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The Deteriorating Maternity Patient Danny Challis
NSW Perinatal Services Network
Danny Challis NSW Perinatal Services Network The parable of the - - PowerPoint PPT Presentation
Danny Challis NSW Perinatal Services Network The parable of the - - PowerPoint PPT Presentation
The Deteriorating Maternity Patient Danny Challis NSW Perinatal Services Network The parable of the Obstetrician and the Cardiologist.. So how is maternity care different? Well patients usually good outcomes Inaccurate tools for
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So how is maternity care different?
- Well patients – usually good outcomes
- Inaccurate tools for fetal welfare assessment
- Maternal physiology is different
- Differing cultures
- Midwifery
- GP
- Obstetricians
- Varied locations – homebirth to quaternary
- No tolerance for bad outcomes
- Expectations
- Impact
- Cost of claims
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How do midwives see labour and birth?
How do midwives see labour and birth?
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How do
- bstetricians
see labour and birth?
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Moving up the ‘slippery slope’
Maternal / fetus Condition
Time Clinical Review Rapid Response
Prevention
Antenatal care / risk assessment
Death ALS
High care unit / facility Clinical Pathway/ guidelines
(pre-eclampsia, PPH, Fetal distress)
Revised Treatment Plan Continued Treatment Plan Referral
Outcomes Clinical support tools
Sepsis Pathway/Alert Diagnostic Error
SMOC CTG stickers SNOC
Fetal welfare assessment Obstetric emergencies Neonatal resuscitation Training
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Prevention – right time and place
- Risk assessment – ongoing
- ACMI Guidelines
- Appropriate models of care
- Continuity models
- Service capability
- Well defined for planned care
- Advice processes
- Tiered Maternity Networks - PAL
- Transfer processes
- PAL/strengthened tiered maternity networks
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Maternity VTE risk assessment
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Moving up the ‘slippery slope’
Maternal / fetus Condition
Time Clinical Review Rapid Response
Prevention
Antenatal care / risk assessment
Death ALS
High care unit / facility Clinical Pathway/ guidelines
(pre-eclampsia, PPH, Fetal distress)
Revised Treatment Plan Continued Treatment Plan Referral
Outcomes Clinical support tools
Sepsis Pathway/Alert Diagnostic Error
SMOC CTG stickers SNOC
Fetal welfare assessment Obstetric emergencies Neonatal resuscitation Training
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How is fetal deterioration different?
- Inaccurate tools
- Intermittent auscultation
- Electronic fetal heart rate monitoring,
- ultrasound
- High false positives from heart rate monitoring
- Failure to recognise gradual deterioration
- Failure to recognise abnormal heart rate
patterns
- Reluctance to use fetal scalp blood sampling
- Chronic vs acute
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Electronic fetal heart rate monitoring algorithms and documentation tools 2018-2019
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Antenatal
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NSW Pregnancy and newborn Services Network
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NSW Pregnancy and newborn Services Network
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NSW Pregnancy and newborn Services Network
Are you sure it’s fetal??
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Determine risk
►Consideration of background risks when assessing the FHR
features
► Introduction of altered calling criteria
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Antenatal label ≥ 32 weeks
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Intrapartum
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Determine risk Consideration of
► Intrapartum risks ► Fetal reserve ► Graded level of risks
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Features
► Baseline ► identifying the rising baseline ► Variability ► Introduction of ‘cycling’ – the normal transition of the fetus through the
awake and asleep states.
► Decelerations ► Language change to complicated variables ► Prolonged decelerations – time frames and recognition of recovery
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Intrapartum label
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The deteriorating mother:
- Maternal Physiology
- Healthy and young – late deterioration
- Reluctance to recognise rare complications eg
peripartum cardiomyopathy
- Sepsis esp GAS
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Maternal BTF – SMOC & ASSOC
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Maternal peripartum BTF - SIOC
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Neonatal BTF - SNOC
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Moving up the ‘slippery slope’
Maternal / fetus Condition
Time Clinical Review Rapid Response
Prevention
Antenatal care / risk assessment
Death ALS
High care unit / facility Clinical Pathway/ guidelines
(pre-eclampsia, PPH, Fetal distress)
Revised Treatment Plan Continued Treatment Plan Referral
Outcomes Clinical support tools
Sepsis Pathway/Alert Diagnostic Error
SMOC CTG stickers SNOC SIOC
Fetal welfare assessment Obstetric emergencies Neonatal resuscitation Training
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Current FONT – resuscitation, scenarios drills and team training
- Neonatal resuscitation
- Adult BLS
- Maternal collapse
- Sepsis
- Eclampsia
- Shoulder dystocia
- Vagina breech delivery
- PPH
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Sepsis – Maternal and neonatal
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Additional neonatal sepsis resources
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Monitoring: what do our RCAs tell us?
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Top system factors in Maternal and perinatal RCAs
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Top three system factors in Maternal and perinatal RCAs
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NSW M&N SAFETY SYSTEM
BTF program launch (Maternal) SMOC
2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
BTF program launch (Paeds & SNOC) Policy Directive
PD2011_077
Policy Directive
PD2013_049
CTG stickers v1 ED Sepsis
PD revision
eMR SMOC & SNOC VERSION 4 Development Updated deteriorating patient education Policy Directive
PD2010_026
Between the Flags program launch (Adult)
Fetal welfare
assessment
Obstetric
emergencies
Neonatal
resuscitation
Training F.O.N.T
revised
Maternal & Newborn Sepsis Pathways.v1 Antenatal short stay
- bservation
chart (ASSOC) Maternal & Newborn Sepsis Pathways.v2
F.O.N.T
revision commenced
SMOC & SNOC revised
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The future imagined
- Neonatal resuscitation training (HETI)
- Maternal essential training
- Fetal essential training
- Team training drills and simulations (Tier II) including
DETECT
- Library of resources and modules
- Responsive escalation, advice, and transfer
systems
- More usable data to allow better analysis of
critical incidents and deaths
- Reports to generate priorities and actions
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Ongoing challenges
- SMO engagement
- Team training – identification of appropriate
trainers
- Equivalence of training/RPL
- Culture and human factors work
- EMR challenges