Protocols for Managing Obstetric Emergencies

Ricki Lewis, PhD

December 17, 2014

Table charts depicting five obstetric emergency situations can help prevent an "all hands on deck" response that can miss crucial details, according to protocols published online October 14 and in the October/November issue of Nursing for Women's Health.

Statistics from the Centers for Disease Control and Prevention indicate that obstetric deaths are on the rise, going from 13.3 deaths per 100,000 live births before 2006 to 15.8 per 100,000 from 2006 to 2009. Cheryl K. Roth, PhD, nurse practitioner in obstetrics at Scottsdale Healthcare in Arizona, and colleagues conducted an extensive literature search covering these years and conclude that some deaths may have resulted from the assumption that all steps will be taken as long as enough people ("all hands on deck") are present at an emergency. The group then created protocols in table chart form to prevent or minimize errors during obstetric crises.

Focus on Details and Teamwork

"When confronted with unexpected or unusual events, like uterine rupture, people have to act immediately [to save] the lives of [the] mother and child and also need specific roles so people don't miss obvious things. Adrenaline kicks in, and even though cognitively everyone knows how to deal with postpartum hemorrhage, when it's severe, very often people will miss a crucial element, such as whether the [intravenous drip] is flowing well or if extra tubes of blood have been transferred to the lab," said James Byrne, MD, chair, Department of Obstetrics and Gynecology at Santa Clara Valley Medical Center, San Jose, and affiliated clinical professor, Stanford University School of Medicine, California. He worked on protocols for postpartum hemorrhage for the California Maternal Quality Care Collaborative, which inspired the new table charts.

Dr Byrne compares the chaos at an obstetric emergency with other complex situations: commercial aviation, the scene of an automobile accident, and military maneuvers. Individuals have specific roles, but the team must function together so well that no detail is missed.

The researchers created guidelines for establishing obstetric emergency response teams to handle five situations: postpartum hemorrhage, shoulder dystocia, and emergency cesarean delivery (considered common emergencies), as well as eclamptic seizure and maternal code (uncommon emergencies). Although all obstetric/gynecologic nurses will have seen emergency cesarean deliveries, some nurses may never have witnessed eclampsia because of the widespread use of magnesium sulfate prophylaxis.

Color-Coded Protocol Table Charts

The protocol table charts consist of columns color-coded to the severity of the emergency, using green (stage 0), red (stage 1), and yellow (stage 2) for all but postpartum hemorrhage, which has an additional stage 3 and proceeds instead from green to yellow to dark orange to red. A short description tops each column.

For eclampsia, for example, stage 0 considers risk factors for all pregnant women, stage 1 is the seizure, and stage 2 is postevent. For emergency cesarean delivery, stage 1 lists the emergent events, assembling the team, and prepping for the procedure. Stage 2 includes communication with the family, preparing the patient for recovery, counting instruments, and documenting all activities.

The body of each table chart breaks down specific tasks by team member, first to nurses, physicians, and laboratory personnel. Nursing responsibilities are subdivided among the patient's nurse; first, second, and third responder nurses assigned by the supervisor at the start of the shift; and others.

The physician sections coordinate with nursing activities and troubleshoot how care might change to suit a particular situation. For some indications, a laboratory section advises how to minimize delays in submitting blood work.

The coordination that the protocols provide is particularly valuable when speed is important. For example, delivery must follow maternal cardiac/respiratory arrest within 4 minutes to maximize chance of maternal survival. For shoulder dystocia, the first step for both nurses and physicians is noting the "turtle sign" (fetal head retraction during delivery). Nurses then go on to call for help, document time when the head delivers and the body delivers, perform certain maneuvers, apply suprapubic pressure, and notify the neonatal intensive care unit team. Meanwhile, physicians perform maneuvers, deliver the posterior arm, and deliver the body.

Implementing the Protocols

The new table charts summarize a tremendous amount of information. "I've seen over the last 10 years this approach embraced by all stakeholders — patients, hospitals, nurses, physicians, midwives — and it actually works. Handouts are never just passed around. Nurses and physicians practice and rehearse, so that when [an] emergency happens, people are trained and aware," said Dr Byrne.

Although bullets for lists and check-off squares next to activities create a clear table chart, the protocols are too extensive to be helpful if consulted for the first time as the emergency transpires. Regularly scheduled lectures and mock exercises to simulate emergencies typically precede use of the table charts.

"We gather our doctors and nurses and do drills. They are the actors. Some play patients in bed, and we use theatrical blood and keep the noise loud on purpose to be the family members, who can be a distraction," said Dr Byrne.

Team members can access the table charts in several ways. Nurses carry pocket cards on lanyards, and the supervisor has a copy on the clipboard. Laminated copies of the appropriate protocol may be kept on top of the code blue carts and emergency postpartum hemorrhage cart.

"Hats off to the authors. They have not just come up with a theory, but have helped summarize the things that actually take place in many hospitals. But they are the leading edge. For the vast majority of hospitals, this will be new information," said Dr Byrne.

The authors and Dr Byrne have disclosed no relevant financial relationships.

Nursing Women's Health. 2014;18:378-390. Abstract

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