Maternal Morbidity - Near Misses Resources

Ideally ACLS providers will prevent pulseless arrest if they are able to intervene in the prearrest period. If arrest occurs, good ACLS begins with high-quality BLS. During resuscitation rescuers must provide good chest compressions (adequate rate and depth), allow complete recoil of the chest between compressions, and minimize interruptions in chest compressions. Rescuers should be careful to avoid provision of excessive ventilation, particularly once an advanced airway is in place. Resuscitation drugs have not been shown to increase rate of survival to hospital discharge, and none has the impact of early and effective CPR and prompt defibrillation.

Successful resuscitation of a pregnant woman and survival of the fetus require prompt and excellent CPR with some modifications in basic and advanced cardiovascular life support techniques. By the 20th week of gestation, the gravid uterus can compress the inferior vena cava and the aorta, obstructing venous return and arterial blood flow. Rescuers can relieve this compression by positioning the woman on her side or by pulling the gravid uterus to the side. Defibrillation and medication doses used for resuscitation of the pregnant woman are the same as those used for other adults in pulseless arrest. Rescuers should consider the need for emergency hysterotomy as soon as the pregnant woman develops cardiac arrest because rescuers should be prepared to proceed with the hysterotomy if the resuscitation is not successful within minutes.

OBJECTIVE: To determine the level of near-miss maternal mortality and morbidity due to severe obstetrical complications or maternal disease in a tertiary maternity hospital.
DESIGN: Retrospective review.
SETTING: A free-standing maternity hospital delivering 5500 infants per year.
METHODS: The information coded in the perinatal database concerning women who had required transfer for critical care to a general hospital was reviewed for the 14 year period 1980 to 1993. The complications necessitating transfer and the specialised consultants and services required were noted.
RESULTS: Over 14 years there were 76,119 women delivered with two maternal deaths (2.6/100,000). Fifty-five women required transfer for critical care (0.7/1000). The main reasons for transfer were hypertensive disease (25%), haemorrhage (22%) and sepsis (15%). Transfer to an intensive care unit was required by 80%, and the remainder were transferred to specialised medical or surgical units. Twenty different specialist groups were consulted. The 55 patients spent 280 days in critical care and 464 days hospital after-care (mean 13 days, range 3-92).
CONCLUSION: A review of near-miss maternal mortality helps delineate the continuing threats to maternal health and the type of support services most commonly required.

INTRODUCTION: The 2000-2002 triennial UK Report on Confidential Enquiries into Maternal Deaths concluded that over 50% of maternal deaths involved substandard care and that many could have been prevented. Catastrophic events leading to cardio-respiratory arrest may necessitate the resuscitation of pregnant women in various hospital locations. This study was designed to evaluate knowledge about resuscitation of parturients among anesthesiologists, obstetricians and emergency physicians.
METHODS: A 12-question survey was distributed anonymously to residents and faculty in the anesthesia (ANES), obstetrics (OB), and emergency medicine (EM) departments at Stanford University Medical Center/Lucile Packard Children's Hospital, Stanford, California. Questions were designed to elicit knowledge deficiencies in four critical areas: need for left uterine displacement (LUD), advanced cardiac life support algorithms (ACLS), physiologic changes of pregnancy (PHYS), and the recommendation to perform cesarean delivery in parturients (>20 weeks gestation) after 4-5 min of unsuccessful resuscitation for cardiac arrest (5CD).
RESULTS: In total, 74/75 physicians (43% ANES, 37% OB, and 20% EM) completed the test. ANES scored highest in overall test scores, and in knowledge of PHYS (P<0.05). Scores for LUD and 5CD were similar among groups, but 25-40% of these questions were answered incorrectly. In the ACLS category, the EM group scored highest (93%).
CONCLUSION: We conclude that knowledge of important basic concepts, including the need for LUD and the potential benefit of early cesarean delivery during cardiac arrest, is inadequate among all three specialties. All three departments should provide ACLS physician training with emphasis on the special considerations for parturients.

OBJECTIVE: The objective of this study was to develop a scoring system for identifying women with near-miss maternal morbidity, and differentiating these women from those with severe but not life-threatening conditions.
STUDY DESIGN AND SETTING: The study was conducted at the University of Illinois Medical Center at Chicago (UIMC), which is a tertiary care hospital with approximately 2,220 births per year. UIMC is in a major urban area serving a predominantly African-American and Latina population. This article focuses on five clinical factors: organ failure (>/=1 system), extended intubation (>12 hr), ICU admission, surgical intervention, and transfusion (>3 units), grouped into several scoring system alternatives. The total score on each scoring system was calculated as the weighted sum of the clinical factors present for each woman.
RESULTS: The five-factor scoring system had the highest specificity (93.9%), but the four-factor scoring system, which eliminated organ system failure for simplification of data collection, still had a specificity of 78.1%.
CONCLUSION: Near-miss morbidities identified using the scoring systems presented can be incorporated into clinical case review and epidemiologic studies to enhance the monitoring of obstetric care and to improve estimates of the incidence of life-threatening complications in pregnancy.

Maternal mortality is the major indicator used to monitor maternal health in the United States. For every woman who dies, however, many suffer serious life-threatening complications of pregnancy. Yet relatively little attention has been given to identifying a general category of morbidities that could be called near misses. Characterizing near-miss morbidity is valuable for monitoring the quality of hospital-based obstetric care and for assessing the incidence of life-threatening complications. Cases of near-miss morbidity also provide an appropriate comparison group both for dinical case review and for epidemiologic analysis. This paper presents an initial framework and a process for the definition and identification of near-miss morbidity that minimizes loss of information yet has practical utility. A clinical review team classified 22 of 186 women as near misses and 164 as other severe morbidity. A quantitative score classified 28 women as near misses and 156 as other severe morbidity. Precise classification of near-miss morbidity is the first step in analyzing factors that may differentiate survival from death on the continuum from morbidity to mortality. Ultimately, a methodology for the identification and analysis of near-miss morbidity will allow for integrated morbidity and mortality reviews that can then be institutionalized. The results will serve as important models for other researchers, state health agencies, and regionalized perinatal systems that are engaged in morbidity and mortality surveillance.

OBJECTIVE: The goal of this study was to examine whether sociodemographic, clinical, and other service-related factors, as well as preventability issues affect a woman's progression along the continuum of morbidity and mortality.
STUDY DESIGN: This was a case-control study of pregnancy-related deaths, women with near-miss morbidity, and those with other severe, but not life threatening, morbidity. Factors associated with maternal outcome were examined.
RESULTS: Provider factors (related to preventability) and clinical diagnosis were significantly associated with progression along the continuum after controlling for sociodemographic characteristics (P < .01 for both associations).
CONCLUSION: In order to improve mortality rates, we must understand maternal morbidity and how it may lead to death. This study shows that important initiatives include addressing preventability, in particular, provider factors, which may play a role in moving women along the continuum of morbidity and mortality.

OBJECTIVE: To identify risk factors for life-threatening maternal outcomes.
STUDY DESIGN: Hospital charts were reviewed for cases of maternal mortality or near-miss and for controls overmatched 1:3. Significant risk factors were identified through simple and best subsets multiple logistic regression.
RESULT: Eight cases of mortality and 69 near-miss cases were found. Significant risk factors with their odds ratios and 95% confidence intervals are: age 35 to 39 years (2.3, 1.2 to 4.4) and >39 years (5.1, 1.8 to 14.4); African-American race (7.4, 2.5 to 22.0) and Hispanic ethnicity (4.2, 1.3 to 13.2); chronic medical condition (2.7, 1.5 to 4.8); obesity (3.0, 1.7 to 5.3); prior cesarean (5.2, 2.8 to 9.8) and gravidity (1.2, 1.1 to 1.5 per pregnancy). In multivariable logistic regression, race remained significant while controlling for other significant factors and markers of socioeconomic status.
CONCLUSION: Some risk factors can be modified through medical care, education or social support systems. Racial disparity in outcome is confirmed and is unexplained by traditional risk factors.

In developed countries where maternal death is rare, the factors surrounding the death are often peculiar to the event and are not generalizable, making analysis of maternal deaths less useful. Near misses are defined as pregnant women with severe life-threatening conditions who nearly die but, with good luck or good care, survive. Incorporation of near misses into maternal death enquiries would strengthen these audits by allowing for more rapid reporting, more robust conclusions, comparisons to be made with maternal deaths, reinforcing lessons learnt, establishing requirements for intensive care and calculating comparative indices. The survival of a pregnant woman is dependent on the disease, her basic health, the health care facilities and personnel of the health care system. The criteria currently used to identify a near miss vary greatly. However, areas with similar health care facilities, medical records and personnel should be able to agree on suitable criteria, making their incorporation into maternal death enquiries feasible.

Objective To assess the most commonly employed diagnostic indicators of severe maternal morbidity (obstetric near-miss). Methods Review of the literature from January 1989 to August 2008. Results Fifty-one manuscripts met the eligibility criteria, and 96 indicators were utilized at least once. Admission to intensive care unit (n = 28 studies) was the indicator most frequently utilized, followed by eclampsia and hemorrhage (n = 27), blood transfusion (n = 26) and emergent hysterectomy (n = 24). Conclusion Considering these Wndings, a trial version of a 13-item instrument for diagnosing obstetric near-miss is proposed. It includes the indicators eclampsia, severe hypertension, pulmonary edema, cardiac arrest, obstetrical hemorrhage, uterine rupture, admission to intensive care unit, emergent hysterectomy, blood transfusion, anesthetic accidents, urea >15 mmol/l or creatinine >400 mmol/l, oliguria (<400 ml/24 h) and coma. Further studies should focus on consensual deWnitions for these indicators and evaluate the psychometric proprieties of this trial version.

Aim: To determine the prevalence of severe acute maternal morbidity (SAMM) worldwide (near miss). Method: Systematic review of all available data. The methodology followed a pre-defined protocol, an extensive search strategy of 10 electronic databases as well as other sources. Articles were evaluated according to specified inclusion criteria. Data were extracted using data extraction instrument which collects additional information on the quality of reporting including definitions and identification of cases. Data were entered into a specially constructed database and tabulated using SAS statistical management and analysis software. Results: A total of 30 studies are included in the systematic review. Designs are mainly crosssectional and 24 were conducted in hospital settings, mostly teaching hospitals. Fourteen studies report on a defined SAMM condition while the remainder use a response to an event such as admission to intensive care unit as a proxy for SAMM. Criteria for identification of cases vary widely across studies. Prevalences vary between 0.80% – 8.23% in studies that use disease-specific criteria while the range is 0.38% – 1.09% in the group that use organ-system based criteria and included unselected group of women. Rates are within the range of 0.01% and 2.99% in studies using management-based criteria. It is not possible to pool data together to provide summary estimates or comparisons between different settings due to variations in case-identification criteria. Nevertheless, there seems to be an inverse trend in prevalence with development status of a country. Conclusion: There is a clear need to set uniform criteria to classify patients as SAMM. This standardisation could be made for similar settings separately. An organ-system dysfunction/failure approach is the most epidemiologically sound as it is least open to bias, and thus could permit developing summary estimates.

Objective To develop an indicator of maternal near miss as a proxy for maternal death and to study its association with maternal factors and perinatal outcomes. Methods In a multicenter cross-sectional study, we collected maternal and perinatal data from the hospital records of a sample of women admitted for delivery over a period of two to three months in 120 hospitals located in eight Latin American countries. We followed a stratified multistage cluster random design. We assessed the intra-hospital occurrence of severe maternal morbidity and the latter’s association with maternal characteristics and perinatal outcomes. Findings Of the 97 095 women studied, 2964 (34 per 1000) were at higher risk of dying in association with one or more of the following: being admitted to the intensive care unit (ICU), undergoing a hysterectomy, receiving a blood transfusion, suffering a cardiac or renal complication, or having eclampsia. Being older than 35 years, not having a partner, being a primipara or para > 3, and having had a Caesarean section in the previous pregnancy were factors independently associated with the occurrence of severe maternal morbidity. They were also positively associated with an increased occurrence of low and very low birth weight, stillbirth, early neonatal death, admission to the neonatal ICU, a prolonged maternal postpartum hospital stay and Caesarean section. Conclusion Women who survive the serious conditions described could be pragmatically considered cases of maternal near miss. Interventions to reduce maternal and perinatal mortality should target women in these high-risk categories.

A reasonable trigger tool for nursing charting on L&D. From: Appendix to Saving Mother's Lives (2007); also published in: International Journal of Obstetric Anesthesia (2006) 15, S1-S43 Abstracts of free papers presented at the annual meeting of the Obstetric Anaesthetists? Association, Glasgow 11-12 May, 2006. “Early-warning scoring in obstetrics”. P Harrison, C Hawe, F McIlveney. Department of Anaesthesia, Stirling Royal Infirmary, Stirling, UK.

My focus is on post partum hemorrhage (PPH) and emergency hysterectomy (this is commonly called “the ordeal” by the women who have experienced it) is driven by a desire to understand several interwoven questions, 1) what takes place during the ordeal and how embodied knowledge is disjointed and ruptured, 2) how women recreate embodied wholeness through narrative and defining the ordeal, and 3) how women create healing and resiliency through collective empathy and a redefine family through various means. PPH often results in death or near death experiences as a result of various complications brought on from hemorrhaging.