The Tetralogy...Hemorrhage, Hypertension, DVT, Infection...Implementation of a Perinatal Safety Net

Purpose for the program:

Pregnancy and childbirth may unexpectedly become an obstetrical emergency. The Centers for Disease Control and Prevention, National Center for Health Statistics (2004) report the rate of perinatal mortality in the U.S. has increased since 2002. Hypertensive disorders/emergencies are the most common medical complication of pregnancy and 2^ndleading cause of maternal death in the United States. Pulmonary embolism remains a leading cause of death after hemorrhage in New York State.  Advanced maternal age, obesity; cesarean delivery and significant chronic disease contribute to postpartum infection.

Proposed change:

1. Initiate a “Realistic” screening process to identify obstetrical patients at risk for hemorrhage, hypertension, thromboembolic events, and infection, after delivery.
2. Enhance nursing and medical staff education regarding evidence based standards of care.
3. Establish specific triggers for responding to changes in maternal vital signs and condition, and activation of emergency response teams.
4. Conduct multidisciplinary obstetrical emergency drills.

Implementation, outcomes and evaluation:

A Team STEPPS approach established a process to identify obstetrical patients at risk for hemorrhage, hypertension, thromboembolic events, and infection, the tetralogy. Individualized plan of care, medications, and home care referrals are driven by physician orders and nurse handoff communication. Multidisciplinary education included evidence-based standards of care, specific triggers for responding to changes in maternal vital signs and condition, and activation of emergency response teams. Pre-eclampsia /eclampsia and magnesium sulfate education was also provided in the ICU and Emergency Department.

Obstetrical emergency drills emphasizing team goals, knowledge, mutual support, situation monitoring and, SBAR communication were conducted using video play back to assist with debriefing.

  The medical Rapid Response Team (RRT) quickly recognized it was imperative to collaborate with obstetrics to meet the physiological needs of pregnant/postpartum women. The Code H Team (Hemorrhage) and Obstetrical Crisis Team (OCT) were established.

Implications for nursing practice:

The OCT respond along with the RRT for obstetrical emergencies, i.e. hypertensive emergency, seizures, cardiac compromise, change in patient status or when the nurse feels something is not right via one phone call to the emergency operator. When the changing needs of the patient are identified quickly,and a revised plan of care implemented, transfer to the intensive care area is frequently avoided fostering mother infant bonding.

A shared mental model is the foundation of this multidisciplinary perinatal safety initiative. Recognizing early deviations in the plan of care and escalation of patient care needs have fostered team work and provide an obstetrical safety net.

Keywords: obstetrical emergency team, Team STEPPS