Maternal Mortality Panel Discussion with St.Luke’s at AWHONN 2017
[Lora Sparkman] You’re going to hear from our partners at St. Luke’s in Boise, Idaho, two nurse leaders, Deb Ketchum and Julya Miner, tell a story about a mother who died in one of their hospitals. She died of a postpartum hemorrhage. Postpartum hemorrhage is the number one complication in the U.S., and every 10 minutes, a mother dies in the U.S. related to pregnancy complications. Let’s hear their story.
[Deb Ketchum] So our story was set in a beautiful resort community, nestled in the mountains of central Idaho. It was early January during the winter with record snowfall. If you watch the news this winter, Idaho had an amazing amount of snow. And it was still snowing in May, middle of June.
The 25-bed critical access hospital has dedicated obstetrical team comprised of nurses, family practice, and obstetrical providers. The nearest acute care facility is 70 miles south.
Maria arrived to the community from Mexico just a few days before delivering her second child. She was 40 years old, gravida 2 para 1 at 37 to 38 weeks. Her bag of water ruptured at home and she presented to the hospital for care. No medical records were available, although the patient and her family shared she had been receiving regular prenatal care in Mexico prior to coming to the United States. Her current pregnancy as well as her pregnancy and delivery 12 years earlier were reportedly uncomplicated.
This labor was augmented with oxytocin and it resulted in a successful vaginal delivery of a male infant. After initial resuscitation, the infant transitioned very well. During repair of the second degree of perinatal and vaginal laceration, increased vaginal bleeding was noted. Pitocin, Methergine, and Cytotec were given. Additional IV access was acquired and labs were drawn. The obstetric surgeon was called along with the operating room team. Maria was transferred to the operating room, where additional doses of Pitocin, Methergine, and Cytotec were given along with Hemabate. A Bakri Balloon was placed in an unsuccessful attempt to achieve homeostasis. Pressers and IV fluids were administered for blood pressure support. Transfusion of packed red blood cells and fresh frozen plasma were initiated. Platelets were not available on site.
Ultimately, a super cervical hysterectomy was performed. At the time, Maria’s blood loss was estimated at 7,000 milliliters. The patient was transferred from the OR to the ICU where Tele-ICU was initiated. The internal code, critical patient, was activated and simulated an all hands on deck response from the emergency department provider, support team nurses, lab personnel, and all others.
Upon arrival to the ICU, Maria coded. The interprofessional team acted quickly to stabilize Maria. Consults were obtained from the maternal fetal medicine and intensivists to the tertiary care center to guide a plan of care. Requests for patient transport out of the critical access for the facility were repeatedly turned down due to the hazardous weather conditions. Imagine how hopeless that team felt. The critical access team huddled to explore alternatives.
Arrangements were made for additional products to be transported to the facility. Once Maria was stabilized enough for ground transport, arrangements were made with the state highway district to provide a snowplow to lead the way and clear a path for the local team to transport her to a rendezvous with the transport team.
Continued bleeding as a result of DIC led to a quantitative blood loss of 11,000 milliliters. By that time, she had received 12 units of packed red blood cells, 10 units of fresh frozen plasma, and countless liters of crystalloid. Ten minutes into the transport, Maria coded again. The team returned with her to the critical access hospital. Valiant efforts to resuscitate her were unsuccessful and Maria died. The care team was devastated. Resources were immediately deployed to support healing for the care team and for the patient’s family.
As the care team debrief later that afternoon, reassurance was felt as the team recognized good communication and strong teamwork throughout the experience. The team hungered to identify ways to prevent such an experience from ever happening again. This experience has ignited a sense of urgency across the health system to find ways to better support front line care of members in our state and across all states, and being ready to identify and respond to OB hemorrhage.
The GNOSIS OB hemorrhage module has provided welcome education. Thank you so much for having this purpose. Simulation scenarios with reinforcement of our active OB hemorrhage bundles, massive transfusion policies, and emergency algorithm and kits are being developed to focus attention on the areas of greatest opportunity for each team. While we are deeply saddened by the death of Maria, this experience has prompted us to face the opportunities with greater result and determination to improve the safety of the care we provide. Thank you very much.
Improving Perinatal Safety
[Lora Sparkman] – Unfortunately, these events and these stories happen far too often. But the good news is St. Luke’s has not had a postpartum hemorrhage death since the implemented Relias for OB. So, doing nothing is not a clinical strategy. Thank you, St. Luke’s for inspiring all of us to improve perinatal safety and create high reliability.