Download Severely Ill Obstetric Woman - Royal Cornwall Hospitals NHS Trust

SEVERELY ILL OBSTETRIC WOMEN - CLINICAL GUIDELINE
1. Aim/Purpose of this Guideline
1.1. To provide Obstetricians, Anaesthetists, Midwives and Nurses guidance on early
recognition and management of the severely ill obstetric women.
2. The Guidance
2.1. Introduction
The majority of women delivering their babies in the maternity unit will be well women.
Some will have been identified as high risk either because of pre-existing co- morbidities or
as a result of the pregnancy. The challenge is to identify early, the women who become
unwell during their antenatal, intrapartum or postnatal course. The provision of higher
dependency care for obstetric women is carried out either in a designated area on the
maternity unit or the Intensive Care Unit (CCU). Where mothers are cared for will be
influenced by the level of care they require and the multidisciplinary competencies.
Sepsis and septic shock was the leading cause of maternal death in the CEMACE report
2006-2008 (MBRACE). The speed and appropriateness of therapy administered in the
initial hours after severe sepsis develops is likely to influence outcome with early
resuscitation improving survival rates.
2.2. Antenatal Identification of a High Risk Woman
At booking all women undergo a maternity risk assessment by the booking midwife. If a risk
factor is identified a referral should be made to the Consultant Obstetrician and if indicated
the Consultant Anaesthetist for review.
For women who are at risk of becoming severely ill, multidisciplinary planning of their
pregnancy and intra-partum care should take place. This may involve referral to a Maternal
Medicine Clinic or involvement of clinicians from outside the maternity service. The plan
should be clearly documented in the woman’s notes and reviewed and updated at each
appointment.
A letter outlining the woman’s condition and the plan for her care should be written and filed
in the appropriate ‘Risk Folder’ on delivery suite, by the person making the plan.
The monitoring of these women requires vigilance and an early opportunity to predict, and
therefore avoid any potential deterioration in their clinical condition.
2.3. Intrapartum Identification of a High Risk Woman
For all women admitted to delivery suite the responsible midwife must check the ‘Risk
Folders’ for any information relevant to the woman’s care. On admission a risk assessment
should be completed by the admitting midwife and any risk factors identified. For women
with existing risk factors or risk factors identified in the admission risk assessment, the duty
Obstetrician should be informed and a plan of care documented in the woman’s notes.
2.4. Identification of the Ill Woman
Maternity Early Obstetric Warning Scoring system (MEOWS) is an essential tool for
assessing a woman’s clinical condition. All women requiring regular observations more
frequently than the routine care in labour guideline should have them recorded and scored
on a MEOWS chart.
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If the clinical condition becomes unstable the frequency of the observations should be
increased as dictated by the MEOWS scoring system.
2.5. Use of the MEOWS Chart
All vital signs, as indicated on the MEOWS chart, should be recorded and scored.
The midwife should then refer to the risk category page on the front of the MEOWS chart,
and follow the instructions.
 Score ≤ 4 the category is low and routine care can continue
 Score ≥ 5 (or SpO² 88-92% or GCS ≤ 13 or Resp rate 20-30 bpm) observations
should increase to every 5-10 minutes and a medical review requested within 15
minutes
 Score ≥ 8 (or SpO² <88% or GCS ≤12 or Resp rate >30) observations should
increase to every 5 minutes and an immediate medical review requested
2.6. Management of the Severely Ill Pregnant Women
Women who have been identified from MEOWS chart score as MEOWS ≥5
 Follow directions to increase frequency of vital signs monitoring and referral for
medical review
 Instigate management as instructed by medical personnel
 If score increases and/or clinical condition continues to deteriorate identify
women as severely ill, requiring a step up to high dependency care (level 2 care).
A HDU chart should be commenced and the date and time of the step up to HDU
documented in the notes.
 An experienced midwife should undertake one-to-one care
 Multidisciplinary involvement is essential from senior grades of Obstetrician and
Anaesthetist and, if the woman has any underlying condition, the opinion of a
senior professional with expertise in that condition should be sought.
 Septic shock should be managed in accordance with the Surviving Sepsis
Campaign guidelines (see below)
2.7. High Dependency Care
 One-to-one care must be undertaken by an experienced midwife and/or
maternity nurse and should continue on delivery suite
 Vital signs now need to be documented on the High Dependency chart
 Multidisciplinary care plans must be documented and regularly updated within
the patient notes
2.8. Level 2 Care
 This constitutes basic respiratory and/or cardiovascular support and includes
neurological support
 Any patient requiring more than 50% oxygen delivered by face mask
 Circulatory instability - from bleeding resulting in hypovolaemia or secondary to
hypertensive disease requiring the administration of an intravenous vasoactive
drug to control BP
 The use of invasive monitoring techniques e.g. arterial or central venous
pressure monitoring.
 Continuous intravenous medication to control seizures e.g. Intravenous
Magnesium to control and prevent seizures in pre-eclampsia
 Intravenous drugs to control cardiac arrhythmias
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2.9. Essential Equipment on the high dependency and crash trolleys
All drugs, equipment, fluids and algorithms required for resuscitation and management of
women receiving high dependency care should be immediately available. This includes:

Airways -Guedel

Oxygen supply-Disposable oxygen mask and tubing

Ambu bag and Waters circuit

Suction equipment - selection of suction catheters

Electronic monitor (Phillips monitor) that can record: blood pressure, ECG, pulse,
SpO2, respirations and invasive monitoring.
2.10. Transfer to Intensive Care Unit (ICU)
If there is a continued deterioration of the woman’s condition and the woman is requiring
advanced respiratory or cardiovascular support, transfer to the Intensive Care Unit (ICU)
should be arranged
Other factors to influence the transfer to ICU include:

Staffing levels and skills mix of the midwives and medical staff on duty

Current workload of the clinical area

Preference of the obstetric/anaesthetic team managing the woman’s care
Once the decision has been made to transfer the woman to ICU, the Obstetric Anaesthetist
will liaise with the ICU Consultant. The anaesthetic team will take responsibility for
arranging the equipment (the Transfer Grab Bag in the anaesthetic room) required to
facilitate the safe transfer of the woman to ICU.
The obstetric anaesthetist and midwife involved in the care of the woman will communicate
with the ICU staff and hand over care on arrival in the ICU.
The consultant obstetrician will provide obstetric advice for the on-going care of the woman
on ICU.
2.11. Management of Septic shock
This should be managed in accordance with the Surviving Sepsis Campaign guidelines and
requires a multidisciplinary team approach.
Bacteraemia can progress rapidly to severe sepsis and septic shock leading to collapse.
The most common organisms implicated in obstetrics are the streptococcal groups A,B and
D, pneumococcus and E coli.
2.12. Recognition of sepsis
Each hour of delay in achieving administration of effective antibiotics is associated with an
increase in mortality.
Regular completion of vital signs on a MEOWS chart, and documentation of results will
assist in the early recognition of sepsis and the critically ill woman.
Refer to the RCHT Maternity Sepsis Guideline.
2.13. Maternal Transfer to Intensive Care Unit (ICU) Summery:
All hand over of care or transfer to ICU should be done using the maternal transfer to ICU
form (See Appendix 3).
The health professional handing over care should use SBAR as a prompt for handing over
all relevant information, the person receiving the hand over should repeat back to
information they have received. Both health professionals should then sign the form to
confirm that handover has been completed.
2.14. Training

All midwives, obstetricians and obstetric anaesthetists will attend annual training
SEVERLEY ILL OBSTETRIC WOMAN – CLINICAL GUIDELINE
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
on the recognition and management of the critically ill woman, including the use
of the MEOWS chart.
All midwives, obstetricians and obstetric anaesthetists will attend annual training
in maternal resuscitation
2.15. Incident reporting
Any woman transferred to ICU must be Datix reported.
2 Monitoring compliance and effectiveness
Element to be
monitored
Use of the MEOWS chart
Use of the HDU chart
Use of the transfer form
Criteria for transfer to HDU/ICU
Communication and documentation
Lead
Tool
Maternity Risk Management Midwife
 Did the woman require routine observations in the AN/PN
period or additional observations in the intrapartum period?
 If yes, was a MEOWS chart commenced?
 Were all vital signs documented and scored on the MEOWS
chart?
 Was the risk category page on the front of the MEOWS chart
correctly followed?
 If step up to level 2 care was required was an HDU chart
commenced?
 Was the date and time of step up to level 2 documented in
the notes?
 Did the woman have an underlying non obstetric condition?
 If yes, was a clinician from outside the maternity service
consulted?
 Did the woman required advanced respiratory or
cardiovascular support?
 If yes, was she transferred to ICU?
 If yes, was the appropriate transfer form completed?
 Has the anaesthetist documented the handover to the ICU
anaesthetist?
Has the obstetrician documented the hand over to the ICU
clinician
 1% or 10 sets, whichever is greater, of all health records of
women who have delivered and in whom a MEOWS was
undertaken, will be audited over a 12 month period
 1% or 10 sets, whichever is greater, of all health records of
women who have delivered who have required high
dependency/intensive care, will be audited over a 12 month
period
 A formal report of the results will be received annually at the
maternity risk management and clinical audit forum, as per the
audit plan
 During the process of the audit if compliance is below 75% or
other deficiencies identified, this will be highlighted at the next
Frequency
Reporting
arrangements
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Acting on
recommendations
and Lead(s)



Change in
practice and
lessons to be
shared



maternity risk management and clinical audit forum and an
action plan agreed.
Any deficiencies identified on the annual report will be
discussed at the maternity risk management and clinical audit
forum and an action plan developed
Action leads will be identified and a time frame for the action to
be completed by
The action plan will be monitored by the maternity risk
management and clinical audit forum until all actions complete
Required changes to practice will be identified and actioned
within a time frame agreed on the action plan
A lead member of the forum will be identified to take each
change forward where appropriate.
The results of the audits will be distributed to all staff through
the risk management newsletter/audit forum as per the action
plan
Equality and Diversity
This document complies with the Royal Cornwall Hospitals NHS Trust service Equality and
Diversity statement.
Equality Impact Assessment
The Initial Equality Impact Assessment Screening Form is at Appendix 2.
Appendix 1. Governance Information
Document Title
SEVERLEY ILL WOMAN – CLIINICAL
GUIDELINE
Date Issued/Approved:
2nd July 2015
Date Valid From:
2nd July 2015
Date Valid To:
2nd July 2018
Directorate / Department responsible
(author/owner):
Dr Sam Banks
Consultant Anaesthetist
Contact details:
01872 253132
Brief summary of contents
To provide obstetricians, anaesthetists,
midwives and nurses guidance on early
recognition and management of the severely
ill obstetric women.
Severely, ill, obstetric, women, MEOWS,
oxygen, monitoring, transfer, HDU/ICU,
sepsis.
RCHT
PCH
CFT
KCCG
Suggested Keywords:
Target Audience
SEVERLEY ILL OBSTETRIC WOMAN – CLINICAL GUIDELINE
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
Executive Director responsible for
Policy:
Medical Director
Date revised:
2nd July 2015
This document replaces (exact title of
previous version):
The management and early recognition of
the severely ill pregnant women
Maternity Guidelines Group
Obs and Gynae Directorate
Divisional Board for noting
Approval route (names of
committees)/consultation:
Divisional Manager confirming
approval processes
Head of Midwifery
Name and Post Title of additional
signatories
Not required
Signature of Executive Director giving
approval
Publication Location (refer to Policy
on Policies – Approvals and
Ratification):
{Original Copy Signed}
Internet & Intranet
 Intranet Only
Document Library Folder/Sub Folder
Midwifery and obstetrics
Anaesthetics
Links to key external standards
CNST 2.8 & 2.9 & 1.9 & 1.10





Related Documents:



SEVERLEY ILL OBSTETRIC WOMAN – CLINICAL GUIDELINE
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Department of Health DH 2000:
Comprehensive Critical Care.
London
Department of Health 2007:The
Confidential Enquiry into Maternal
Deaths.CEMACH
RCOG 2007: Safer Childbirth,
Minimum Standards for the
Organisation and Delivery of Care in
Labour. London.
CCIAG – Critical Care Information
Advisory Group.
CCMDS – Critical Care minimum
Dataset- a database developed by
CCIAG in 2006 updated in 2008 to
include data collected from Obstetric
critical care patients within maternity
units.
MBRRACE (2014) 2008-2012Saing
lives: improving mothers Care
Dellinger RP, Levy MM, Carlet JM,
Bion J, Parker MM, Jaeschke R, et
al.; International Surviving Sepsis
Campaign Guidelines Committee;
American Association of Critical-Care
Nurses; American College of Chest
Physicians; American College of
Emergency Physicians; Canadian
Critical Care Society;European
Society of Clinical Microbiology and
Infectious Diseases; European
Society of Intensive Care Medicine;
European Respiratory Society;
International Sepsis Forum;
Japanese Association for Acute
Medicine; Japanese Society
ofIntensive Care Medicine; Society of
Critical Care Medicine; Society of
Hospital Medicine; Surgical Infection
Society; World Federation of
Societies of Intensive and Critical
Care Medicine. Surviving Sepsis
Campaign: international guidelines
for management of severe sepsis
and septic shock. Crit Care
Med2008;36:296–327
Training Need Identified?
Yes Annual TOME training day
Version Control Table
Date
Version
Summary of Changes
No
November
V1.0
2004
Changes Made by
(Name and Job Title)
Dr Bill Harvey
Initial Issue: Guidelines for the Transfer of
Consultant
Patients to High Dependency / Intensive Care
Anaesthetist
Addition of recognition of the severely ill
obstetric woman, use of MEOWS and SBAR
Dr Catherine Ralph
Consultant
Anaesthetist
Dr Catherine Ralph
Consultant
Anaesthetist
January
2010
V1.1
March
2012
V1.2
August
2012
V 1.3
Changes to compliance monitoring only
Dr Catherine Ralph
Consultant
Anaesthetist
2nd July
2015
V 1.4
Proforma includes documentation of vaginal
packs/Bakri Balloon situ on transfer to ICU
Dr Sam Banks
Consultant
Anaesthetist
Inclusion of recognition and management of
maternal sepsis and compliance monitoring
All or part of this document can be released under the Freedom of Information
Act 2000
This document is to be retained for 10 years from the date of expiry.
This document is only valid on the day of printing
SEVERLEY ILL OBSTETRIC WOMAN – CLINICAL GUIDELINE
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Controlled Document
This document has been created following the Royal Cornwall Hospitals NHS Trust
Policy on Document Production. It should not be altered in any way without the
express permission of the author or their Line Manager.
SEVERLEY ILL OBSTETRIC WOMAN – CLINICAL GUIDELINE
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Appendix 2. Initial Equality Impact Assessment Form
Name of Name of the strategy / policy /proposal / service function to be assessed (hereafter
referred to as policy) (Provide brief description): SEVERLEY ILL OBSTETRIC WOMAN –
CLINICAL GUIDLINE
Directorate and service area:
Is this a new or existing Policy?
Obs & Gynae Directorate
Existing
Name of individual completing
assessment:
Elizabeth Anderson
Telephone:
01872 252879
1. Policy Aim*
Who is the strategy /
policy / proposal /
service function
aimed at?
2. Policy Objectives*
To provide obstetricians, anaesthetists, midwives and nurses
guidance on early recognition and management of the severely ill
obstetric women.
3. Policy – intended
Outcomes*
Safe outcome for pregnant and newly delivered women.
4. *How will you
measure the
outcome?
5. Who is intended to
benefit from the
policy?
6a) Is consultation
required with the
workforce, equality
groups, local interest
groups etc. around
this policy?
Compliance Monitoring Tool.
b) If yes, have these
*groups been
consulted?
N/A
C). Please list any
groups who have
been consulted about
this procedure.
N/A
To recognise a deteriorating obstetric woman and ensure swift
management appropriate to her needs.
All pregnant and newly delivered women.
No
7. The Impact
Please complete the following table.
Are there concerns that the policy could have differential impact on:
Equality Strands:
Age
Yes
No
X
Rationale for Assessment / Existing Evidence
SEVERLEY ILL OBSTETRIC WOMAN – CLINICAL GUIDELINE
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Sex (male, female, trans-
X
All pregnant and newly delivered women
Race / Ethnic
communities /groups
X
All pregnant and newly delivered women
Disability -
X
All pregnant and newly delivered women
Religion /
other beliefs
X
All pregnant and newly delivered women
Marriage and civil
partnership
X
All pregnant and newly delivered women
Pregnancy and maternity
X
All pregnant and newly delivered women
Sexual Orientation,
X
All pregnant and newly delivered women
gender / gender
reassignment)
learning
disability, physical
disability, sensory
impairment and
mental health
problems
Bisexual, Gay, heterosexual,
Lesbian
You will need to continue to a full Equality Impact Assessment if the following have been
highlighted:
 You have ticked “Yes” in any column above and
 No consultation or evidence of there being consultation- this excludes any policies
which have been identified as not requiring consultation. or
 Major service redesign or development
No
8. Please indicate if a full equality analysis is recommended.
Yes
X
9. If you are not recommending a Full Impact assessment please explain why.
N/A
Signature of policy developer / lead manager / director
Elizabeth Anderson
Names and signatures of
members carrying out the
Screening Assessment
Date of completion and submission
2nd July 2015
1. Elizabeth Anderson
2. Sam Banks
Keep one copy and send a copy to the Human Rights, Equality and Inclusion Lead,
c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Knowledge Spa,
Truro, Cornwall, TR1 3HD
A summary of the results will be published on the Trust’s web site.
Signed: Elizabeth Anderson
Date: 2nd July 2015
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Maternal identification sticker
Name:
Hospital number:
Date of birth:
NHS number:
Appendix 3:
Maternal Transfer to Intensive Care Unit (ICU) Summary
Midwife to complete for ALL maternal transfers
To be completed in black ink (tick boxes, circle or complete areas) this summary should
accompany the patient and case notes to the referring unit
Decision date & time
Transfer from:
Name of health professional
making decision
Transfer to:
Name of health professional
contacting ICU
Name of health
professional accepting
transfer
Rational for transfer
discussed with woman
Next of kin informed
Yes / No
Yes/No
Time transfer commenced
Time transfer completed
Situation:
Identify yourself the site/unit you are calling from:

I am and current location

The problem is…
__________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
____________________
Background:

Risk factors:
_______________________________________________________________

Medical problems, if any:
_____________________________________________________

Obstetric
history_____________________________________________________________

Current pregnancy
___________________________________________________________
(scan report, blood tests etc;)
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Assessment:
Maternal Vital signs:________________________________________________
Abdominal palpation:_______________________________________________
Vaginal examination:________________________________________________
Fetal wellbeing:____________________________________________________
Vaginal Packs in situ Yes/ No
Uterine Balloon in Situ
Yes/No
Recommendation & Plan of Management:
Management plan by transferring
midwife:__________________________________________________
Telephone recommendations by receiving
unit:_______________________________________________
Signature of transferring midwife/nurse: _________________________
Printed name of transferring midwife/nurse: ______________________
Signature of receiving Midwife/Nurse: ___________________________
Printed name of receiving Midwife/Nurse: ________________________
Date and time: ____________________________
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Appendix 4:
SBAR - Situation - Background - Assessment – Recommendation & Decision
What is it and how can it help me?
SBAR is an easy to remember mechanism to frame conversations, especially critical ones,
requiring a clinician's immediate attention and action. It enables staff to clarify what information
should be communicated between members of the team, and how. It can also help to develop
teamwork and foster a culture of patient safety.
The tool consists of standardised prompt questions within four sections, to ensure that staff are
sharing concise and focused information. It allows staff to communicate assertively and effectively,
reducing the need for repetition.
The tool helps staff anticipate the information needed by colleagues and encourages assessment
skills. Using SBAR prompts staff to formulate information with the right level of detail. The use of
SBAR prevents the hit and miss process of ‘hinting and hoping'.
How to use it
S Situation:
 Identify yourself the site/unit you are calling from
o I am and current location
o I am…
o The problem is…
 Identify the patient by name and the reason for your report
o I am calling about…
o She was low risk, but…
 Describe your concern
o I am calling because I am concerned that…
Firstly, describe the specific situation about which you are calling, including the patient's name,
consultant, patient location, code status, and vital signs.
B Background:
 Give the patient's reason for admission
o Woman’s/Baby’s condition has changed
 Explain significant medical history
o She was low risk or has had one episode of raised blood pressure
 You then inform the consultant of the patient's background: admitting diagnosis, date of
admission, prior procedures, current medications, allergies, pertinent laboratory results
and other relevant diagnostic results. For this, you need to have collected information
from the patient's chart, flow sheets and progress notes.
o Her observations are…
o The fetal heart was…and is now…
o Her progress has…and she has been in labour for…
A Assessment:
 Vital signs
o Her vital signs are…
o I think the problem is…
 Contraction pattern, progress in labour, breech presentation in labour or APH
o I feel there is no/slow progress or cervical dilatation has not improved
o I think the presentation is breech and she’s in labour
o She’s in pre-term labour
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o She’s bleeding…
 Clinical impressions, concerns
o The fetal heart has changed from…to…
o It may be a PPH/APH
R Recommendation:
 Explain what you need - be specific about request and time frame
o I wish to transfer her now
 Make suggestions
o She requires a medical assessment
o She’s now a higher risk…
 Clarify expectations
o She needs immediate transfer to hospital
Recommended uses and settings for SBAR:





Urgent or non urgent communications
Conversations with a doctor or midwife, either in person or over the phone
o Particularly useful in nurse to doctor communications
Also helpful in doctor to doctor consultation
Discussions with allied health professionals
o Respiratory therapy
Physiotherapy
Conversations with peers
o Change of shift report
Escalating a concern
Hospitals using SBAR have found the following useful:



Notepads or paper with the tool printed on them
Pocket cards
Stickers on or next to telephones to act as a visual prompt
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