When Everything Came Together To Save Two Lives; How Evidence-Based Quality Improvement Measures Contributed To Saving a Woman and Her Baby Experiencing Amniotic Fluid Embolism In The Second Stage Of Labor

Background:

The World Health Organization issued a report in 2007 listing the United States as being 41^st in the world for maternal mortality. This report triggered a call for action to improve care for our pregnant women. 

The Institute for Healthcare Improvement (IHI) advocates for the development of Rapid Response Teams  to improve outcomes in critical situations by providing critical care expertise at the bedside.  A 2009 IHI report cited a study reporting a 56% reduction in the number of deaths from cardiac arrest, and a 25% reduction in total number of deaths after the implementation of a Rapid Response Team. At our facility we have had similar results. Along with a Rapid Response Team, our hospital has established special codes to bring additional needed personnel to the bedside in situations of suspected sepsis (Gold alert), stroke (Stroke alert) and hemorrhage (Code white). A Massive Transfusion Protocol has been put in place when large blood volume replacement is needed.  To improve outcomes by improving communication, our Maternal Child Units was the pilot for implementation of Team STEPPS training.

Case:

Our team training was put to the test when a 34 year multiparous woman was admitted to Labor and Delivery in active labor with an uncomplicated pregnancy. Labor progressed rapidly and shortly after starting to push, the patient coughed, said “I don’t feel very well”, and lost consciousness. A “code blue” was called and the team arrived within 2 minutes. Within 7 minutes the baby was delivered by the Midwife and resuscitated by the NICU team. The mother was suspected of having an Amniotic Fluid Embolism (Anaphylactoid Syndrome of Pregnancy). Over the next 9 hours the patient went into cardiac arrest 4 times, developed DIC, a code white (hemorrhage) was called, Rapid Response was called for extra help and the massive transfusion protocol implemented. Communication and team work was evident throughout the night and as a result, a healthy baby boy was discharged home with family at 5 days of age and the mother followed 11 days later.

Conclusion:

After this dramatic event a debriefing was held so the team could discuss the successes and opportunities for improvement. The word heard repeatedly describing the care given was “seamless”. Some confusion was identified with our massive transfusion protocol and plans to improve the process were put in place.

Keywords: Communication, Rapid Response Teams, Team STEPPS, Amniotic Fluid Embolism, Anaphylactoid Syndrome of Prenancy