Preventing Deaths During and After Pregnancy

• 2/4/2010
• Author: Audrie Bretl Roelf
• Category: Benchmark Blog
• 14468 Views
• 0 Comments
• 

• A new Sentinel Event Alert from The Joint Commission reminds us that women and infants dying during childbirth is still a significant patient safety issue that deserves our attention.
  
  The Alert comes as federal and state governments are increasing efforts to identify causes and prevent maternal deaths. The current statistics from the Centers for Disease Control and Prevention show that there are 13.3 maternal deaths per 100,000 live births, well over the target of 3.3 maternal deaths per 100,000 live births set as part of the U.S. government’s Healthy People 2010 initiative. Common preventable causes that lead to maternal deaths include uncontrolled high blood pressure, undiagnosed fluid build-up in the lungs of women with pre-eclampsia, failure to pay attention to vital signs after a Cesarean section, and hemorrhage following a Cesarean section.
  
  To prevent pregnancy-related deaths and severe illness, The Joint Commission’s Sentinel Event Alert suggests that hospitals take a series of six specific steps, including the following:
  • Educate physicians and other caregivers about underlying conditions such as high blood pressure, diabetes or morbid
     obesity that may put women at risk if they become pregnant.
  • Use specific protocols to treat pregnant women who have, for example, experienced a change in vital signs, hemorrhage or
     pre-eclampsia.
  • Train emergency room staff to consider whether female patients may be pregnant or recently pregnant. Pregnancy can affect
     the diagnostic process or change a woman’s response to treatment.
• 
  For women who are identified as being at high risk because of existing conditions such as high blood pressure, diabetes or morbid obesity, the Alert calls for referrals to experienced prenatal care providers who can provide specialized services. In order to avoid pulmonary embolism, The Joint Commission recommends hospitals make pneumatic compression devices available to high-risk patients undergoing a Cesarean section. Finally, hospitals are urged to evaluate whether pregnant women who are at high risk for dangerous blood clots (thromboembolism) should receive a special dosage of blood thinner after giving birth.
  
  This is in connection with a new set of perinatal core measures from The Joint Commission. This measure set reflects the following:
  • Elective delivery
  • Cesarean section
  • Antenatal steroids
  • Health care–associated bloodstream infections in newborns
  • Exclusive breast milk feeding
  
  For more information on these measures, see the March/April issue of The Joint Commission Benchmark.
  
  What are your organization’s measures saying about instances in childbirth? Are there any specific interventions your organization takes to ensure a healthy mother and child for every birth?