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De-coding obstetric codes: a retrospective cohort study in a high-risk tertiary care centre.
Abstract Number: F3I-128
Abstract Type: Original Research
Background: The World Health Organization estimates that for every maternal death there are just over five near misses . Obstetric specific rapid response teams (RRTs) have been developed for obstetric emergencies, but there is limited literature on their role and impact. This study aimed to better understand obstetric near misses by examining obstetric codes, RRT efficiency and patient outcomes.
Methods: We conducted a retrospective chart review on obstetric codes from Jan 1, 2014 to May 31, 2018. This included: “Code 77” (C77, obstetric emergency), “Code Blue” (CB, cardiopulmonary compromise) and “Code Omega” (CO, massive transfusion). Data on maternal, obstetric and RRT characteristics, etiology, resuscitation and maternal/neonatal outcomes was collected.
Results: 147 codes were identified in 29,862 deliveries (C77 n=110; CB n=12; CO n=25). The incidence of obstetric codes was 492 per 100,000 deliveries. The incidence of maternal and neonatal mortality after codes was 0.68% and 7%, respectively. The most common code etiologies were fetal bradycardia (63%) and cord prolapse (32%) for C77 and postpartum hemorrhage and amniotic fluid embolism for both CB (23%,23%) and CO (68%,16%) (Table 1). The most common obstetric conditions associated with C77 were premature rupture of membranes (28%) and preterm labor (18%); for CB were preeclampsia (36%) and placenta previa (18%); for CO were invasive placentation (43%), placenta previa (24%) and gestational diabetes (24%). 61% of codes were called after hours. The median (IQR) time (min) for RRTs to arrive was 2 (1,3) for C77, 3.5 (2,5) for CB and 6.5 (3,11) for the first blood product to arrive for CO. The decision to delivery interval was 8 (5,15) min after C77. An obstetrics and anesthesia staff/fellow, respiratory therapist/anesthesia assistant were present at least 80% of the time. Emergency cesarean delivery (CD) was performed after most (57%) codes and general anesthesia was administered in 62% of CDs. Five patients who had CB received chest compressions and four received defibrillation. Ten women required hysterectomy after CO. Major maternal morbidity was seen in 31%. Debrief was documented in only 4% of codes.
Conclusion: We have identified high-risk patients for various obstetric codes who may benefit from closer peripartum monitoring. Adequate staffing, education and debriefing of RRTs are essential to ensure safe and timely CD and resuscitation.