say everything was done

Sakala 2013

Definitions of Labor Progress per the ACOG/SMFM Consensus Statement

• Prolonged latent phase as currently defined is not indication for c/s

• Slow but progressive labor in the 1st stage should not be indication for c/s

• Cervical dilation of 6cm is a threshold for active labor and standards of active labor progress should not be applied before then

• C/S for active phase arrest in 1st stage should be reserved for women beyond 6cm with ROM who FTP despite 4 hours of adequate contractions or 6 hours of oxytocin administration.

20.2

28.5

36.3

47.9

0

10

20

30

40

50

< 20 20‐29 30‐39 40+

C/S rate by age

C/S rate

Cesarean delivery rate: Number of births delivered by cesarean per 100 births.

National Center for Health Statistics

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Cesarean Rates by State 2017

Is there a better way to calculate rate?

• 10 group classification system – Robson

• Allows standardized comparisons of data

• Identifies clinical scenarios driving changes in cesarean rates.

• Hospitals and health organizations can use the Robson 10‐Group Classification System to evaluate quality and processes associated with cesarean delivery.

• Supported by WHO

Robson, M.S. (2018)

World Health Organization

https://www.who.int/reproductivehealth/publications/maternal_perinatal_health/robson‐classification/en/

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Consortium of safe labor

• To decrease cesarean delivery rate in the U.S:

• Reduce primary cesarean delivery is the key

• Increase VBAC rate is urgently needed

• Cesarean section for dystocia should be avoided before the active phase is established, particularly in nulliparas and in induced labor.

Zhang, et. al, 2015

Maternal Morbidity vaginal / CS / VBAC

P

P P

P

R

R

R

R

Obstetric hemorrhage with cesarean birth

Compared with vaginal delivery, women undergoing cesarean delivery

incur the highest risk of PPH and hemorrhage‐related morbidity

Dunkerton et.al, 2018

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Hemorrhage Definition

Cumulative blood loss

of greater than or equal to 1000mL

or blood loss accompanied by

signs and symptoms of hypovolemia

within 24 hours after the birth process

(includes intrapartum loss)

regardless of route of delivery

ACOG Practice bulletin 183, 2017

Hemorrhage incidence

In the United States, between 1994 and 2006,

the rate of atonic PPH increased

160%among women undergoing cesarean after induction

and

130%among women undergoing noninduced cesarean

Butwick, 2017

Evidence based bundle ‐ hemorrhage

• Obstetric hemorrhage protocols

• Anticipatory planning / transfer Readiness

• Risk factor assessment

• Cumulative QBL

• Identify etiologyRecognition

• Uterotonics / D&C / return to OR

• Blood product replacement

• Enhanced postpartum awarenessResponse

• Internal quality review

• M&M reviewReporting

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Comparison of predicted probability for EBL>1000mL with CS

Dunkerton et.al, 2018

Risk Assessment tools

• Risk assessment tools have been shown to identify 60‐85% of patients who will experience a hemorrhage in the postpartum period

• Examples:

• Postpartum Hemorrhage Risk Assessment Tool (AWHONN)

• Risk assessment tool

ACOG Safe Motherhood Initiative

CMQCC Obstetric Hemorrhage Toolkit

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When should I do hemorrhagerisk assessment?

•Antepartum•On admission

• Throughout birthing process• Prolonged second stage• Prolonged oxytocin use• Active bleeding• Chorioamnionitis• Operative vaginal delivery• Cesarean birth (especially emergent/urgent)• Retained placenta

• Postpartum

• AWHONN recommends that cumulative blood loss be formally measured or quantified after every birth.

• Calibrated under‐buttocks drapes to measure blood loss

• Dry weight card, laminated and attached to all scales, for measurement of items that may become blood‐soaked when a woman is in labor or after giving birth

• With C/S ‐ Suction and measure all amniotic fluid within the suction canister of collected fluid before delivery of the placenta.

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Underlying Etiology for Hemorrhage

Tone Tissue Trauma Thrombin

Uterine Atony

Retained products of conception

Lacerations hematoma

Coagulationabnormalities

TONE abnormality

• Over distended uterus• Polyhydramnios

• Macrosomia

• Multiple gestation

• Uterine muscle exhaustion• Rapid labor

• Prolonged labor

• Prolonged use of oxytocin

• Medication used in labor• Terbutaline

• Magnesium sulfate, Procardia

• Intraamniotic infection• Fever

• Prolonged ROM

• Anatomic distortion• Fibroid uterus

• Uterine anomalies

• Placental abnormalities• Placenta previa

• Abruption

• Couvelaire uterus

tissue abnormality

•Abnormal placental adherence :• accreta, increta, percreta

•Retained placental/ amnion fragments

trauma with cesarean

• Incision extensions

• Laceration at cesarean birth

• Uterine rupture / dehiscence

• Uterine inversion

• Manual removal of the placenta

• Hematoma

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Abnormalities of coagulation(Thrombin)

Preexisting states

• Hemophilia A

• vonWillebrand’s disease

• History of hereditary coagulopathies

• History of liver disease

Acquired in pregnancy

• Idiopathic thrombocytopenic

purpura (ITP)

• Thrombocytopenia with HTN

• Disseminated intravascular

coagulopathy (DIC)

• Massive hemorrhage

• IUFD

• Sepsis

• Abruption

• Amniotic fluid embolus

Palpitations, DizzinessSlight tachycardia

B/P Normal

Weakness, SweatingTachycardia

SBP 80-95 mmHg

Pallor, OliguriaRestlessness,

SBP 70-80 mmHg

Anuria,Air Hunger

Circulatory collapseSBP 50‐70 mmHg

500-1000

1000-1500

1500-2000

2000-3000+

Vo

lum

e

Sym

pto

ms o

f hem

orrh

age

Volume vs. symptoms

Management plan• Goals:

• Maintain SBP > 90mmHg

• Urine output > 30mL/hr (Foley required)

• Normal mental status

• Identify source of hemorrhage

• Requires additional resources

• 2 large bore IV’s

• Rapidly infuse crystalloids while blood products are being obtained

• Accurate vital signs

• Prevent hypothermia via use of external adjuncts for patient warming.

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Management plan (Continued)

• Use pulse ox

• Maintain oxygenation 8‐10L/min via nonrebreather mask

• Discuss with anesthesia or ICU team need for invasive hemodynamic monitoring especially with large volume replacement and ease of blood draws with central line

• Insert Foley catheter with urometer

• Evaluate mental status

• Critical labs: CBC, ABG and coagulation studies (fibrinogen, platelet count, fibrin degradation products).

• The prothrombin time (PT), activated partial thromboplastin time (aPTT) and International Normalized Ratio (INR) tests were developed to assess and adjust dosing of anticoagulant medications such as warfarin (INR) and heparin (aPTT).

Fluid Replacement ‐ Crystalloids

• Lactated Ringer's is a mildly hypotonic solution often used for large‐volume fluid replacement.

• Sodium chloride at 0.9% concentration is close to the concentration in the blood (isotonic).

Crystalloid replacement 3:1 ratio 3 liters of crystalloid to each liter of blood loss

ACOG practice bulletin 76, Obstetric hemorrhage

Product Volume Components Effect

Packed Red Cells 240 RBC, WBC, plasma Increase Hct 3%, Hgb 1g/dL

Platelets 50 Platelets, RBC, WBC, plasma Increase platelet count 5,000‐10,000/mm3 per unit

Fresh Frozen Plasma

250 Fibrinogen, antithrombin III, factors V and VIII

Increase fibrinogen by 10mg/dL

Cryoprecipitate 40 Fibrinogen, factors VIII and XIII, von Willebrand factor

Increase fibrinogen by 10mg/dL

Blood Component Therapy

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Communicate

Communicate

Communicate

•Make the mental shift from “normal delivery” to

• Clarify between the Obstetrician and Anesthesiologist regarding who will primarily manage blood loss quantification, laboratory assessment, and blood component therapy

• Be responsible to alert OB and Anes regarding• Blood volume loss

• Vital signs, I&O•Mental status

• Document as you go

Communicate

Communicate

Communicate

• Alert charge nurse, OR team, IR readiness, blood bank

• Insist that the MD evaluate at the bedside, not just on the phone

• Do a time‐out with every escalation of blood loss to the next tier ( acronym)

ackground / blood product availability

ab data / time drawn

BL total / increase in last hour (quantification)

mergency team notified

ecision / plan

Communicate

Communicate

Communicate

Don’t forget the family

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Surgical site infectionfollowing cesarean birth

Infection accounts for a disproportionate contribution to maternal mortality.

Incidence of SSI

• Cesarean birth is the single most important factor associated with

postpartum infection and carries a 5‐20 fold increased risk of infection

when compared to vaginal delivery

• Some studies show up to 20% of all women develop a postpartum

infection as:

• Endometritis (3X more common after C/S in Stage 2 vs. Stage 1)

• Wound infection and

• Urinary tract infection

• 85% occurring within 7 days of hospital discharge

Lamont et al., 2011Axelsson et al., 2018

SSI Definition / Category

Superficial incisional

Deep incisional

Organ / space

Infection which occurs within 30 days after operative procedure (Cesarean section) and must meet the

following criteria:

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Superficial incisional

Skin and subq tissue + 1 of the following:• Purulent drainage• Organisms from culture• Pain, tenderness, swelling, redness or heat• Diagnosis by a surgeon or attending MD

Deep incisional

Deep soft tissue (fascia and muscle) +1 of the following:• Purulent drainage• Spontaneous dehisces or opened by MD • Fever > 38C, localized pain or tenderness• Abscess found on exam or reoperation or radiologic

exam• Diagnosis by a surgeon or attending MD

Organ/space

Infection involves any part of the anatomy deeper than the fascial/muscle layers that is opened or manipulated during operative procedure +1 of the following:

• Purulent drainage from a drain into the organ• Culture of fluid/tissue• Abscess or evidence of infection involving the organ found

on exam or reoperation or radiologic exam• Diagnosis by a surgeon or attending MD

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Endometritis

• Infection of the lining of the uterus

• The most common cause of postpartum fever

• Endometritis complicates the postoperative course of a cesarean delivery 6‐27% of the time

• Signs / Symptoms

• Postoperative fever / chills

• Fundal / uterine tenderness

• Malodorous and/or purulent lochia

Haas, 2010

Evidence based bundle – surgical site infection

• Evidence based prophylaxis

• Anticipatory planningReadiness


• Identify etiology

• Recognize signs of sepsisRecognition

• Sepsis bundle

• Transfer to higher level of care

• Patient educationResponse

• Internal quality review

• M&M reviewReporting

Evidence‐based prophylaxis

• Preoperative washing for scheduled cesarean:

• Lowers the microbial load at the surgical site and risk of surgical site

contaminants

• Shower or bathe with antimicrobial soap night before C/S

• Consider vaginal cleansing

• Immediately prior to the cesarean birth, especially for women with

ruptured membranes and those who have labored prior to surgery.

• Currently, only povidone‐iodine is approved for use in the vagina, (swab

for 30 seconds) however, off‐label use of chlorhexidine solutions can be

considered, especially in women with allergies to iodine

• Utilize intraoperative skin preparation with chlorhexidine products or povidone

iodine products

AORN, 2018CDC Guideline for the Prevention of Surgical Site Infection,

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Prophylactic Antibiotics

• A narrow‐spectrum, first‐generation cephalosporin: cefazolin (Rx)

• Women with a penicillin allergy: A single dose combination of clindamycin with an aminoglycoside is a second option

• Timing: Ideally, the administration of prophylactic antibiotics should occur 60 minutes prior to skin incision, whenever possible.

• Administer additional doses of antibiotics or higher doses of antibiotics if indicated.

• Surgical procedures lasting longer than 3–4 hours• Obesity• Excess blood loss

• For GBS: (fetal benefit) determine the need for intrapartum prophylaxis in the case of unplanned cesarean or planned cesarean with rupture of membranes.

AAP & ACOG, 2017

Hypothermia prevention

•Hypothermia is associated with cardiac events, delayed surgical wound healing, surgical site infections, increased blood loss, increased hospital stay, and thermal discomfort.

•Suggested methods to maintain temperature:• Forced air• Warmed blankets

• Warmed IV fluid

• OR temperature at 20–23º C (68–73º F)

SSI RiskPatient related factors

Pregnancy related factors

Procedure related factors

● Obesity● Chronic hypertension● Tobacco use in pregnancy● Lower socioeconomic status● ASA class >= 3

● Gestational diabetes● Labor prior to cesarean or

emergent cesarean● ROM > 6 hours● Inadequate prenatal care

● > 6 vaginal exams during labor● Operative time > 49 minutes● Increased blood loss > 500 mL● General anesthesia● Type of closure

(staple vs. subcuticular)● Type of incision● Surgical drains

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When should I do AN infectionrisk assessment?

•Antepartum•On admission


• Postpartum

4 pathways of invasion

Retrograde infection from the pelvis via the

fallopian tubes

MOST COMMON

Incision type

• Joel‐Cohen incision was found superior to Pfannenstiel for reduced morbidity in obese women

• Joel‐Cohen is a straight incision that is 3 cm below the line joining both anterior superior iliac spines.

Ayres-de-Campos, 2015

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Incision closure

Subcuticular

• Decreased wound separation

• Slightly longer surgical time

Staple

Mackeen, Schuster, & Berghella, 2015

Sepsis pathophysiology

Capillary permeabilityLeaking blood vessels, Plasma extravascularReduced circulating volumePlatelet consumption leads to coagulopathy

Organ dysfunctionKidneys, liver, lungs,

uterusSource of infection

Bacteria in the blood

Releases cytokines,histamines, serotonin

Vasodilation, hypotensionpoor perfusionDecreased oxygento tissues leads toTachycardiaLactic acid (serum lactate)

Metabolic acidosis

C/S, prolonged labor, PROM, chorio, multiple vag. exams, retained products, anemia, UTI, pyelo pneumonia, endometritis

Signs of septic shock in mother

• Fever (100.4) or abnormally low temp (96.8)

• Tachycardia > 110 bpm

• Hypotension

• Difficulty breathing, tachypnea > 24 bpm

• Significantly decreased urine output

• Areas of mottled skin / jaundice

• Abrupt change in mental status

• Decrease in platelet count

• Lactate > 2mmol/L

2 or more of these symptoms

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Symptoms of sepsis

• BP may also decrease due to:

• Vasodilation induced by pregnancy

• Epidural anesthesia

• Blood loss

• Normal physiological changes during pregnancy can cause abnormal readings when compared with the non‐pregnant population, potentially leading to a missed diagnosis of sepsis.

Hypotension

A systolic blood pressure of • <90 mm Hg, • mean arterial pressure <70 mm Hg,

or • reduction of >40 mm Hg from

baseline.

Symptoms of sepsis

• Trauma

• Retention due to loss of tone

• Cesarean birth

• Dehydration with prolonged labor

• Antidiuretic effect of oxytocin

Decreased urinary output

Urinary output may decrease also due to:

Symptoms of sepsis

• Exhaustion following labor

• Effect of narcotic administration

Changed mental state

Lethargy may also due to:

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• Lactic acid is a by‐product of anaerobic metabolism (serum lactate)

• Poorly perfused tissue beds result in global tissue hypoxia which result in increased serum lactate

• A serum lactate is correlated with increased severity of illness and poorer outcomes even if hypotension is not present

• May be elevated in labor…

Want a lactate drawn?

SYMPTOMS OF SEPSIS

The most important change in the revision of the Surviving Sepsis Campaign bundles is that

the 3-hour and 6-hour bundles have been combined into a single “Hour-1 Bundle”

with the explicit intention of beginning resuscitation and management immediately.

3 hour bundle

6 hour bundle

1 hour bundle

Evidence based bundle ‐ sepsis

1 hour bundle

effective 5/11/18

Measure Blood Lactate

• Remeasure if initial lactate is >2 mmol/L.• A high lactate level indicates that the tissues are not getting enough oxygen

Perform Blood Culture

Antibiotics

IV Fluids

Vasopressors

• Blood cultures identify the cause of the infection.• Should be taken before antibiotics are administered, if possible.

• Broad‐spectrum antibiotics that are active against the causative organism

• Rapid administration of 30ml/kg crystalloid for hypotension or lactate > 4mmol/L

• Raise blood pressure• This is a critical resuscitation step in patients with septic shock.

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Nursing implications

• Aware of potential maternal deterioration

• Vigilance with vital sign and symptom assessment

• Prompt administration of antibiotics

• Delivery is not always the ‘cure’ for the mother with

intraamniotic infection

• Patient education for signs of maternal infection

• Attend / participate in severe maternal morbidity review

sessions

Complication: Venous thromboembolism

The risk of VTE is 4 times greater after cesarean section compared to vaginal birth.

The risk of VTE is 4 times greater after cesarean section compared to vaginal birth.

80%

20%

VTE

DVTPE

Part of clot breaks off and carried to the lungs

(PE)

DVT causes pain and swelling

(rarely fatal)

Blood clot forms in deep vein

• chest pain• shortness of breath• hemoptysis (coughing blood) and, if large,

severe hypoxia and collapse, which can be fatal

• chest pain• shortness of breath• hemoptysis (coughing blood) and, if large,

severe hypoxia and collapse, which can be fatal

Venous thromboembolism

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VenousThromboembolism (VTE)

Deep Vein Thrombosis (DVT)

Pulmonary Embolism (PE)

1st trimester

2nd trimester3rd trimester

! 60 fold increase during first 3

months after birth

The incidence of VTE, is 2.6 per 1000 cesarean birthsThe incidence of VTE, is

2.6 per 1000 cesarean births

Stasis of blood flow

Endothelial injury Hypercoagulability

Virchow's triad

Hypercoagulability• Increased fibrinogen• Factor V Leiden mutation• Trauma• Late pregnancy and birth • Cigarette smoking• Obesity

Alterations in normal blood flow

• Venous stasis• Prolonged immobility • Varicose veins

Endothelial trauma• Hypertension• Biomaterials, implants• Platelet membranes• Chronic inflammation

Pregnancy has ALL the factors

Evidence based bundle:venous thromboembolism

• VTE prophylaxis

• Anticipatory planningReadiness


• Recognize signs of VTE (DVT / PE)Recognition

• Use standardized recommendations for dosing of prophylactic and therapeutic anticoagulation

• Timing with neuraxial anesthesia

Response

• M&M quality review of thrombotic events for protocol complianceReporting

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Vte prophylaxis

• All patients undergoing cesarean birth require• Knee‐high mechanical prophylaxis (SCD) while in bed, prior to cesarean and continued postop

• Early /encourage ambulation

• Adequate hydration

• Empiric prophylaxis is a reasonable option for strict antepartum bed rest >72 hrs. / or 1 week

• Anesthesia consult before starting LMWH or UFH

Anticoagulant therapy in pregnancy

HeparinSafe in pregnancy, does not cross placentaUnfractionated (UFH)

Low molecular weight (LMWH) ex: Enoxaparin (Lovenox)

fewer adverse effects

More predictable therapeutic responseLower incidence of HIT (heparin induced thrombocytopenia)

Longer half‐life (risk with neuraxial anesthesia – need to delay 12‐24 hours)

Protamine Sulfate 1mg by slow infusion is antidote

Some common herbs, NSAIDS, antibiotics can potentiate LMWH and UFH resulting in excessive bleeding

When should I do VTErisk assessment?

•Antepartum, especially hospitalization

•On admission


• Postpartum

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Risk factors for VTE

Major Risk Factors

• BMI > 35kg/m2 at delivery

• Immobility (strict antepartum bed rest

>72 hrs. / or 1 week)

• Postpartum hemorrhage with C/S

requiring blood transfusion or IR

• Previous VTE

• Preeclampsia with fetal growth

restriction

• Thrombophilia: e.g. Factor V Leiden

• Medical condition: Lupus, heart

disease, sickle cell disease

Minor risk factors

• Postpartum infection

• BMI > 30 kg/m2

• Multiple gestation

• Age > 40

• Emergency cesarean

• Smoking > 10 cigarettes/day

• Fetal growth restriction

• Preeclampsia

Women with one major or two minor risk factors should receive in-hospital

post cesarean pharmacologic prophylaxis

©California Department of Public Health, 2017; supported by Title V funds. Developed in partnership with California Maternal Quality Care Collaborative Maternal Venous Thromboembolism Task Force. Visit: www.CMQCC.org for details

3 Levels of VTE Risk

Utilize the “3 bucket model” risk assessment that stratifies VTE risk in pregnant or postpartum women into three color-coded levels for rapid identification

Medium VTE RiskLow VTE Risk High VTE Risk

Hameed AB, Montgomery D, Peterson N, Morton CH, and A Friedman. Improving Health Care Response to Maternal Venous Thromboembolism. Developed under contract #11-10006 with the California Department of Public Health, Maternal, Child and Adolescent Health Division. Published by the California Department of Public Health, 2017.


Modified PADUA Risk Assessment Model for OB

Risk Factors Points

Previous VTE 3

Reduced mobility (bedrest with bathroom privileges for at least >72 hours

3

Thrombophilia 3

Acute infection and/or Rheumatologic disorder 1

Pregnancy 1

Obesity (BMI > 25 kg/m2) 1

Barbar, Noventa et al. 2010; D’Alton, Friedman et al. 2016; Harris, Sulmers et al. 2016

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symptoms of DVT

• Heaviness / swelling in affected limb• Warmth• Pain or tenderness• Redness, pallor or other change in skin color• Increased calf / thigh circumference

pulmonary embolus

Symptoms:

• Dyspnea / tachypnea

• Fever

• Tachycardia

• Hemoptysis

• Chest pain may be worse

with inspiration

Investigation:

• ABG• CT angiogram• Pulmonary angiogram

Mayo foundation for medical education and research

HIGH RISKTHERAPEUTIC

ANTICOAGULATIONfor 6 weeks from date of

delivery*

LOW RISKNO ANTICOAGULATION

MEDIUM RISKPROPHYLACTIC

ANTICOAGULATIONfor 6 weeks from date of

delivery*


* E.g. Women discharged at 1 week postpartum would receive

extended duration anticoagulation for another 5 weeks

Follow Up Questions

No to all

Yes

Recent VTE or other conditions requiring therapeutic dose of anticoagulation

Personal history of eithero VTE with high risk thrombophilia oro VTE with Antiphospholipid

Syndrome (APS) oro Multiple VTE episodes

Management

Personal history of either Idiopathic VTE or

o VTE with low risk thrombophilia o VTE related to pregnancy or OCP’so VTE Provoked

NO personal history of VTE but with either:

o High risk thrombophilia (including APS) regardless family history of VTE or

o Low risk thrombophilia with family history VTE

Low risk thrombophilia (isolated)

Screening Questions

Algorithm 3: Post-Discharge Extended Duration Anticoagulation:Maternal VTE Risk Assessment

Receiving Prenatal Anticoagulation?

Thrombophilia?

Personal or Family History of VTE?

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Early warning systems

Key to optimizing outcomes and reducing preventable harm.

Need to address the four most common causes of maternal morbidity:

hemorrhage, preeclampsia, sepsis and cardiovascular dysfunction

Screening systems

General Morbidity Scores

Obstetric Screening Systems

Maternal early warning criteria

Agitation, confusion or unresponsiveness

SBP < 90 or > 160

mmHg

DBP > 100

HR

< 50 or > 120 BPM

RR

< 10 or > 30

O2 sat < 95% in room air (sea level)

Oliguria < 30mL/hr. for 2 hrs.

+ Women with hypertension reporting a non‐remitting headache or shortness of breath.

Mhyre, 2014

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• 2 abnormal values sustained for >20 minutes

• Identifies 4 causes of maternal morbidity

MEWT

Maternal Early Warning Trigger

• Identify maternal sepsis by using the vital signs, WBC and lactic acid as measurement parameters

SOSSepsis in Obstetrics

Score

• Utilizes 2 moderately abnormal parameters (yellow alerts) or 1 severely abnormal parameter (red alert) to trigger a clinical response

MEOWS Modified Early

Obstetric Warning System

• Identifies women at a higher risk for requiring interventions in the ICU such as mechanical ventilation and/or vasoactive support

OEWS

Obstetric Early Warning Score

Summary

• Cesarean birth increases potential for maternal morbidity, but may also be necessary

• Culture change is needed to support physiologic labor and vaginal birth

• Risk assessment tools have been shown to identify 60‐85% of higher‐risk women

• Recommendations vary with specialty groups – adopt one and perform quality assessment

• Continued work to reach consensus with maternal early warning systems may improve communication, reduce desensitization, and improve response

Patient Education

Bleeding, soaking through one pad/hour or blood clots the size of an egg or bigger

Incision that is not healing Red or swollen leg, that is painful or warm to touch

Temperature of 100.4F or higher

4 key warning signs for hemorrhage, infection and DVT

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Participate in Severe Maternal Morbidity Reviews

1. Were significant risk factors for complications identified?

2. Was the suspicion of hemorrhage, sepsis or DVT made in a timely fashion?

Did the Early Warning System alert the team?

3. Were appropriate uterotonics, antibiotics or anticoagulants used after diagnosis? How long to treatment?

4. Did the woman receive appropriate volume of IV fluids?

Kilpatrick, 2018

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