Evidence-Based Quality Improvement Measures Contributed to Saving a Woman and Experiencing Amniotic Fluid Embolism and her Fetus in the Second Stage of Labor

Abstract

Background In 2007, the World Health Organization listed the United States as 41st in the world for maternal mortality. This report triggered a call for action to improve care for 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. In 2009, IHI cited a study that reported 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 unit piloted implementation of Team STEPPS training. Case Our team training was put to the test when a 34-year-old multiparous woman was admitted to the labor and delivery unit in active labor with an uncomplicated pregnancy. The labor progressed rapidly, but shortly after she started to push, the woman coughed, said “I don't feel very well,” and then lost consciousness. A code blue was called, and the team arrived within 2 minutes. Within 7 minutes the infant was delivered by the midwife and resuscitated by the neonatal intensive care unit team. We suspected the woman had an amniotic fluid embolism (anaphylactoid syndrome of pregnancy). Over the next 9 hours, the woman went into cardiac arrest four times and developed a disseminated intravascular coagulation. A code white (hemorrhage) was called, the rapid response team was called for extra help, and the massive transfusion protocol was implemented. Communication and teamwork were evident throughout the night, and as a result a healthy newborn male infant was discharged home with his family at 5 days of age; the mother followed 11 days later. Conclusion After this dramatic event a debriefing was held so the team could discuss successes and opportunities for improvement. The word heard repeatedly to describe the care provided was seamless. Some confusion regarding the massive transfusion protocol was identifed, and plans to improve the process were put in place. In 2007, the World Health Organization listed the United States as 41st in the world for maternal mortality. This report triggered a call for action to improve care for 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. In 2009, IHI cited a study that reported 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 unit piloted implementation of Team STEPPS training. Our team training was put to the test when a 34-year-old multiparous woman was admitted to the labor and delivery unit in active labor with an uncomplicated pregnancy. The labor progressed rapidly, but shortly after she started to push, the woman coughed, said “I don't feel very well,” and then lost consciousness. A code blue was called, and the team arrived within 2 minutes. Within 7 minutes the infant was delivered by the midwife and resuscitated by the neonatal intensive care unit team. We suspected the woman had an amniotic fluid embolism (anaphylactoid syndrome of pregnancy). Over the next 9 hours, the woman went into cardiac arrest four times and developed a disseminated intravascular coagulation. A code white (hemorrhage) was called, the rapid response team was called for extra help, and the massive transfusion protocol was implemented. Communication and teamwork were evident throughout the night, and as a result a healthy newborn male infant was discharged home with his family at 5 days of age; the mother followed 11 days later. After this dramatic event a debriefing was held so the team could discuss successes and opportunities for improvement. The word heard repeatedly to describe the care provided was seamless. Some confusion regarding the massive transfusion protocol was identifed, and plans to improve the process were put in place.