Preventing Maternal Deaths
Half the reported maternal deaths in the United States could have been prevented by early diagnosis and treatment, according to the Centers for Disease Control and Prevention. This and other important information regarding maternal mortality was conveyed at the Association of Women’s Health, Obstetric and Neona tal Nurses 2010 meeting by Suzanne McMurtry Baird, MSN, RN, of Vander bilt University School of Nursing, Nashville, TN.
“Maternal deaths are rare,” she noted. “But when they happen they are devastating, not only to families but to the obstetrical staff.”
Whereas a recent or current pregnancy need not be listed on a death certificate, maternal (pregnancy-related) deaths are thought to be underestimated. They are reported via the “honor system,” no penalties are levied for misreporting or failing to report them, no standard reporting system exists, and a confidential review of all maternal deaths (which would help to identify causes and inform preventive efforts) is not required, according to Ms Baird.
US Mortality Rate Too High
The overall US maternal mortality rate in 2006 was 13.3 per 100,000 live births; it was 9.1 for white women and 34.8 for non-Hispanic black women. This is an increase from 9.9 deaths in 1999, and double the 1982 rate, according to the National Center for Health Statistics.
These numbers fall far short of the Healthy People 2010 goal of <3.3 maternal deaths per 100,000 live births and place the United States behind at least 40 other nations. “It’s safer to deliver a baby in Bosnia and Kuwait than in the United States, and we thought we had safety initiatives in place,” Ms Baird commented.
Mortality Is Not the Only Problem
Deaths are just a part of the problem. In 2004 and 2005, more than 68,000 American women “nearly died” in childbirth. “In other words, these were near misses,” she said.
Problems frequently encountered in the delivery suite put many women at risk, including hypertension, preeclampsia, gestational and preexisting diabetes, asthma, and postpartum hemorrhage; 5% of women have preexisting medical conditions.
Severe morbidity related to childbirth occurs in 50 women for every 1 maternal death. These complications include:
- Transfusions (the most common)
- Eclampsia
- Hysterectomy
- Cardiac events/procedures
- Respiratory failure
- Complications of anesthesia
- Septicemia
- Mechanical ventilation
- Cerebrovascular accidents
- Acute renal failure
- Need for invasive hemodynamic monitoring
- Obstetric shock
- Pulmonary embolism.
Unnecessary Interventions
The high rates of morbidity and mortality are at least partly a result of unnecessary interventions. In vaginal deliveries, the maternal death rate is 0.2 deaths per 100,000 live births; for cesarean deliveries, it is 2.2 per 100,000, according to a review by Clark and colleagues (Am J Obstet Gynecol. 2008;199: e1-e5. Epub 2008 May 2), who concluded that thromboembolism prophylaxis would greatly reduce this risk.
In addition to cesarean sections, elective inductions and the use of Foley catheters contribute to the risk of maternal death.
Early Warning Signs
Maternal hemodynamics affects the outcome of the fetus and newborn, Ms Baird emphasized. Physiologic changes in pregnancy include increased heart rate, intravascular volume, stroke volume, oxygen consumption, and cardiac output; compensated respiratory alkalosis; and a hypercoagulable state.
Nurses should watch for risk factors, which include obesity, cardiac disease, hypertension, substance use, pulmonary embolism, amniotic fluid embolism, and obstetric hemorrhage.
“Pregnant women can decompensate faster, and with standard signs we can miss this,” she noted. “The patient can become critically ill if we wait for symptoms to appear. The key is early recognition.”
The Joint Commission’s Sentinel Event Alert (Preventing maternal death. 2010;44) stipulates that centers should have a process for recognition and response as soon as a patient’s condition worsens. In addition, there should be written criteria describing early warning signs of change or deterioration and indicating when to seek further assistance (Table). The rapid response team should be called first, and then the patient’s physician.
“You want to recognize the early signs of compromise and promptly communicate this,” she said. “Look for trends, not isolated signs, such as a decrease in urine output or change in vital signs. You are the experts in physiological changes in pregnancy, so your input to the team is important.”
Once the mother is discharged, ideally by 6 weeks postpartum, she should receive a home visit by a nurse who can assess the environment and evaluate for depression, infection, bleeding, and deep-vein thrombosis. “Many other countries provide this,” Ms Baird noted.