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Mhyre JM, Riesner MN, Polley LS, Naughton NN. A series of anesthesia-related maternal deaths in Michigan, 1985-2003. Anesthesiology Jun 2007; 106: 1096-104.

BACKGROUND: Maternal Mortality Surveillance has been conducted by the State of Michigan since 1950, and anesthesia-related maternal deaths were most recently reviewed for the years 1972-1984. METHODS: Records for pregnancy-associated deaths between 1985 and 2003 were reviewed to identify 25 cases associated with a perioperative arrest or major anesthetic complication. Four obstetric anesthesiologists independently classified these cases, and disagreements were resolved by discussion. Precise definitions of anesthesia-related and anesthesia-contributing maternal death were constructed. Anesthesia-related deaths were reviewed to identify the chain of medical errors or care management problems that contributed to each patient death. RESULTS: Of 855 pregnancy-associated deaths, 8 were anesthesia-related and 7 were anesthesia-contributing. There were no deaths during induction of general anesthesia. Five resulted from hypoventilation or airway obstruction during emergence, extubation, or recovery. Lapses in either postoperative monitoring or anesthesiology supervision seemed to contribute to 5 of the 8 anesthesia-related deaths. Other characteristics common to these cases included obesity (n=6) and African-American race (n=6). CONCLUSIONS: The 8 anesthesia-related and seven anesthesia-contributing maternal deaths in Michigan between 1985 and 2003 illustrate three key points. First, all anesthesia-related deaths from airway obstruction or hypoventilation took place during emergence and recovery, not during the induction of general anesthesia. Second, system errors played a role in the majority of cases. Of concern, lapses in postoperative monitoring and inadequate supervision by an anesthesiologist seemed to contribute to more than half of the deaths. Finally, this report confirms previous work that obesity and African-American race are important risk factors for anesthesia-related maternal mortality.

Bingham D, Lyndon A, Lagrew D, Main E. A State-Wide Obstetric Hemorrhage Quality Improvement Initiative. The American Journal of Maternal/Child Nursing 36: 297-304.

Purpose: The mission of the California Maternal Quality Care Collaborative is to eliminate preventable maternal death and injury and to promote equitable maternity care in California. This article describes California Maternal Quality Care Collaborative's (CMQCC's) statewide multistakeholder quality improvement initiative to improve readiness, recognition, response, and reporting of maternal hemorrhage at birth and details the essential role of nurses in its success.

Project Design and Approach: In partnership with the State Department of Maternal, Child, and Adolescent Health, CMQCC identified maternal hemorrhage as a significant quality improvement opportunity. CMQCC organized a multidisciplinary, multistakeholder task force to develop a strategy for addressing obstetric (OB) hemorrhage.

Project Description: The OB Hemorrhage Task Force, co-chaired by nurse and physician team leaders, identified four priorities for action and developed a comprehensive hemorrhage guideline. CMQCC is using a multilevel strategy to disseminate the guideline, including an open access toolkit, a minimal support-mentoring model, a county partnership model, and a 30-hospital learning collaborative.

Clinical Implications: In participating hospitals, nurses have been the primary drivers in developing both general and massive hemorrhage policies and procedures, ensuring the availability of critical supplies, organizing team debriefing after a stage 2 (or greater) hemorrhage, hosting skills stations for measuring blood loss, and running obstetric (OB) hemorrhage drills. Each of these activities requires effort and leadership skill, even in hospitals where clinicians are convinced that these changes are needed. In some hospitals, the burden to convince physicians of the value of these new practices has rested primarily upon nurses. Thus, the statewide initiative in which nurse and physician leaders work together models the value of teamwork and provides a real-time demonstration of the potential for effective interdisciplinary collaboration to make a difference in the quality of care that can be achieved. Nurses provide significant leadership in multidisciplinary, multistakeholder quality projects in California. Ensuring that nurses have the opportunity to participate in formal leadership of these teams and are represented at all workgroup levels is critical to the overall initiative. Nurses brought key understanding of operational issues within and across departments, mobilized engagement across the state through the regional perinatal programs, and developed innovative approaches to solving clinical problems during implementation. Nursing leadership and integrated participation was especially critical in considering the needs of lower-resource settings, and was essential to the toolkit's enthusiastic adoption at the unit/service level in facilities across the state.

The Ohio Perinatal Quality Collaborative Writing Committee. A Statewide initiative to reduce inappropriate scheduled births at 36 0/7 - 38 6/7 weeks' gestation. Am J Obstet Gynecol 202: 243.e1-8.
Donovan EF, Lannon C, Bailit J. et al. A statewide initiative to reduce inappropriate scheduled births at 36(0/7)-38(6/7) weeks' gestation. American Journal of Obstetrics and Gynecology 202: 243.e1-8.

OBJECTIVE: We sought to reduce scheduled births between 360/7-386/7 weeks that lack appropriate medical indication.
STUDY DESIGN: Twenty Ohio maternity hospitals collected baseline data for 60 days and then selected locally appropriate Institute for Healthcare Improvement
Breakthrough Series interventions to reduce the incidence of scheduled births. Deidentified birth data were analyzed centrally. Rates of
scheduled births without a documented indication, birth certificate data, and implementation issues were shared regularly among sites.
RESULTS: The rate of scheduled births between 360/7-386/7 weeks without a documented medical indication declined from 25% to 5% (P.05) in participating hospitals. Birth certificate data showed inductions without an indication declined from a mean of 13% to 8% (P .0027). Dating criteria were documented in 99% of charts.
CONCLUSION: A statewide quality collaborative was associated with fewer scheduled births lacking a documented medical indication.

National Partnership for Action to End Health Disparities. A Strategic Framework for Improving Racial/Ethnic Minority Health and Eliminating Racial/Ethnic Health Disparities. U.S. Dept. Health and Human Services

Although the health of all Americans has continued to improve over the more than two decades since the 1985 Task Force Report on Black and Minority Health was issued, racial and ethnic health disparities persist and, in some cases, are increasing. The persistence of such disparities suggests that current approaches and strategies are not producing the kinds of results needed to ensure that all Americans are able to achieve the same quality and years of healthy life, regardless of race/ethnicity, gender and other variables (as reflected in the two overarching goals of Healthy People 2010).

The mission of the HHS Office of Minority Health (OMH) is to improve the health of racial and ethnic minority populations through the development of health policies and programs that will help eliminate disparities. OMH has a unique leadership and coordination role to play within the Department and across the nation, relative to this mission. However, such a mission cannot be accomplished by OMH alone. We need the active engagement and sustained efforts of all stakeholders working together with us and each other to effect the necessary changes at every level and across all sectors over time. These stakeholders include racial and ethnic minority communities and those who serve them, other HHS and Federal entities, academic and research institutions, State and Tribal governments, faith- and community-based organizations, private industry, philanthropies and many others. We also need to examine what we are doing, identify what must be done differently and determine how best to work together - within and across our respective disciplines, areas of interest, organizational/institutional or geographic boundaries and spheres of influence - to enhance our individual and collective effectiveness and impacts.

The Strategic Framework for Improving Racial and Ethnic Minority Health and Eliminating Racial and Ethnic Health Disparities (Framework) presented here is intended to help guide, organize and coordinate the systematic planning, implementation and evaluation of efforts within OMH, HHS and across the nation to achieve better results relative to minority health improvements and health disparities reductions. The Framework reflects current knowledge and understanding of the nature and extent of health disparities, their causes or contributing factors, effective solutions and desired outcomes and impacts. It reinforces the importance of having and using science and knowledge as the basis for planning and implementing our program-, research-, or policy-oriented actions and activities. The Framework also suggests the need to adequately evaluate our efforts so that new knowledge can be used for continuous improvement. In addition, the Framework infers the need to fund our efforts accordingly, and to explore ways to enhance efficient use of programmatic and research funds as well as other resources and assets at our disposal.

Several aspects of this framework are worth highlighting:

1. By using a logic model approach, which builds upon current science and expert consensus about racial/ethnic minority health/health disparities and systems problems, contributing or causal factors and strategies that work, the Framework provides the rationale for efforts funded and conducted as well as for the kinds of outcomes and impacts needed . This approach can be used as a guide to move us toward a common set of objectives and goals.
2. In addition to identifying the usual determinants of health, the Framework emphasizes the role that "systems-level factors" play in promoting or inhibiting the effectiveness of strategies and practices aimed at improving racial and ethnic minority health or reducing racial and ethnic health disparities. These systems factors include: the nature and extent of available resources and how they are used, coordination and collaboration through partnerships and communication, leadership and commitment through strategic visioning and sustained attention, user-centered design in which the products and services of the system are conceived with the needs of their users in mind and the use of science and knowledge to inform programs and policies.
3. Ultimately, the Framework presents a vision – and provides the basis - for a "systems approach" to addressing racial/ethnic minority health problems within and outside of HHS. A systems approach implies that all parties engaged, in this case, in racial/ethnic minority health improvement and health disparities reduction are, themselves, part of a 'system' or 'nested' systems. As such, each party considers the causal or contributing factors and problems it is most likely to be able to impact with its particular strengths and talents. Resources and assets can then be coordinated and leveraged in more systematic and strategic ways, to achieve a range of outcomes and impacts needed so that, together, all parties can more effectively and efficiently contribute to and achieve long-term objectives and goals. This focus on systems applies as well to how various fields of research work together for greater effectiveness and efficiency to address weaknesses and gaps in scientific knowledge. A systems approach to working across diverse research disciplines may be better able to illuminate our understanding about the nature and extent of minority health and health disparities problems, especially for small population groups, the relative importance of and interrelationships between causal or contributing factors, more effective ways to break the causal chain that produces greater burdens of preventable disease and premature death among racial and ethnic minorities and the means for measuring desired outcomes and assessing progress.

We believe that the structure and approach outlined in the Framework offers a rational and systematic, yet broad and flexible, way of viewing and informing our efforts to achieve the OMH and, in reality, the national mission. We hope that the Framework will provide context for the actions needed by OMH and its partners across HHS and the nation to better leverage resources, establish priorities for ensuring effectiveness of programs and activities funded and conducted, enable identification and promotion of best practices and concrete solutions at all levels and serve as the foundation for a national results-oriented culture on racial and ethnic minority health improvement and the elimination of racial and ethnic health disparities.

B-Lynch C. A textbook of Postpartum Hemorrhage (Table of Contents).
Berwick, D. A user's manual for the IOM's 'quality chasm' report. Health Affairs 21:

Fifteen months after releasing its report on patient safety (To Err Is Human), the Institute of Medicine released Crossing the Quality Chasm. Although less sensational than the patient safety report, the Quality Chasm report is more comprehensive and, in the long run, more important. It calls for improvements in six dimensions of health care performance: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity; and it asserts that those improvements cannot be achieved within the constraints of the existing system of care. It provides a rationale and a framework for the redesign of the US health care system at four levels: patients' experiences; the "Microsystems" that actually give care; the organizations that house and support Microsystems; and the environment of laws, rules, payment, accreditation, and professional training that shape organizational action.

Singh S, McGlennan A, England A, Simons R. A validation study of the CEMACH recommended modified early obstetric warning systesm (MEOWS). Anaesthesia 67: 12-18.

The 2003–2005 Confidential Enquiry into Maternal and Child Health report recommended the introduction of the modified early obstetric warning system (MEOWS) in all obstetric inpatients to track maternal physiological parameters, and to aid early recognition and treatment of the acutely unwell parturient. We prospectively reviewed 676 consecutive obstetric admissions, looking at their completed MEOWS charts for triggers and their notes for evidence of morbidity. Two hundred patients (30%) triggered and 86 patients (13%) had morbidity according to our criteria, including haemorrhage (43%), hypertensive disease of
pregnancy (31%) and suspected infection (20%). The MEOWS was 89% sensitive (95% CI 81–95%), 79% specific (95% CI 76–82%), with a positive predictive value 39% (95% CI 32–46%) and a negative predictive value of 98% (95% CI 96–99%). There
were no admissions to the intensive care unit, cardio respiratory arrests or deaths during the study period. This study suggests that MEOWS is a useful bedside tool for predicting morbidity. Adjustment of the trigger parameters may improve positive predictive value.

El-Hamamy E, B-Lynch C. A worldwide review of the uses of the uterine compression suture techniques as alternative to hysterectomy in the management of severe post-partum haemorrhage. J Obstet Gynaecol Feb 2005; 25: 143-9.

Postpartum haemorrhage (PPH) is a worldwide problem. The historical background dates back to William Smelley's in the seventeenth century in his famous treaty of the theory and practice of midwifery in 1752. Changes in clinical factors and surgical expertise compel the modern day midwife and obstetrician to be vigilant in identifying risk factors and apply appropriate solution early. The recent confidential enquiry into maternal death (why mothers die (2000-2002)) identifies areas of substandard care. The rising caesarean section rate adds to the rising incidence of PPH. The reduction in junior doctor's hours may limit the pool of experienced obstetric surgeons available to manage severe PPH competently. There can be major complications following radical surgery for PPH. These include loss of fertility, other morbidity and even maternal death. The invention of the B-Lynch surgical technique for the conservative management of PPH was first performed and reported by a consultant obstetrician and gynaecological surgeon in Milton Keynes NHS Trust publishing the first series of cases in BJOG 1997. This has made a significant impact on the conservative surgical management of massive PPH. There are now over 1300 successful applications of this technique worldwide (CB-Lynch personal communication). Other similar or modified techniques such as Cho's Square Suture and Haymen's modification of the B-Lynch Suture Technique have been introduced adding to more available methods of conservative surgery. The current list of publications of successful application of the B-Lynch compression technique is encouraging and more outcome data can be reported by a letter or e-mail to Obstetricians and midwives both in developed and underdeveloped countries should seek training and attend fire drills in PPH control to avoid maternal morbidity and death. There should be special concentration on effective conservative surgery such as uterine compression techniques to avoid major morbidity and loss of fertility.

Ehrenberg HM, Merc BM. Abbreviated Postpartum Magnesium Sulfate Therapy for Women with Mild Preeclampsia: A Randomized Controlled Trial. Obstet Gynecol 108: 833-8.

OBJECTIVE: To determine whether women receiving 12-hour and 24-hour postpartum magnesium sulfate (MgSO4) therapy for mild preeclampsia have differing
clinical courses.
METHODS:Consenting women with suspected mild preeclampsia were randomly assigned to12 hours or 24 hours of MgSO4 postpartum therapy. Treatment was
continued after the assigned time period if there was evidence of severe preeclampsia. The frequency of progression to severe disease and other outcomes werecompared between study groups using the Fisher exact, 2 and Student t tests where appropriate.
RESULTS: Between January 2001 and August 2004, 200 women were enrolled. The 12-hour and 24-hour groups were similar in age, parity, delivered gestational age, anesthesia, and mode of delivery, as well as for proteinuria and blood pressure. In the 12-hour group, MgSO4 treatment was extended in seven women (6.9%) for progression to severe disease versus one (1.1%) in the
24-hour group (P.07). Women who developed severe disease had higher blood pressures at the first prenatalvisit (140/78 versus 122/69,P<.02 for="" systolic="" and="" diastolic="" pressures="" at="" the="" time="" of="" randomization="" were="" more="" likely="" to="" have="" insulin-requiring="" diabetes="" versus="" no="" patients="" required="" treatment="" beyond="" hours="" postpartum.="" there=""> seizures, MgSO4 toxicity, or intolerance in either group.
CONCLUSION: Twelve hours of postpartum MgSO4 therapy for mild preeclampsia is associated with infrequent disease progression and a clinical course similar to
that with 24-hour therapy. Patients with chronic hypertension and insulin-requiring diabetes are at risk for progression to severe disease postpartum.