Maternal Health Closed Claim Review: Preparing a Facility for Emergencies

According to the American College of Obstetricians and Gynecologists and March of Dimes, more than 2.2 million U.S. women ages 15 to 33 live in maternity care deserts—meaning their county has no hospitals that provide obstetric care, birth centers, ob/gyns, or certified nurse-midwives. This case study highlights risk reduction strategies facilities can use to prepare for and address maternal health emergencies.

The Overview

• A 34-week pregnant patient with abdominal pain and vaginal bleeding presented to the emergency department (ED) of a hospital that had no obstetric services.
• The ED doctor ordered an ultrasound, suspecting placental abruption. Fetal heart rate was auscultated with a stethoscope at 135 bpm.
• The ultrasound was performed 90 minutes later but was somewhat inconclusive.
• The ED doctor ordered an ambulance transfer (not stat) to the closest obstetric care facility an hour away. The transfer was not completed until six hours later.

The Patient Outcome

• Upon arrival at the receiving hospital, there were no fetal heart tones.
• An emergency C-section revealed a detached placenta and a blue uterus, with the baby showing no signs of life.
• The mother faced complications resulting in multiple days in the ICU and eventually recovered.

Risk Management Strategies

Prepare an obstetric supply emergency kit:

• If obstetric services are not available at your facility, equip the ED with a maternal/newborn supply kit. Include a fetal heart tone doppler or fetoscope, supplies to manage an unexpected birth, term- and preemie-sized resuscitation masks, nitrazine paper, and a scale for hemorrhage quantification.

Use available clinical tools:

• Use the AWHONN Maternal Fetal Triage Index for obstetric patient acuity.
• Follow the CMQCC obstetric hemorrhage algorithm.
• Include a quick reference guide for documenting fetal heart tones in different obstetric scenarios.

Follow monitoring guidelines:

• Normal fetal heart rate: 120 to 160 bpm.
• In acute situations (e.g., hemorrhage), document fetal heart rate every five minutes.
• In less acute situations, verify heart rate every 15 to 30 minutes (AWHONN Position Statement on Fetal Heart Monitoring 2018).

Prepare for emergencies:

• Identify the nearest maternal care facilities and establish transfer protocols for stat and routine cases.
• Establish standing transfer agreements with maternal care facilities if possible.
• Consult receiving facilities for patient preparation preferences before transfer (e.g., two large bore IVs).
• Conduct annual drills to keep ED staff familiar with obstetric supplies and protocols.