Opportunities for improvement in care among women with severe maternal morbidity.

BACKGROUND: Severe maternal morbidity is increasing in the United States and has been estimated to occur in up to 1.3% of all deliveries. A standardized, multidisciplinary approach has been recommended to identify and review cases of severe maternal morbidity to identify opportunities for improvement in maternal care. OBJECTIVE: The aims of our study were to apply newly described gold standard guidelines to identify true severe maternal morbidity and to utilize a recently recommended multidisciplinary approach to determine the incidence of and characterize opportunities for improvement in care. STUDY DESIGN: We conducted a retrospective cohort study of all women admitted for delivery at Cedars-Sinai Medical Center from Jan. 1, 2012, through June 30, 2014. Electronic medical records were screened for severe maternal morbidity using the following criteria: International Classification of Diseases, Ninth Revision codes for severe illness identified by the Centers for Disease Control and Prevention; prolonged length of stay; intensive care unit admission; transfusion of ≥4 U of packed red blood cells; or hospital readmission within 30 days of discharge. A multidisciplinary team conducted in-depth review of each medical record that screened positive for severe maternal morbidity to determine if true severe maternal morbidity occurred. Each true case of severe maternal morbidity was presented to a multidisciplinary committee to determine a consensus opinion about the morbidity and if opportunities for improvement in care existed. Opportunity for improvement was described as strong, possible, or none. The incidence of opportunity for improvement was determined and categorized as system, provider, and/or patient. Morbidity was classified by primary cause, organ system, and underlying medical condition. RESULTS: There were 16,323 deliveries of which 386 (2%) screened positive for severe maternal morbidity. Following review of each case, true severe maternal morbidity was present in 150 (0.9%) deliveries. We determined by multidisciplinary committee review that there was opportunity for improvement in care in 66 (44%) cases. The 2 most common underlying causes of severe maternal morbidity were hemorrhage (71.3%) and preeclampsia/eclampsia (10.7%). In cases with opportunity for improvement in care, provider factors were present in 78.8%, followed by patient (28.8%) and system (13.6%) factors. CONCLUSION: We demonstrated the feasibility of a recently recommended review process of severe maternal morbidity at a large, academic medical center. We demonstrated that opportunity for improvement in care exists in 44% of cases and that the majority of these cases had contributing provider factors.

Anesthetic Management of a Super Morbidly Obese Obstetric Patient With a Body Mass Index of 109 kg/m2 Presenting for Her Fourth Caesarean Delivery.

Morbidly obese obstetric patients undergoing anesthesia present many unique challenges. Previous caesarean sections (CSs) further complicate their management. We present the successful anesthetic management of a super morbidly obese obstetric patient with body mass index (BMI) of 109 kg/m2 who underwent her fourth CS. As per our review, this patient has the highest recorded BMI in the obstetric anesthesia literature. A 27-year-old female, G4P3003, presented for fourth repeat CS at 38 weeks' gestation. She had obstructive sleep apnea, hypertension, atrial fibrillation, and type 2 diabetes. Her first CS was emergent under general anesthesia (GA), and the other two were performed under neuraxial anesthesia, with the most recent one complicated by intraoperative cardiac arrest requiring cardiopulmonary resuscitation. Preoperative preparation involved multidisciplinary preparation, planning, and risk stratification. Although neuraxial anesthesia is preferred over GA for CS, she refused neuraxial anesthesia due to her prior traumatic experience and the potential that it caused her prior cardiac arrest. In addition, her inability to position for a block or lay flat, poor anatomical landmarks, unknown length of surgery, plan for periumbilical incision, uncertain placental status, and risk of massive hemorrhage convinced us to consider GA. Surprisingly, her airway examination was reassuring. Two 18G peripheral intravenous lines and an arterial line were obtained prior to induction. With optimum patient positioning and preoxygenation, modified rapid sequence induction with mask ventilation and endotracheal intubation with direct laryngoscopy were performed. A healthy baby was delivered without significant intraoperative complications. Intraoperative lung-protective strategy with recruitment maneuvers, multimodal analgesia, and elective postoperative continuous positive airway pressure aided in successful extubation. Postoperatively, pulmonary toilet, early mobilization, physical therapy, and venous thromboembolism prophylaxis were employed. Her postoperative course was complicated by severe preeclampsia and pulmonary embolism, which were managed successfully in the intensive care unit. She was discharged initially to outpatient rehabilitation followed by home. This case highlights the complexities and significance of an individualized approach in managing super morbidly obese obstetric patients.