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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. SEVERLEY ILL OBSTETRIC WOMAN – CLINICAL GUIDELINE Page 1 of 14 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 SEVERLEY ILL OBSTETRIC WOMAN – CLINICAL GUIDELINE Page 2 of 14 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 Page 3 of 14 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 SEVERLEY ILL OBSTETRIC WOMAN – CLINICAL GUIDELINE Page 4 of 14 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 Page 5 of 14 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 Page 6 of 14 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 Page 7 of 14 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 Page 8 of 14 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 Page 9 of 14 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 SEVERLEY ILL OBSTETRIC WOMAN – CLINICAL GUIDELINE Page 10 of 14 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;) SEVERLEY ILL OBSTETRIC WOMAN – CLINICAL GUIDELINE Page 11 of 14 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: ____________________________ SEVERLEY ILL OBSTETRIC WOMAN – CLINICAL GUIDELINE Page 12 of 14 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 SEVERLEY ILL OBSTETRIC WOMAN – CLINICAL GUIDELINE Page 13 of 14 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 SEVERLEY ILL OBSTETRIC WOMAN – CLINICAL GUIDELINE Page 14 of 14