Episode #276 Maternal Care, Transformed

Hello and welcome back to the Anesthesia Patient Safety Podcast. My name is Alli Bechtel, and I am your host. Thank you for joining us for another show. We are kicking off an exciting series today. That’s right. It’s time to talk about the 2025 APSF Stoelting Conference: “Transforming Maternal Care: Innovations and Collaborations to Reduce Morbidity and Mortality.” If you weren’t able to attend the Stoelting conference this year, then we hope that you will enjoy this podcast  series, and you can also check out recordings from the conference on our website and YouTube channel. Thank you to our industry sponsors for supporting the 2025 APSF Stoelting Conference: BD, Medtronic, Solventum, and Intelliguard. Check out the show notes for more information.

Before we dive further into the episode today, we’d like to recognize GE Healthcare, a major corporate supporter of APSF. GE Healthcare has generously provided unrestricted support to further our vision that “no one shall be harmed by anesthesia care”. Thank you, GE Healthcare – we wouldn’t be able to do all that we do without you!”

Now, it’s time to get into the conference and focus on transforming maternal care. Our first speaker is Elliott Main, a professor of obstetrics and gynecology to delivery the keynote address, “ A call to action: why we’re here, why this is important.” Elliott starts with some background history of maternal morbidity and mortality. Reporting started with case reports in the New England Journal of Medicine and confidential enquiries on maternal deaths in England and Wales that was published every 3 years. Then, there were editorial summaries in the British Journal of Anesthesia published every 3 years. But if we are going to identify a problem with maternal patient safety and put in the work to make improvements then we need more data. By 2007, we see the establishment of the first California maternal mortality review committee which focused on quality improvement opportunities, multidisciplinary QI toolkits, large scale collaboratives and robust rapid-cycle data center which was expanded to national efforts.

So, why are we here? There are a number of causes of pregnancy-related mortality in the US including hemorrhage, hypertensive disorders of pregnancy, infection, pulmonary embolus, amniotic fluid embolism, anesthesia complications, cardiovascular, cardiomyopathy, cerebrovascular accidents and other conditions. The percentage of pregnancy-related deaths due to anesthesia complications are low and have fallen from 2.5 between 1987 and 1990 to 0.2 from 2011-2013. The trend for cardiovascular conditions and cardiomyopathy are not quite so good. Cardiomyopathy, for example, may develop postpartum and be difficult to diagnose since the symptoms related to heart failure are similar to how patients are feeling immediately postpartum with tiredness and fatigue. Did you know that women often present 4-5 times before the diagnosis is made?

We are also here because compared to other high-income countries, the US mortality rate is quite high. We have work to do when it comes to improving maternal patient safety. If we look at some QI opportunities related to hemorrhage and preeclampsia from the California Pregnancy associated mortality reviews, we see some concerning factors. There were the 3 deadly D’s = Denial, Delay, and Dismissal. This means that doctors or nurses may have been in denial and refused to believe the potential severity of patient complaints or findings or normalized these complaints. There may be delays with key medications or therapies and finally, doctors and nurses may have dismissed patient complaints and not listened to their patients.

This brings us to a call for action for the National Partnership for Maternal Safety which started in 2015. Th first bundle was on obstetric hemorrhage. Over time, this has become AIM or the Alliance for Innovation in Maternal Health. There are now 8 core AIM bundles which are supplemented by toolkits to provide detailed background information to help with implementation and it is all open source. I will include a link to the website for more information. Have you incorporated AIM bundles at your institution?  The most widely used bundles are for hemorrhage and hypertension. Keep in mind that improving patient safety doesn’t just mean doing the right thing, we also need to act fast to avoid delays in anesthesia involvement, treatment for severe hypertension to prevent stroke, and starting antibiotics and IVF for sepsis treatment for some examples.

Elliot helps to answer the important question, “how do you implement these changes.” One strategy has been partnering with the Joint Commission which is responsible for accreditation of most of the hospitals in the US and working to translate these bundles into standards. Improved reporting is another important consideration.

So, how are we doing and where are we going? We have seen significant reductions in hemorrhage and hypertension using large scale quality improvement projects, but there is still more work to do especially for black, Hispanic, and Asian pacific islander patients. The rates of severe morbidity and in-hospital deaths for black parturients are 3-4 times higher than white parturients. Using these bundles may help improve the process, but we need to make sure that we are continuing to work to improve outcomes and address these disparities.

Elliot leaves us with some important considerations. Some of the keys to improving maternal patient safety include teamwork, tools, timeliness, and trust. This is an important area for anesthesia professionals to work to develop trust, sometimes in a very short amount of time. When time allows you may be able to sit with your patient and ask what their goals are for care or analgesia?

Another important consideration is improving patient safety with early warning signs. We have talked about patient engagement and patient empowerment before on the podcast. There are 15 key symptoms and signs brought to you by ACOG and the council on Patient Safety and the CDC in the “Hear Her Campaign.” I will include a link for more information in the show notes and it is available in 90 different languages. Some of the urgent maternal warning signs include headache that won’t go away or gets worse over time, dizziness or fainting, changes in vision, fever, chest pain or fast-beating heart, severe belly pain that doesn’t go away, extreme swelling of your hands or face.

Elliot reminds us about the “Statement on Anesthesiologists’ Role in Reducing Maternal Mortality and Severe Maternal Morbidity” by the ASA Committee on Obstetric Anesthesia from 2022. I will include a link to the full statement in the show notes. We hope that you will check it out, but we are going to fast forward to the recommendations, which include the following:

• “A physician anaesthesiologist should be an active member of each state’s maternal mortality review committee.
• A physician anaesthesiologist should be an active member of institutional-, regional-, or state-level Obstetric Quality Committees (or equivalent) and should provide reviews of cases involving acute care, especially care in a hospital.
• Antenatal anesthesiology consultations should be sought on high-risk patients in an appropriate time frame.
• Physician anesthesiologists should lead in implementation of elements of ACOG’s Levels of Maternal Care related to local and regional anesthesiology practices in maternity centers. The SOAP Centers of Excellence elements can be used to guide essential anesthesiology practices.
• All hospital-based birthing centers should implement Safety Bundles and Early Warning Systems. Ideally, implementation of these bundles and systems should involve a physician anesthesiologist as part of the leadership team.
• Regular institutional multidisciplinary simulation for maternal emergencies should include teaching or planning by a physician anesthesiologist and should include all team members who work on labor and delivery including anesthesia providers.
• Physician anesthesiologists should be part of the local leadership teams involved with quality management, case reviews, and other programming surrounding pregnancy hypertensive disorders and postpartum haemorrhage management.”

We hope that you following these recommendations in your obstetric practice. Elliot leaves us with this call to action: It is important to deliver appropriate care at the bedside and consider how we move beyond the bedside to move the needle when it comes to maternal M&M.

The next session covers major co-morbidities and up first is Jen Banayan to talk about Cardio-Obstetrics: Understanding the Why, When, and How to Prevent it. Did you know that cardiovascular disease is the leading cause of pregnancy related mortality? To help illustrate the challenges with cardio-obstetrics, Jen starts with a case presentation. A 34 year old woman, G1P0 with no known cardiac history presented to the hospital with SOB. She was later diagnosed with peripartum cardiomyopathy and moved to delivery. Following delivery, she deteriorated and required placement of a balloon pump, which helped her to survive and eventually recover. This case occurred at a major teaching hospital and there was no system in place to manage the rapid decompensation. Has this ever happened in your practice? Do you have a plan and system in place? How can you be ready before things go wrong?

Anesthesia professionals definitely need to be ready since cardiovascular disease is the leading cause of pregnancy-related deaths. We know about the significant hemodynamic changes that occur during pregnancy and especially during labor and delivery and this is even more important for patients with underlying cardiac disease. Jen tells us that pregnancy is nature’s stress test. Patients who were compensated may not pass the pregnancy stress test leading to arrhythmias, ischemia, and decompensated heart failure.

Let’s review some of the important factors when it comes to cardiovascular disease and maternal morbidity and mortality.

• Patient with Higher Maternal Age: This means more co-morbidities and increased cardiovascular risk. The changing demographics of pregnant patients are contributing to this.
• Congenital Heart Disease Survivorship: Due to advances in care. Currently, the number of adults with congenital heart disease outnumbers the number of children.
• Missed diagnosis: Keep in mind that SOB, palpitations, and oedema may be dismissed as normal since these are all very common in pregnancy. These symptoms are the first warning signs and when we miss this, we are behind. Delayed or missed diagnosis are major factors. We need a high index of suspicion to help make the diagnosis and keep patients safe.
• Failure to act effectively: We are missing important steps with pre-conception counselling. Plus, patients may find it difficult to make and attend appointments. For anesthesia professionals, we are often brought in a the last minute and may not have a plan or system in place. Another important component is that follow-up care may be delayed or inadequate for patients at risk for cardiovascular disease.
• Racial and SE disparities persist: This involves implicit bias, patients’ chronic health risk, and systemic inequities.

Remember, this is the Why, When, and How talk and Jen tells us that the majority of maternal deaths from cardiovascular disease occur during the postpartum period. This is an important time for healthcare professionals to remain vigilant.

And now, we get to the How to prevent it part of the talk. Let’s talk about action items. First up, it is important to identify the cardiac risk as early as possible. Prenatal consult pathways can help patients get the care they need in a timely manner. Risk stratification and patient counselling are important steps that can help keep patients safe. High risk patients will likely need multidisciplinary care that involves a pregnancy heart team with OB, cardiology, anaesthesia, maternal and fetal medicine, and nursing.

Let’s zoom in and look at the role of the anesthesia professional. We hope that you will check out the American Heart Association statement on Anesthetic Care of the Pregnant Patient with Cardiovascular Disease from October 2022. I will include the citation in the show notes. This is one of the first articles that focuses on the role for anesthesia professionals in cardio-obstetrics. Here are some important considerations for anesthesia professionals during labor and delivery.

Monitoring patients and managing changes in patient condition

Placement of invasive lines and monitors.

Fluid management tailored to the patient.

Working with the ECMO team if needed. ECMO can be a life-saving intervention and has improved survival for maternal cardiac arrest.

Here are some important considerations during the postpartum period.

Transfer to an OB intermediate care unit for continuous telemetry, higher nursing ratio, and more frequent assessments. This is an important bridge to see patients safely through delivery to discharge.

Jen leaves us with a call to action that anaesthesia professionals have a powerful role to play related to creating care models for patients with cardiac disease to help keep patients safe during labor and delivery, and beyond.

We have only just started our coverage of the 2025 APSF Stoelting Conference. Next week, we will be talking about maternal sepsis, hemorrhage, and venous thromboembolism, and more. We hope that you will tune. What do you think about the role for the anesthesia professional in transforming maternal care? We want to hear from you. Send us an email at [email protected]. You can include a short audio message or write to us with your story. And mark you calendars for next week as we continue our series.

If you have any questions or comments from today’s show, please email us at [email protected]. Please keep in mind that the information in this show is provided for informational purposes only and does not constitute medical or legal advice. We hope that you will visit APSF.org for detailed information and check out the show notes for links to all the topics we discussed today.

Until next time, stay vigilant so that no one shall be harmed by anesthesia care.

© 2025, The Anesthesia Patient Safety Foundation