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Cesarean Birth Complications
Carol Burke MSN, APRN/CNS, RNC‐OB, CEFM
April 8, 2019
Disclosures• No FDA “off label” pharmaceutical or medical devices will be discussed in today’s presentation.
• No commercial support was received for this presentation.
• No conflict of interest
Objectives
1. Review assessments and interventions for complications of hemorrhage, surgical site infection and venous thromboembolism following cesarean birth
2. Compare early warning systems to identify maternal deterioration.
3. Discuss use of evidence‐based bundles in management of cesarean birth complications.
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Barber et. al, 2011
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Why us rate at 32%?
• EFM• Without any evidence at all to suggest continuous fetal monitoring improves outcomes, it has become a standard of care. False positive outcome
•Macrosomia• There’s no simple test to determine a baby’s size
•Duration second stage• Varied opinion on how long a woman should spend pushing before a C‐section is called
•Defensive medicine• If a baby is born via C‐section and there’s a bad outcome, you can say everything was done
Sakala 2013
Definitions of Labor Progress per the ACOG/SMFM Consensus Statement
• Prolonged latent phase as currently defined is not indication for c/s
• Slow but progressive labor in the 1st stage should not be indication for c/s
• Cervical dilation of 6cm is a threshold for active labor and standards of active labor progress should not be applied before then
• C/S for active phase arrest in 1st stage should be reserved for women beyond 6cm with ROM who FTP despite 4 hours of adequate contractions or 6 hours of oxytocin administration.
20.2
28.5
36.3
47.9
0
10
20
30
40
50
< 20 20‐29 30‐39 40+
C/S rate by age
C/S rate
Cesarean delivery rate: Number of births delivered by cesarean per 100 births.
National Center for Health Statistics
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Cesarean Rates by State 2017
Is there a better way to calculate rate?
• 10 group classification system – Robson
• Allows standardized comparisons of data
• Identifies clinical scenarios driving changes in cesarean rates.
• Hospitals and health organizations can use the Robson 10‐Group Classification System to evaluate quality and processes associated with cesarean delivery.
• Supported by WHO
Robson, M.S. (2018)
World Health Organization
https://www.who.int/reproductivehealth/publications/maternal_perinatal_health/robson‐classification/en/
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Consortium of safe labor
• To decrease cesarean delivery rate in the U.S:
• Reduce primary cesarean delivery is the key
• Increase VBAC rate is urgently needed
• Cesarean section for dystocia should be avoided before the active phase is established, particularly in nulliparas and in induced labor.
Zhang, et. al, 2015
Maternal Morbidity vaginal / CS / VBAC
P
P P
P
R
R
R
R
Obstetric hemorrhage with cesarean birth
Compared with vaginal delivery, women undergoing cesarean delivery
incur the highest risk of PPH and hemorrhage‐related morbidity
Dunkerton et.al, 2018
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Hemorrhage Definition
Cumulative blood loss
of greater than or equal to 1000mL
or blood loss accompanied by
signs and symptoms of hypovolemia
within 24 hours after the birth process
(includes intrapartum loss)
regardless of route of delivery
ACOG Practice bulletin 183, 2017
Hemorrhage incidence
In the United States, between 1994 and 2006,
the rate of atonic PPH increased
160%among women undergoing cesarean after induction
and
130%among women undergoing noninduced cesarean
Butwick, 2017
Evidence based bundle ‐ hemorrhage
• Obstetric hemorrhage protocols
• Anticipatory planning / transfer Readiness
• Risk factor assessment
• Cumulative QBL
• Identify etiologyRecognition
• Uterotonics / D&C / return to OR
• Blood product replacement
• Enhanced postpartum awarenessResponse
• Internal quality review
• M&M reviewReporting
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Comparison of predicted probability for EBL>1000mL with CS
Dunkerton et.al, 2018
Risk Assessment tools
• Risk assessment tools have been shown to identify 60‐85% of patients who will experience a hemorrhage in the postpartum period
• Examples:
• Postpartum Hemorrhage Risk Assessment Tool (AWHONN)
• Risk assessment tool
ACOG Safe Motherhood Initiative
CMQCC Obstetric Hemorrhage Toolkit
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When should I do hemorrhagerisk assessment?
•Antepartum•On admission
• Throughout birthing process• Prolonged second stage• Prolonged oxytocin use• Active bleeding• Chorioamnionitis• Operative vaginal delivery• Cesarean birth (especially emergent/urgent)• Retained placenta
• Postpartum
• AWHONN recommends that cumulative blood loss be formally measured or quantified after every birth.
• Calibrated under‐buttocks drapes to measure blood loss
• Dry weight card, laminated and attached to all scales, for measurement of items that may become blood‐soaked when a woman is in labor or after giving birth
• With C/S ‐ Suction and measure all amniotic fluid within the suction canister of collected fluid before delivery of the placenta.
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Underlying Etiology for Hemorrhage
Tone Tissue Trauma Thrombin
Uterine Atony
Retained products of conception
Lacerations hematoma
Coagulationabnormalities
TONE abnormality
• Over distended uterus• Polyhydramnios
• Macrosomia
• Multiple gestation
• Uterine muscle exhaustion• Rapid labor
• Prolonged labor
• Prolonged use of oxytocin
• Medication used in labor• Terbutaline
• Magnesium sulfate, Procardia
• Intraamniotic infection• Fever
• Prolonged ROM
• Anatomic distortion• Fibroid uterus
• Uterine anomalies
• Placental abnormalities• Placenta previa
• Abruption
• Couvelaire uterus
tissue abnormality
•Abnormal placental adherence :• accreta, increta, percreta
•Retained placental/ amnion fragments
trauma with cesarean
• Incision extensions
• Laceration at cesarean birth
• Uterine rupture / dehiscence
• Uterine inversion
• Manual removal of the placenta
• Hematoma
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Abnormalities of coagulation(Thrombin)
Preexisting states
• Hemophilia A
• vonWillebrand’s disease
• History of hereditary coagulopathies
• History of liver disease
Acquired in pregnancy
• Idiopathic thrombocytopenic
purpura (ITP)
• Thrombocytopenia with HTN
• Disseminated intravascular
coagulopathy (DIC)
• Massive hemorrhage
• IUFD
• Sepsis
• Abruption
• Amniotic fluid embolus
Palpitations, DizzinessSlight tachycardia
B/P Normal
Weakness, SweatingTachycardia
SBP 80-95 mmHg
Pallor, OliguriaRestlessness,
SBP 70-80 mmHg
Anuria,Air Hunger
Circulatory collapseSBP 50‐70 mmHg
500-1000
1000-1500
1500-2000
2000-3000+
Vo
lum
e
Sym
pto
ms o
f hem
orrh
age
Volume vs. symptoms
Management plan• Goals:
• Maintain SBP > 90mmHg
• Urine output > 30mL/hr (Foley required)
• Normal mental status
• Identify source of hemorrhage
• Requires additional resources
• 2 large bore IV’s
• Rapidly infuse crystalloids while blood products are being obtained
• Accurate vital signs
• Prevent hypothermia via use of external adjuncts for patient warming.
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Management plan (Continued)
• Use pulse ox
• Maintain oxygenation 8‐10L/min via nonrebreather mask
• Discuss with anesthesia or ICU team need for invasive hemodynamic monitoring especially with large volume replacement and ease of blood draws with central line
• Insert Foley catheter with urometer
• Evaluate mental status
• Critical labs: CBC, ABG and coagulation studies (fibrinogen, platelet count, fibrin degradation products).
• The prothrombin time (PT), activated partial thromboplastin time (aPTT) and International Normalized Ratio (INR) tests were developed to assess and adjust dosing of anticoagulant medications such as warfarin (INR) and heparin (aPTT).
Fluid Replacement ‐ Crystalloids
• Lactated Ringer's is a mildly hypotonic solution often used for large‐volume fluid replacement.
• Sodium chloride at 0.9% concentration is close to the concentration in the blood (isotonic).
Crystalloid replacement 3:1 ratio 3 liters of crystalloid to each liter of blood loss
ACOG practice bulletin 76, Obstetric hemorrhage
Product Volume Components Effect
Packed Red Cells 240 RBC, WBC, plasma Increase Hct 3%, Hgb 1g/dL
Platelets 50 Platelets, RBC, WBC, plasma Increase platelet count 5,000‐10,000/mm3 per unit
Fresh Frozen Plasma
250 Fibrinogen, antithrombin III, factors V and VIII
Increase fibrinogen by 10mg/dL
Cryoprecipitate 40 Fibrinogen, factors VIII and XIII, von Willebrand factor
Increase fibrinogen by 10mg/dL
Blood Component Therapy
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Communicate
Communicate
Communicate
•Make the mental shift from “normal delivery” to
• Clarify between the Obstetrician and Anesthesiologist regarding who will primarily manage blood loss quantification, laboratory assessment, and blood component therapy
• Be responsible to alert OB and Anes regarding• Blood volume loss
• Vital signs, I&O•Mental status
• Document as you go
Communicate
Communicate
Communicate
• Alert charge nurse, OR team, IR readiness, blood bank
• Insist that the MD evaluate at the bedside, not just on the phone
• Do a time‐out with every escalation of blood loss to the next tier ( acronym)
ackground / blood product availability
ab data / time drawn
BL total / increase in last hour (quantification)
mergency team notified
ecision / plan
Communicate
Communicate
Communicate
Don’t forget the family
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Surgical site infectionfollowing cesarean birth
Infection accounts for a disproportionate contribution to maternal mortality.
Incidence of SSI
• Cesarean birth is the single most important factor associated with
postpartum infection and carries a 5‐20 fold increased risk of infection
when compared to vaginal delivery
• Some studies show up to 20% of all women develop a postpartum
infection as:
• Endometritis (3X more common after C/S in Stage 2 vs. Stage 1)
• Wound infection and
• Urinary tract infection
• 85% occurring within 7 days of hospital discharge
Lamont et al., 2011Axelsson et al., 2018
SSI Definition / Category
Superficial incisional
Deep incisional
Organ / space
Infection which occurs within 30 days after operative procedure (Cesarean section) and must meet the
following criteria:
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Superficial incisional
Skin and subq tissue + 1 of the following:• Purulent drainage• Organisms from culture• Pain, tenderness, swelling, redness or heat• Diagnosis by a surgeon or attending MD
Deep incisional
Deep soft tissue (fascia and muscle) +1 of the following:• Purulent drainage• Spontaneous dehisces or opened by MD • Fever > 38C, localized pain or tenderness• Abscess found on exam or reoperation or radiologic
exam• Diagnosis by a surgeon or attending MD
Organ/space
Infection involves any part of the anatomy deeper than the fascial/muscle layers that is opened or manipulated during operative procedure +1 of the following:
• Purulent drainage from a drain into the organ• Culture of fluid/tissue• Abscess or evidence of infection involving the organ found
on exam or reoperation or radiologic exam• Diagnosis by a surgeon or attending MD
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Endometritis
• Infection of the lining of the uterus
• The most common cause of postpartum fever
• Endometritis complicates the postoperative course of a cesarean delivery 6‐27% of the time
• Signs / Symptoms
• Postoperative fever / chills
• Fundal / uterine tenderness
• Malodorous and/or purulent lochia
Haas, 2010
Evidence based bundle – surgical site infection
• Evidence based prophylaxis
• Anticipatory planningReadiness
• Risk factor assessment
• Identify etiology
• Recognize signs of sepsisRecognition
• Sepsis bundle
• Transfer to higher level of care
• Patient educationResponse
• Internal quality review
• M&M reviewReporting
Evidence‐based prophylaxis
• Preoperative washing for scheduled cesarean:
• Lowers the microbial load at the surgical site and risk of surgical site
contaminants
• Shower or bathe with antimicrobial soap night before C/S
• Consider vaginal cleansing
• Immediately prior to the cesarean birth, especially for women with
ruptured membranes and those who have labored prior to surgery.
• Currently, only povidone‐iodine is approved for use in the vagina, (swab
for 30 seconds) however, off‐label use of chlorhexidine solutions can be
considered, especially in women with allergies to iodine
• Utilize intraoperative skin preparation with chlorhexidine products or povidone
iodine products
AORN, 2018CDC Guideline for the Prevention of Surgical Site Infection,
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Prophylactic Antibiotics
• A narrow‐spectrum, first‐generation cephalosporin: cefazolin (Rx)
• Women with a penicillin allergy: A single dose combination of clindamycin with an aminoglycoside is a second option
• Timing: Ideally, the administration of prophylactic antibiotics should occur 60 minutes prior to skin incision, whenever possible.
• Administer additional doses of antibiotics or higher doses of antibiotics if indicated.
• Surgical procedures lasting longer than 3–4 hours• Obesity• Excess blood loss
• For GBS: (fetal benefit) determine the need for intrapartum prophylaxis in the case of unplanned cesarean or planned cesarean with rupture of membranes.
AAP & ACOG, 2017
Hypothermia prevention
•Hypothermia is associated with cardiac events, delayed surgical wound healing, surgical site infections, increased blood loss, increased hospital stay, and thermal discomfort.
•Suggested methods to maintain temperature:• Forced air• Warmed blankets
• Warmed IV fluid
• OR temperature at 20–23º C (68–73º F)
SSI RiskPatient related factors
Pregnancy related factors
Procedure related factors
● Obesity● Chronic hypertension● Tobacco use in pregnancy● Lower socioeconomic status● ASA class >= 3
● Gestational diabetes● Labor prior to cesarean or
emergent cesarean● ROM > 6 hours● Inadequate prenatal care
● > 6 vaginal exams during labor● Operative time > 49 minutes● Increased blood loss > 500 mL● General anesthesia● Type of closure
(staple vs. subcuticular)● Type of incision● Surgical drains
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When should I do AN infectionrisk assessment?
•Antepartum•On admission
• Throughout birthing process• Prolonged second stage• Prolonged oxytocin use• Active bleeding• Chorioamnionitis• Operative vaginal delivery• Cesarean birth (especially emergent/urgent)• Retained placenta
• Postpartum
4 pathways of invasion
Retrograde infection from the pelvis via the
fallopian tubes
MOST COMMON
Incision type
• Joel‐Cohen incision was found superior to Pfannenstiel for reduced morbidity in obese women
• Joel‐Cohen is a straight incision that is 3 cm below the line joining both anterior superior iliac spines.
Ayres-de-Campos, 2015
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Incision closure
Subcuticular
• Decreased wound separation
• Slightly longer surgical time
Staple
Mackeen, Schuster, & Berghella, 2015
Sepsis pathophysiology
Capillary permeabilityLeaking blood vessels, Plasma extravascularReduced circulating volumePlatelet consumption leads to coagulopathy
Organ dysfunctionKidneys, liver, lungs,
uterusSource of infection
Bacteria in the blood
Releases cytokines,histamines, serotonin
Vasodilation, hypotensionpoor perfusionDecreased oxygento tissues leads toTachycardiaLactic acid (serum lactate)
Metabolic acidosis
C/S, prolonged labor, PROM, chorio, multiple vag. exams, retained products, anemia, UTI, pyelo pneumonia, endometritis
Signs of septic shock in mother
• Fever (100.4) or abnormally low temp (96.8)
• Tachycardia > 110 bpm
• Hypotension
• Difficulty breathing, tachypnea > 24 bpm
• Significantly decreased urine output
• Areas of mottled skin / jaundice
• Abrupt change in mental status
• Decrease in platelet count
• Lactate > 2mmol/L
2 or more of these symptoms
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Symptoms of sepsis
• BP may also decrease due to:
• Vasodilation induced by pregnancy
• Epidural anesthesia
• Blood loss
• Normal physiological changes during pregnancy can cause abnormal readings when compared with the non‐pregnant population, potentially leading to a missed diagnosis of sepsis.
Hypotension
A systolic blood pressure of • <90 mm Hg, • mean arterial pressure <70 mm Hg,
or • reduction of >40 mm Hg from
baseline.
Symptoms of sepsis
• Trauma
• Retention due to loss of tone
• Cesarean birth
• Dehydration with prolonged labor
• Antidiuretic effect of oxytocin
Decreased urinary output
Urinary output may decrease also due to:
Symptoms of sepsis
• Exhaustion following labor
• Effect of narcotic administration
Changed mental state
Lethargy may also due to:
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• Lactic acid is a by‐product of anaerobic metabolism (serum lactate)
• Poorly perfused tissue beds result in global tissue hypoxia which result in increased serum lactate
• A serum lactate is correlated with increased severity of illness and poorer outcomes even if hypotension is not present
• May be elevated in labor…
Want a lactate drawn?
SYMPTOMS OF SEPSIS
The most important change in the revision of the Surviving Sepsis Campaign bundles is that
the 3-hour and 6-hour bundles have been combined into a single “Hour-1 Bundle”
with the explicit intention of beginning resuscitation and management immediately.
3 hour bundle
6 hour bundle
1 hour bundle
Evidence based bundle ‐ sepsis
1 hour bundle
effective 5/11/18
Measure Blood Lactate
• Remeasure if initial lactate is >2 mmol/L.• A high lactate level indicates that the tissues are not getting enough oxygen
Perform Blood Culture
Antibiotics
IV Fluids
Vasopressors
• Blood cultures identify the cause of the infection.• Should be taken before antibiotics are administered, if possible.
• Broad‐spectrum antibiotics that are active against the causative organism
• Rapid administration of 30ml/kg crystalloid for hypotension or lactate > 4mmol/L
• Raise blood pressure• This is a critical resuscitation step in patients with septic shock.
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Nursing implications
• Aware of potential maternal deterioration
• Vigilance with vital sign and symptom assessment
• Prompt administration of antibiotics
• Delivery is not always the ‘cure’ for the mother with
intraamniotic infection
• Patient education for signs of maternal infection
• Attend / participate in severe maternal morbidity review
sessions
Complication: Venous thromboembolism
The risk of VTE is 4 times greater after cesarean section compared to vaginal birth.
The risk of VTE is 4 times greater after cesarean section compared to vaginal birth.
80%
20%
VTE
DVTPE
Part of clot breaks off and carried to the lungs
(PE)
DVT causes pain and swelling
(rarely fatal)
Blood clot forms in deep vein
• chest pain• shortness of breath• hemoptysis (coughing blood) and, if large,
severe hypoxia and collapse, which can be fatal
• chest pain• shortness of breath• hemoptysis (coughing blood) and, if large,
severe hypoxia and collapse, which can be fatal
Venous thromboembolism
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VenousThromboembolism (VTE)
Deep Vein Thrombosis (DVT)
Pulmonary Embolism (PE)
1st trimester
2nd trimester3rd trimester
! 60 fold increase during first 3
months after birth
The incidence of VTE, is 2.6 per 1000 cesarean birthsThe incidence of VTE, is
2.6 per 1000 cesarean births
Stasis of blood flow
Endothelial injury Hypercoagulability
Virchow's triad
Hypercoagulability• Increased fibrinogen• Factor V Leiden mutation• Trauma• Late pregnancy and birth • Cigarette smoking• Obesity
Alterations in normal blood flow
• Venous stasis• Prolonged immobility • Varicose veins
Endothelial trauma• Hypertension• Biomaterials, implants• Platelet membranes• Chronic inflammation
Pregnancy has ALL the factors
Evidence based bundle:venous thromboembolism
• VTE prophylaxis
• Anticipatory planningReadiness
• Risk factor assessment
• Recognize signs of VTE (DVT / PE)Recognition
• Use standardized recommendations for dosing of prophylactic and therapeutic anticoagulation
• Timing with neuraxial anesthesia
Response
• M&M quality review of thrombotic events for protocol complianceReporting
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Vte prophylaxis
• All patients undergoing cesarean birth require• Knee‐high mechanical prophylaxis (SCD) while in bed, prior to cesarean and continued postop
• Early /encourage ambulation
• Adequate hydration
• Empiric prophylaxis is a reasonable option for strict antepartum bed rest >72 hrs. / or 1 week
• Anesthesia consult before starting LMWH or UFH
Anticoagulant therapy in pregnancy
HeparinSafe in pregnancy, does not cross placentaUnfractionated (UFH)
Low molecular weight (LMWH) ex: Enoxaparin (Lovenox)
fewer adverse effects
More predictable therapeutic responseLower incidence of HIT (heparin induced thrombocytopenia)
Longer half‐life (risk with neuraxial anesthesia – need to delay 12‐24 hours)
Protamine Sulfate 1mg by slow infusion is antidote
Some common herbs, NSAIDS, antibiotics can potentiate LMWH and UFH resulting in excessive bleeding
When should I do VTErisk assessment?
•Antepartum, especially hospitalization
•On admission
• Throughout birthing process• Prolonged second stage• Prolonged oxytocin use• Active bleeding• Chorioamnionitis• Operative vaginal delivery• Cesarean birth (especially emergent/urgent)• Retained placenta
• Postpartum
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Risk factors for VTE
Major Risk Factors
• BMI > 35kg/m2 at delivery
• Immobility (strict antepartum bed rest
>72 hrs. / or 1 week)
• Postpartum hemorrhage with C/S
requiring blood transfusion or IR
• Previous VTE
• Preeclampsia with fetal growth
restriction
• Thrombophilia: e.g. Factor V Leiden
• Medical condition: Lupus, heart
disease, sickle cell disease
Minor risk factors
• Postpartum infection
• BMI > 30 kg/m2
• Multiple gestation
• Age > 40
• Emergency cesarean
• Smoking > 10 cigarettes/day
• Fetal growth restriction
• Preeclampsia
Women with one major or two minor risk factors should receive in-hospital
post cesarean pharmacologic prophylaxis
©California Department of Public Health, 2017; supported by Title V funds. Developed in partnership with California Maternal Quality Care Collaborative Maternal Venous Thromboembolism Task Force. Visit: www.CMQCC.org for details
3 Levels of VTE Risk
Utilize the “3 bucket model” risk assessment that stratifies VTE risk in pregnant or postpartum women into three color-coded levels for rapid identification
Medium VTE RiskLow VTE Risk High VTE Risk
Hameed AB, Montgomery D, Peterson N, Morton CH, and A Friedman. Improving Health Care Response to Maternal Venous Thromboembolism. Developed under contract #11-10006 with the California Department of Public Health, Maternal, Child and Adolescent Health Division. Published by the California Department of Public Health, 2017.
©California Department of Public Health, 2017; supported by Title V funds. Developed in partnership with California Maternal Quality Care Collaborative Maternal Venous Thromboembolism Task Force. Visit: www.CMQCC.org for details
Modified PADUA Risk Assessment Model for OB
Risk Factors Points
Previous VTE 3
Reduced mobility (bedrest with bathroom privileges for at least >72 hours
3
Thrombophilia 3
Acute infection and/or Rheumatologic disorder 1
Pregnancy 1
Obesity (BMI > 25 kg/m2) 1
Barbar, Noventa et al. 2010; D’Alton, Friedman et al. 2016; Harris, Sulmers et al. 2016
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symptoms of DVT
• Heaviness / swelling in affected limb• Warmth• Pain or tenderness• Redness, pallor or other change in skin color• Increased calf / thigh circumference
pulmonary embolus
Symptoms:
• Dyspnea / tachypnea
• Fever
• Tachycardia
• Hemoptysis
• Chest pain may be worse
with inspiration
Investigation:
• ABG• CT angiogram• Pulmonary angiogram
Mayo foundation for medical education and research
HIGH RISKTHERAPEUTIC
ANTICOAGULATIONfor 6 weeks from date of
delivery*
LOW RISKNO ANTICOAGULATION
MEDIUM RISKPROPHYLACTIC
ANTICOAGULATIONfor 6 weeks from date of
delivery*
©California Department of Public Health, 2017; supported by Title V funds. Developed in partnership with California Maternal Quality Care Collaborative Maternal Venous Thromboembolism Task Force. Visit: www.CMQCC.org for details
* E.g. Women discharged at 1 week postpartum would receive
extended duration anticoagulation for another 5 weeks
Follow Up Questions
No to all
Yes
Recent VTE or other conditions requiring therapeutic dose of anticoagulation
Personal history of eithero VTE with high risk thrombophilia oro VTE with Antiphospholipid
Syndrome (APS) oro Multiple VTE episodes
Management
Personal history of either Idiopathic VTE or
o VTE with low risk thrombophilia o VTE related to pregnancy or OCP’so VTE Provoked
NO personal history of VTE but with either:
o High risk thrombophilia (including APS) regardless family history of VTE or
o Low risk thrombophilia with family history VTE
Low risk thrombophilia (isolated)
Screening Questions
Algorithm 3: Post-Discharge Extended Duration Anticoagulation:Maternal VTE Risk Assessment
Receiving Prenatal Anticoagulation?
Thrombophilia?
Personal or Family History of VTE?
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Early warning systems
Key to optimizing outcomes and reducing preventable harm.
Need to address the four most common causes of maternal morbidity:
hemorrhage, preeclampsia, sepsis and cardiovascular dysfunction
Screening systems
General Morbidity Scores
Obstetric Screening Systems
Maternal early warning criteria
Agitation, confusion or unresponsiveness
SBP < 90 or > 160
mmHg
DBP > 100
HR
< 50 or > 120 BPM
RR
< 10 or > 30
O2 sat < 95% in room air (sea level)
Oliguria < 30mL/hr. for 2 hrs.
+ Women with hypertension reporting a non‐remitting headache or shortness of breath.
Mhyre, 2014
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• 2 abnormal values sustained for >20 minutes
• Identifies 4 causes of maternal morbidity
MEWT
Maternal Early Warning Trigger
• Identify maternal sepsis by using the vital signs, WBC and lactic acid as measurement parameters
SOSSepsis in Obstetrics
Score
• Utilizes 2 moderately abnormal parameters (yellow alerts) or 1 severely abnormal parameter (red alert) to trigger a clinical response
MEOWS Modified Early
Obstetric Warning System
• Identifies women at a higher risk for requiring interventions in the ICU such as mechanical ventilation and/or vasoactive support
OEWS
Obstetric Early Warning Score
Summary
• Cesarean birth increases potential for maternal morbidity, but may also be necessary
• Culture change is needed to support physiologic labor and vaginal birth
• Risk assessment tools have been shown to identify 60‐85% of higher‐risk women
• Recommendations vary with specialty groups – adopt one and perform quality assessment
• Continued work to reach consensus with maternal early warning systems may improve communication, reduce desensitization, and improve response
Patient Education
Bleeding, soaking through one pad/hour or blood clots the size of an egg or bigger
Incision that is not healing Red or swollen leg, that is painful or warm to touch
Temperature of 100.4F or higher
4 key warning signs for hemorrhage, infection and DVT
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Participate in Severe Maternal Morbidity Reviews
1. Were significant risk factors for complications identified?
2. Was the suspicion of hemorrhage, sepsis or DVT made in a timely fashion?
Did the Early Warning System alert the team?
3. Were appropriate uterotonics, antibiotics or anticoagulants used after diagnosis? How long to treatment?
4. Did the woman receive appropriate volume of IV fluids?
Kilpatrick, 2018
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