Failure to Appreciate Deteriorating Pregnant and Postpartum Persons

Recent Canadian studies indicate a severe maternal morbidity rate of 16.1 per 1,000 deliveries for the period of 2012-16 and a maternal death rate of 8-9 per 100,000 for 1990 to 2013 (Ray, et al., 2018) (Dzakpasu, et al., 2019). Both outcome categories are associated with clinical causes that are largely preventable. Organization-level programs such as, interdisciplinary team training and simulation for obstetrical emergencies, early warning and trigger tools, and evidence-based rapid response protocols, are promising interventions to reduce intrapartum and postpartum mortality and morbidity in the hospital and community care settings.

Expected Outcomes

Implement standardized evidence-based protocols for the prevention, identification, and management of:
o        Postpartum hemorrhage (PHH) and hemorrhagic shock;
o        Sepsis and septic shock;
o        Non-emergent, severe hypertension, and hypertensive emergencies.

Implement formal strategies to provide education and training (including skill drills and simulations) to support and enhance the interdisciplinary team’s clinical knowledge, skills (technical and non-technical), and practical experience surrounding the prevention, recognition, and response to intrapartum and postpartum clinical deterioration, PPH, hemorrhage shock, severe and emergent hypertension, and sepsis and septic shock.

Adopt a standardized, interdisciplinary, collaborative, and evidence-based protocol for conducting quality of care reviews involving pregnant, labouring, and postpartum person clinical deterioration resulting in harm or death.

Definitions and Acronyms

• Client – includes all persons who receive healthcare and related services including patients, residents and persons in-care
• ED – emergency department
• BMI – body mass index
• DIC - disseminated intravascular coagulation
• MRP – most responsible practitioner, often a midwife, nurse practitioner or physician.
• PPH – postpartum hemorrhage
• MTP – massive transfusion protocol also known as massive hemorrhage protocol
• OR – operating room
• PACU - post anesthesia care unit 
• Sequential assisted vaginal birth – the sequential or serial use of vacuums and forceps e.g., failed trial of a vacuum birth followed by forceps

Common Claims Themes and Contributing Factors

Organizational

• Lack of interdisciplinary team training and use of simulation programs focused on the identification and management of postpartum hypovolemic and distributive shock.
• Lack of systematic approach to intrapartum and postpartum quality of care reviews.
• Inadequate and outdated:
  • Severe preeclampsia assessment, monitoring, and acute management guidelines;
  • Post anesthesia and surgery (e.g., caesarean) recovery monitoring guidelines;
  • ED policies with insufficient focus on pregnancy and postpartum related complaints and symptoms.
• Clinical protocols (e.g., PPH) not readily available or only online and cumbersome to access.
• Lack of monitoring equipment (e.g., blood pressure cuff) for pregnant persons with high BMI and habitus.
• Delayed access to:
  • Serial laboratory monitoring;
  • PPH kits and trays;
  • Blood and blood products.
• MTPs: 
  • Inadequately designed and implemented (e.g., cumbersome, wordy, outdated);
  • Lack of staff awareness (blood bank, laboratory, labour and delivery, postpartum and surgical programs) of the protocol.

Knowledge and Judgement

• Mismanagement of induction and augmentation medications contributing to a protracted period of uterine hyperstimulation.
• Inadequate, inconsistent, and / or infrequent monitoring and documentation of vital signs, level of consciousness, and blood loss for pregnant and postpartum persons.
• Decreased vigilance following admission to the labour / birth unit especially for persons that have had a caesarean, assisted vaginal birth, or shoulder dystocia.
• Mismanaged pharmacologic management of PPH by MRPs (e.g., wrong drugs / wrong dose for uterine atony).
• Excessive time spent on conservative and temporary PPH interventions with postpartum persons with imminent risk of exsanguination.
• Delays accessing interventional radiology where available on site, externally, or after-hours.
• Evaluation of hemodynamically unstable postpartum persons in the interventional radiology suite versus OR where available.
• Failure to follow or lack of awareness of: 
  • Postpartum monitoring protocols;
  • PPH;
  • Sepsis protocols.
• Lapse in situational awareness, contributing to delayed recognition of and response to insidious, and rapid clinical deterioration of the pregnant or postpartum person. 
• Underestimation of total blood loss and delay MRP notification due to over reliance on the:
  • Pregnant or postpartum person’s skin colour as a means of assessing perfusion;
  • Visual estimation of intrapartum and postpartum blood loss. 
• Inappropriate discharge without confirmation (and documentation) of current vitals, level of consciousness, or blood loss, including discharges from:
  • PACU to postpartum unit; 
  • Postpartum unit to home;
  • Midwifery birth centre to home.
• Lack of sufficient interdisciplinary team familiarity with:
  • Pregnancy-related events such as, intracerebral hemorrhage, severe PPH, hemorrhagic shock, and sepsis and septic shock resulting in sub-optimal care due to ad hoc, frenzied, or chaotic response and inconsistent team communication;
  • MTP.

Communication

• Failure to escalate care concerns in a timely way, or at all (e.g., seek midwife or physician attendance or orders).
• Delayed MRP in-person attendance following notification or report.
• Delayed MRP notification or consultation for:
  • Concerning vitals, level of consciousness, and blood loss;
  • Retained placenta;
  • Perineal wound dehiscence.

Documentation

• Risks factors associated with PPH not documented in care management plans.
• Inconsistent documentation of:
  • Antenatal, intrapartum and postpartum assessments, vitals, and care plans;
  • Perineal tear repair;
  • Placenta assessment; 
  • Antenatal and postpartum fundus height and tone; 
  • Blood loss; 
  • Shared decision making (informed choice - informed consent discussions surrounding expectant versus active management of the third stage of labour; 
  • Shared decision making (informed choice - informed consent) declines for routine and recommended care (e.g., consult for tear repair complications) and intrapartum and postpartum monitoring;
  • Care plans for at risk pregnant persons who choose expectant management of the third stage of labour;
  • Discussions, instructions, and teaching with the person in the postpartum period regarding blood loss, PPH, and infection.

Mitigation Strategies 

Care Processes

• Adopt a standardized evidence-based protocol for the prevention, identification, and management of PPHs and hemorrhagic shock (Robinson, Basso, Chan, Duckitt, & Lett, 2022) (PPH CPG Work Group, 2016) (American College of Obstetricians and Gynecologists, 2020a).

Additional Considerations

Examples of elements to address within the PPH and hemorrhagic shock protocol:

• The need for a documented initial and ongoing risk assessment for each pregnant person in all hospital and community birth locations;
• Standardized order set(s);
• Process for the use emergency-released blood and steps to start the MTP;
• The frequency for surveillance of assessments and vital signs during the intrapartum and immediate postpartum period;
• Criteria for transfer from the PACU to postpartum unit;
• Whom to notify and signs and symptoms require timely communication to the MRP;
• Use of consistent terminology to describe (and document) the severity of the blood loss and shock;
• A systematic approach to interventions based on blood loss, signs and symptoms, staging, and clinical situation;
• Adopt a ‘rapid response’ checklist and / or protocol(s) for PPH and hemorrhagic shock;
• A formal contingency plan for weekends, holidays, and afterhours;
• Standardized discharge criteria for persons at risk for primary and secondary PPH;
• Interdisciplinary team and family debriefing following PPHs;
• Defined process for the periodic review of the protocol (from a quality improvement and safety lens) and quality indicators.

• Implement a formal strategy to quantify blood loss during the antepartum, birth (vaginal and caesareans), and postpartum hospital and community based birth locations (Lyndon, et al., 2015) (Robinson, Basso, Chan, Duckitt, & Lett, 2022) (American College of Obstetricians and Gynecologists, 2022). 
• Adopt a standardized evidence-based protocol for the prevention, identification, and management of pregnant and postpartum person sepsis and septic shock (Gibbs, et al., 2020) (Saskatchewan Health Authority, 2022) (American College of Obstetricians and Gynecologists, 2020b).

Additional Considerations

Examples of elements to address within the obstetrical sepsis and septic shock protocol:

• The need for a documented initial and ongoing / postpartum screening for sepsis;
• A systematic approach to interventions following a positive screening; 
• Standardized order set(s);
• The frequency for surveillance of assessments and vital signs during the intrapartum and immediate postpartum period;
• Who to notify and signs and symptoms that require timely communication to the MRP;
• Adopt a ‘rapid response’ checklist and / or protocol(s) for sepsis and septic shock;
• A formal contingency plan for weekends, holidays, and afterhours;
• Standardized discharge criteria;  
• Interdisciplinary team and family debriefing following pregnant and postpartum person sepsis and septic shock.

• Adopt a standardized evidence-based protocol for the prevention, identification, and management of non-emergent, severe hypertension, and hypertensive emergencies (Magee, et al., 2022) (Association of Ontario Midwives, 2012) (American College of Obstetricians and Gynecologists, 2020c) (Trahan, et al., 2023).

Additional Considerations

Examples of elements to address within the pregnancy and postpartum severe hypertensive protocols:

• The need for documented initial and ongoing risk assessment for each pregnant person in all hospital and community birth locations;
• Standardized definitions for types of hypertension;
• Standardized orders sets;
• The frequency for surveillance of assessments and vital signs during labour and postpartum;
• Who to notify and signs and symptoms that require timely communication to the MRP;
• A systematic approach to first line and second line therapies;
• A ‘rapid response’ checklist and / or protocol(s) for hypertensive emergencies, eclampsia, and postpartum preeclampsia;
• Standardized discharge criteria for clients with preeclampsia;
• A formal contingency plan for weekends, holidays, and afterhours;
• Interdisciplinary team and family debriefing following severe hypertension and hypertensive emergencies.

• In collaboration with the interdisciplinary team leaders, implement standardized, evidence-based protocols that address the frequency, components, and documentation of pregnant and postpartum person assessments, vital signs monitoring, and trending of values including client-specific criteria for adjustments to frequency of monitoring (Healthcare Excellence, n.d.).
• Adopt or pilot a modified obstetrical early warning system to facilitate the early screening / detection and response to intrapartum and postpartum deterioration (Edwards, Dore, van Schalkwyk, & Armson, 2020) (Umar, Ameh, Muriithi, & Mathai, 2019) (Arnolds, et al., 2022).
• Adopt a formal and standardized:
  • Interfacility transport protocol (Whyte & Jefferies, 2021) (Regional Perinatal Outreach Program of Southwestern Ontario & the Southwestern Ontario Perinatal Partnership, 2008);
  • Community birth setting transfer protocol (Home Birth Summit, n.d.) (Avery, Hunter, & Kantrowitz‐Gordon, 2023) (Ontario Medical Association & Association of Ontario Midwives, 2005).
• Implement formal strategies to increase the ready access to clinical protocols and policies (e.g., easy to access algorithms or decision trees to accompany the more comprehensive protocol; key word searches to facilitate searches for policies regardless of the sponsoring domain).

Health Equity

• Where utilized, implement formal strategies to review clinical policies / procedures / guidelines / algorithms and practices that use race as a ‘correction factor’ (trial of labour after caesarean, hypertension, etc.) (Vyas, Eisenstein, & Jones, 2020) (Kane, Bervell, Zhang, & Tsai, 2022) (Becker, 2021) (Cerdena, Plaisime, & Tsai, 2020).

Safety Culture

• Implement formal strategies to develop and maintain a work environment which supports and expects:
  • Early response to suspected and actual clinical deterioration, including seeking assistance from peers and other resources (e.g., rapid response teams);
  • Assertive and respectful questioning and challenging of care decisions (in order to obtain clarity and/or to advance client safety concerns);
  • Zero tolerance of intra- and inter-disciplinary bullying and intimidation.
• In collaboration with interdisciplinary team leaders, adopt formal strategies to support and maintain interprofessional collaboration (Romijn, De Bruijne, Teunissen, Wagner, & De Groot, 2018).
• Adopt a standardized and formalized chain of command (‘escalation’) protocol for the rapid escalation of unresolved care disagreements related to concerns about questionable client conditions, orders, or care delivery (Canadian Medical Protective Association, 2021) (Canadian Patient Safety Institute, 2020) (Provincial Council for Maternal and Child Health, 2022); for smaller organizations, consider the need to include successively higher level of authority (e.g., the Chief of Staff, administration on call or other executive leaders) to ensure a satisfactory resolution is achieved.

Communication

• Adopt a standardized and structured communication framework for team (intra- and inter-disciplinary) communication during the intrapartum and postpartum period (e.g., SBAR). 
• Implement strategies to facilitate timely communication to the MRP or physician consultant in the presence of pregnant or postpartum person deterioration.
• Adopt a standardized and formalized communication process for handovers and transfer of accountability during the intrapartum and postpartum periods, including (but not limited to) handover and transfer of accountability between:
  • Labour, postsurgical, and postpartum areas;
  • Practitioners (e.g., nurse to nurse, midwife to physician).

Equipment, Supplies and Technology

• Implement formal strategies to ensure all intrapartum and postpartum (hospital and community birth locations), caesarean, and surgical recovery areas as well as EDs are consistently stocked with:
  • Monitoring equipment (e.g., blood pressure cuff) for pregnant persons with larger body sizes;
  • Standardized and stage-based PPH and hemorrhagic and ED trays, kits, and carts. 
• Adopt a principle-based formal strategy to manage and allocate critical drugs (e.g., oxytocin shortage) during shortages (Ontario Ministry of Health & Long-Term Care, 2012) (Health Canada, 2017).

Team Training and Education 

• Implement formal strategies to support and enhance the interdisciplinary team’s clinical knowledge, skills (technical and non-technical), and practical experience surrounding the prevention, recognition and response to intrapartum and postpartum clinical deterioration, PPH, hemorrhage shock, severe and emergent hypertension, and sepsis and septic shock, including (but not limited to) scheduled interprofessional and cross-departmental PPH, massive blood transfusion, preeclampsia and eclampsia skill drills and simulations (Robinson, Basso, Chan, Duckitt, & Lett, 2022) (Ontario Regional Blood Coordinating Network, 2020) (Alliance For Innovation on Maternal Health, n.d.) (California Maternal Quality Care Collaborative, n.d.).
• Ensure the scheduled interprofessional and cross-department team training and education strategies consider or involve: 
  • Knowledge, skills, and practical experience required for both hospital and community birth and postpartum locations (Association of Ontario Midwives, 2021);
  • Team and practitioner situational awareness (‘helicopter view’) and human factors (Walshe, et al., 2021);
  • Program areas or sites with limited practical experience with intrapartum and postpartum obstetrical emergencies such as low birth volume sites, EDs, laboratory services, and blood bank;
  • Unregulated care providers (where employed), locums, agency, contracted care providers in addition to regulated health professionals (Petersen, et al., 2019).

Documentation

• Adopt a standardized gross placenta template or dictation tool to trigger the recording of the bedside placenta evaluation (Yetter, 1998).

Additional Considerations

Examples of elements to address within the standardized gross placenta evaluation template or dictation aid:

• Time placenta exam performed;
• Placenta’s completeness (including estimated amount missing), intactness, size, consistency, shape, and postpartum person and fetal surfaces;
• Umbilical cord’s length, thickness, knots, and number of vessels;
• Studies ordered (e.g., placenta to pathology);
• Placenta’s disposal.

• Adopt a standardized intrapartum and PPH ‘resuscitation’ flowsheet or record (Lagrew, et al., 2022).

Additional Considerations

Examples of elements to address within the standardized hemorrhage resuscitation flow sheet or record:

• Amount, colour, consistency, and pattern of bleeding;
• Blood samples sent to the laboratory including time sent and results received;
• Type, volume, and timing for fluids;
• Vital signs and time of the assessment;
• Type, dose, timing, and sequence for prophylactic and emergency medications and the postpartum person’s response;
• Who (team member names) and when assistance was called, and arrival times.

• Ensure complete and timely documentation of the shared decision making (informed choice - informed consent) discussions surrounding the management of the third stage of the labour (Robinson, Basso, Chan, Duckitt, & Lett, 2022) (PPH CPG Work Group, 2016); if an informed consent / decline form is used, ensure it is accompanied by complete and timely documentation in the health record.

Additional Considerations

Example of elements to discuss (and document) surrounding shared decision making (informed choice-informed consent) regarding the management of third stage of labour:

• The pregnant person’s overall and evolving clinical status and risk factors;
• Discussion of national, provincial, and local clinical practice guidelines; 
• Potential, known, and foreseeable risks associated with expectant management and active management of the third stage of labour;
• Expected benefits of expectant management and active management of the third stage of labour;
• Potential, known, and foreseeable consequences of declining active management for higher risk persons; 
• Client-specific care plan for the expectant management, including (but not limited to) higher risk persons.

Client and Family-Centred Care

• Adopt standardized education, training, and discharge instructions for postpartum persons that includes, signs, symptoms, and specific instructions for seeking care for suspected (Centers for Disease Control and Prevention, 2022) (Association of Ontario Midwives, 2016) (Association of Ontario Midwives, 2017):
  • PPH and hemorrhagic shock;
  • Persistent or new onset hypertension and eclampsia;
  • Sepsis and septic shock. 
• Implement strategies to enable access to interpreter services during postpartum person education, training, and discharge instructions when needed.

Monitoring and Measurement

• Adopt a standardized, interdisciplinary, collaborative, and evidence-based protocol for conducting quality of care reviews involving pregnant, labouring, and postpartum person clinical deterioration resulting in harm or death; incorporate system thinking and human factors concepts into the review process (Society of Obstetricians and Gynaecologists of Canada, 2021) (Ray, et al., 2018) (Canadian Institute for Health Information & Canadian Patient Safety Institute, 2016) (Machen, 2023).
• Adopt standardized quality indicators for:
  • PPH and hemorrhagic shock (Canadian Institute for Health Information & Canadian Patient Safety Institute, 2016) (Ontario Regional Blood Coordinating Network, 2020);
  • Severe hypertension (Druzin, et al., 2021) (Trahan, et al., 2023);
  • Sepsis and septic shock (Canadian Institute for Health Information & Canadian Patient Safety Institute, 2021) (Gibbs, et al., 2020);
  • Perinatal health equity (Rochin, et al., 2021).
• Incorporate learning from local, provincial, and national prenatal, intrapartum, and postpartum safety reviews and data into local protocols as well as staff and client education and training. 

Additional Considerations

Examples of sources of learning regarding prenatal, intrapartum and postpartum harm incidents:

• Chart audits and trigger tools;
• Coroner reports;
• Critical incident and quality of care committee reviews;
• Data from provincial / territorial birth and perinatal registries;
• Incident reports;
• Medical legal claims;
• Regional perinatal networks;
• Team debriefs.

References

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