Score MAMÁ y claves obstétricas Protocol 2017 PDF

# Score MAMÁ y claves obstétricas, Protocolo 2017 ## Ministerio de Salud Pública del Ecuador ### Presentación - Ministerio de Salud Pública: Autoridad Sanitaria Nacional - Applied a strategy called "Alarma Materna" to reduce maternal mortality - Implemented protocol titled "Score MAMÁ y claves...

# Score MAMÁ y claves obstétricas, Protocolo 2017 ## Ministerio de Salud Pública del Ecuador ### Presentación - Ministerio de Salud Pública: Autoridad Sanitaria Nacional - Applied a strategy called "Alarma Materna" to reduce maternal mortality - Implemented protocol titled "Score MAMÁ y claves obstétricas" to support determining obstetric risk and managing emergencies - Contains guidelines to aid in the identification of obstetric risk using a system composed of: - Red, blue, and yellow codes. - Quick response system to standardize protocols. - Used to standardize guidelines for the management of pregnant and postpartum women. ### 1. Introduction - Strategy "Alarma Materna" is based on successful experiences in other countries. - Includes 3 activities: - Timely detection, - Standardized care, - Improved management of pregnant and postpartum women. - Aims to: - Identify women with obstetric risk. - Improve timely management to prevent death. - Improve immediate response. - Pregnancy and labor are generally considered normal physiological processes. - Assess vital signs to evaluate potential risks. - Early identification and management of physiological deterioration are essential. - Early recognition of maternal deterioration is a challenge for healthcare professionals. - Obstetric complications are uncommon but potentially severe. - Can lead to death of the mother or baby during pregnancy, labor, or postpartum. - Associated with maternal conditions. - Establishes a framework for improved quality in the diagnosis and management of obstetric emergencies. ### 2. Background and Justification - 830 women died every day worldwide due to pregnancy or labor-related causes. - Most are preventable. - In 2013, 289,000 women globally died from pregnancy or labor-related causes. - Ecuador reported 166 maternal deaths in 2014. - Maternal Mortality Ratio (RMM) decreased by 46% compared to 1990. - Includes close monitoring of delayed maternal mortality. - In 2015, 150 maternal deaths were reported. - Leading causes include: - Hemorrhages, - Sepsis, - Hypertensive disorders. - The rate of maternal mortality in 2015 was 44.58 per 100,000 live births. - Estimated that nine women suffer maternal morbidity for every maternal death. - Emphasizes the need for early detection of maternal deterioration. - Implemented the "Alarma Materna" strategy, which includes: - A system to assess early warning signs of maternal morbidity. - Obstetric codes to manage the three leading causes of maternal morbidity: - Hemorrhage, - Hypertension, - Sepsis. ### 3. General Objective - Provide healthcare professionals with guidelines to: - Identify and manage obstetric emergencies. - Prevent maternal mortality. - Based on the best available scientific evidence. ### 4. Specific Objectives - Identify potential obstetric complications by monitoring vital signs and - To establish criteria for timely diagnosis and treatment of: - Hypertensive disorders, - Obstetric hemorrhage, - Obstetric sepsis. ### 5. Scope - Applicable to all healthcare facilities in Ecuador providing care to pregnant and postpartum women ### 6. Glossary of Academic-Scientific Terms - **Uterine atony:** Inability of the uterus to contract adequately after childbirth. - **Septic shock:** A severe, systemic illness caused by bacterial infection. - **Eclampsia:** Seizures that occur in a pregnant or postpartum woman with preeclampsia. - **Postpartum hemorrhage (PPH):** Blood loss greater than 500 ml after vaginal birth or greater than 1000 ml after a cesarean birth. - **Pregnancy hypertension:** Systolic blood pressure ≥140 mmHg and/or diastolic blood pressure ≥ 90 mmHg, measured at least two times, 15 minutes apart, using the same arm. - **Severe pregnancy hypertension:** Systolic blood pressure ≥ 160 mmHg and/or diastolic blood pressure ≥ 110 mmHg, measured at least two times, 15 minutes apart, using the same arm. - **Avoidable maternal death:** A death that could have been prevented with timely intervention. - **Direct obstetric death:** Caused by complications of pregnancy, labor, or postpartum, including interventions, omissions, or incorrect management. - **Indirect obstetric death:** Caused by a pre-existing condition that was not related to a direct obstetric cause but was aggravated by the physiological effects of pregnancy, labor, or postpartum. - **Preeclampsia:** Hypertensive disorder of pregnancy without organ damage. - **Severe preeclampsia:** Hypertensive disorder of pregnancy with organ damage. - **Proteinuria:** Presence of protein in the urine. - **Score MAMÁ:** A tool to identify early warning signs of obstetric complications. - **Sepsis:** Life-threatening organ dysfunction caused by a dysregulated host response to infection. - **Vital signs:** Measurements that assess circulation, respiration, and neurological function. - **HELLP syndrome:** A complication of preeclampsia, characterized by hemolysis, elevated liver enzymes, and low platelet count. It is often considered a severe preeclampsia complication. - **Systemic Inflammatory Response Syndrome (SIRS):** A condition that can occur in the absence of an infection. It is defined by 2 or more of the following: - Body temperature > 38° C or < 36° C. - Heart rate > 90 BPM. - Respiratory rate > 20 BPM or a partial pressure of carbon dioxide < 32 mmHg. - White blood cell count > 12,000/µL or < 4,000/µL or > 10% of immature forms. ### 7. Score MAMÁ Tool - A scoring system used to assess vital signs for the early identification of obstetric complications. - Helps to identify potential risk. - Facilitates timely decision-making. - Utilized in primary care settings - Provides a means for timely identification of obstetric pathology. - Uses six physiological indicators: - Respiratory rate, - Heart rate, - Blood pressure, - Oxygen saturation, - Temperature, - Level of consciousness. - Each indicator is assigned a score from 0 to 3, with 0 representing normal values. - Vital signs are a crucial part of the Score. - These assessments should be performed during a medical consultation. #### 7.1 Respiratory Rate - Indicator of early and sensitive deterioration in well-being. - Should be assessed for 60 seconds after heart rate evaluation. - Should be documented in the vital sign section of the patient's chart and in the Form 051 - Normal range is 12 to 20 breaths per minute. - Tachypnea is a potential sign of sepsis until ruled out. #### 7.2 Blood Pressure - Crucial for the diagnosis of obstetric complications. - Essential that healthcare personnel properly assess blood pressure. - The appropriate cuff size is essential for accurate blood pressure measurements. - General recommendation is to use a cuff size that measures the mid-arm circumference. - For those with a mid-arm circumference greater than 33 cm, use an adult large cuff. #### 7.3 Heart Rate - Best measured in the radial artery in adults. - The brachial artery is used to measure blood pressure. - The carotid and femural arteries can be palpated in cases of circulatory collapse. - Palpate using the index and middle fingers for 30 seconds and double the number if the rate is regular, or 60 seconds if it is irregular. - Pulse oximeters also provide a heart rate reading but a manual assessment is recommended for bradycardia or tachycardia. - Normal values are 60 to 100 BPM. - Any deviation from the norm may signal a critical condition requiring investigation. #### 7.4 Oxygen Saturation - Reflects the amount of arterial hemoglobin saturated with oxygen. - Known as SpO2. - Routine monitoring is recommended for all pregnant women. - Closer monitoring is recommended for: - Abnormal respiratory rates, - Any medical or obstetric conditions requiring continuous oxygen monitoring. - Accuracy depends on adequate blood flow to the fingertip. - In critical cases, the results might be inaccurate. - Normal levels are 94% to 100%. - Artificial nails and nail polish can adversely affect the results. #### 7.5 Body Temperature - Should be taken at the appropriate site: - Oral, - Axillary , - Tympanic - Use a reliable thermometer. - Record axillary temperature as a general guideline. - Normal body temperature is 36° C to 37.2° C in the morning and 37.7° C in the afternoon. - Score MAMÁ acceptable values are 35.6° C to 37.2° C. - A drop or increase in temperature or fluctuations in fever may indicate sepsis. - Hypothermia should be addressed and is a potential sign of infection. - Fever may not be apparent if antipyretics have been administered. #### 7.6 Level of Consciousness - Assesses the patient's level of alertness. - Evaluate based on the following parameters - Alert: Oriented to time, space, and person - Responsive to verbal stimuli. - Responsive to painful stimuli. - No response. - Any alteration in level of consciousness should be considered significant and warrant immediate action. #### 7.7 Proteinuria - The presence of protein in the urine. - Of significance when associated with hypertension since this could indicate preeclampsia-eclampsia. - A positive result may also be associated with normal physiological conditions. - It is considered a part of the Score MAMÁ but it is not a full diagnostic tool. - It can serve as an alert for further assessment. ### 8. Score MAMÁ Registration - Required for all pregnant and postpartum women during each visit. - Should be recorded in the following forms: - SNS-MSP/HCU-form.005/2008 (follow-up and prescriptions) - SNS-MSP/HCU-form.006/2008 (summary) - SNS-MSP/HCU-form.008/2008 (emergency) - MSP/HCU-form.051/2008 (maternal-fetal health history) - SNS-MSP/HCU-form.053/2008 (referral/counter referral) - Each vital sign is assigned a score of 0 to 3. - Add up the total points. - Action recommended based on the score. ### 9. Obstetric Codes - A system of roles and functions to facilitate effective communication and coordinated teamwork. - Also known as Rapid Response Systems (SRR). - Used to prevent maternal death with a coordinated response. - Recommendations from the American College of Obstetricians and Gynecologists (ACOG) for the implementation of systems for early warning in obstetrics include: - Implementation of early warning systems. - Developing protocols and checklists. - Providing emergency kits for obstetrics. - Using strategies for effective communication during crises. - Conducting practice drills. - The effectiveness of the protocol relies on regular drills. - The objective of the obstetric codes (or SRRs) is to improve the quality of care during obstetric emergencies. - It involves implementing measures to: - Improve the coordinated actions of various professionals. - Standardize procedures. - Provide continuous training based on simulations and practice drills to improve their response to obstetric emergencies. - Selected 3 codes based on the main causes of maternal death in Ecuador: - **Red Code:** - Management of obstetric hemorrhage. - **Blue Code:** - Management of severe hypertensive disorders during pregnancy. - **Yellow Code:** - Management of sepsis or septic shock during pregnancy. #### 9.1 Activation of the Code - The first healthcare professional to come into contact with a patient experiencing an obstetric emergency initiates the code activation. - May occur in: - Emergency room, - Hallways, - Operating room, - Labor and delivery room, - Postpartum recovery room, - Hospital ward, - Other services. - It's essential to establish a mechanism for prompt and efficient code activation. - A loud speaker alarm or a siren is recommended. - The code activation team is determined based on the availability of staff at the healthcare facility and its level of complexity. - Each team member has assigned roles and specific tasks. - At a minimum, 2 healthcare professionals are required, but the ideal number is 4: - **Coordinator:** The leader responsible for coordinating the team. They are typically located at the base of the patient's pelvis (uterus). - **Assistant 1:** The healthcare provider assigned to the patient's head. **Assistant 2:** The healthcare provider positioned on the patient's side. - **Circulator:** Responsible for tasks that don't require direct patient contact. #### 9.2 Red Code: Hemorrhage Management - Management of obstetric hemorrhages in primary, secondary, and tertiary healthcare settings. - Team Organization: - **Coordinator:** - Leader responsible for directing the team. - Located at the base of the patient's pelvis (uterus). - Responsibilities include: - Directing the team. - Continuously monitoring the functions of the assistants and circulator. - Determining the course of action based on the patient's clinical progression. - Assessing the patient's shock level based on vital signs and Score MAMÁ. - Identifying the cause of the hemorrhage. - Initiating treatment. -Making the decision to transfer or manage the patient based on the facility's capacity and resources. - Ordering fluids, blood products, and medications. - Catheterizing the bladder after antisepsis. - Providing information to the family and other companions via the circulator. - Evaluating responses to the treatment. - **Assistant 1:** - Assigned to the patient's head. - Responsibilities include: - Providing explanations about procedures to the patient. - Reassuring the patient. - Assessing the patient's vital signs. - Administering supplemental oxygen. - Monitoring and documenting the patient's urine output. - Re-evaluating the patient's status after fluid boluses. - Assisting the coordinator with procedures. - Keeping the patient warm. - Checking for uterine displacement to the left if the patient is more than 20 weeks pregnant. - **Assistant 2:** - Located on the patient's side. - Responsibilities include: - Opening the Red Code kit. - Establishing two intravenous lines, one in each arm, (ideally, using the left arm for medication and the right arm for fluids.) -Collecting blood in red, lavender, and light blue tubes when available. - Administering fluids and blood products as prescribed. - Assisting the coordinator with procedures. - Performing a coagulation test at the bedside. - **Circulator:** - The healthcare professional who does not need to be directly involved with hands-on care in the room. - Responsibilities include: - Activating laboratory and blood transfusion services. - Labeling blood samples. - Communicating orders for laboratory testing. - Ensuring samples are delivered to the lab. - Calling for additional staff. - Assisting the coordinator with procedures. - Providing information to the family. - Activating the Referral Network if the facility lacks the resources to manage the patient's condition. - Filing a referral form (Form 053) for transfer. ### Protocol for the Red Code **General Actions:** All actions should be performed simultaneously by the code team. **Steps 1-3:** 1. **Identify the bleeding patient.** It includes women with hemorrhage with or without signs of shock. 2. **Use the Basket Scale to assess the level of shock.** The scale is used to estimate blood loss since it's often underestimated by healthcare professionals. 3. **Activate the Red Code and Assemble Your Team.** **Additional Actions:** - **Contact and activate the transfusion services and laboratory (lab) based on the level of care:** - Type C facilities: laboratory and transfusion services - Type C facilities: operating room and obstetrics unit - Any facility: Intensive care unit. - **Transport:** Ambulance - **Assessment:** - Conduct a comprehensive physical assessment including vital signs and level of consciousness. - Apply an antishock garment if available. **Additional Actions to Perform** - **Maintain an open airway and provide supplemental oxygen** to achieve a Spo2 of 90% or higher. - **Establish two intravenous lines**, one in each arm (ideally, left arm for medications and right arm for fluids). - Initiate rapid fluid resuscitation with a 3:1 crystalloid solution. - Administer boluses as per the patient's clinical progression. - Aim for systolic blood pressure greater than 90 mm Hg. - **In severe shock:** - Transfuse two units of red blood cells after cross-matching. - If cross-matching is not available, transfuse two units of Rh-negative blood. - **Catheterize the bladder** and drain urine to a collection bag. - **Maintain a warm environment.** - **Activate the RED to transfer the patient to a more complex facility** if necessary. - **Perform the following laboratory tests:** - Complete blood count (CBC) - Cross-matching - Coagulation studies (PT, INR, and PTT) - Fibrinogen level - Kidney and liver function tests - Electrolytes - Arterial blood gas analysis - **Perform a bedside coagulation test (tube marked red).** **Actions Based on the Cause of Hemorrhage** - **Atony, Uterine Trauma or Uterine Inversion** **1. Atony:** - Perform uterine massage or bimanual compression. - Administer uterotonics (if available) as indicated: - Intramuscular or intravenous oxytocin (10 U/mL IM or 5 U IV). - Continue with 20 to 40 U in 1000 mL of crystalloid solution intravenously at 250 mL/h. - Sublingual or rectal misoprostol 800 ug. - Intravenous methylergonovine or ergonovine (if preeclampsia is not present) 0.2 mg IM. Repeat every 2 to 4 hours up to 5 doses (1 mg) within a 24-hour period _Note: At the first level of care, only oxytocin and misoprostol are typically available. - If hemorrhage persists, place a uterine balloon tamponade. (See Appendix 7) **2. Trauma:** - Perform a visual inspection. - Apply pressure to the area. - Repair any tears or lacerations. - Transfer the patient if necessary. **3. Inversion:** - Avoid administering uterotonics. - Do not attempt to remove the placenta. - Transfer the patient to a higher-level facility for definitive treatment. **4. Coagulopathy:** - Transfer the patient for definitive treatment. - Administer tranexamic acid 1 g intravenously. - If it's been 6 hours since the last dose, administer it every 6 hours. - Consider administering tranexamic acid if: - Postpartum hemorrhage (PPH) is secondary to traumatic birth. - Clinical signs of an abnormal clotting cascade. - HPP that is not improving after initial uterotonic treatment. **5. Placental Retention:** - Transfer the patient for definitive treatment. **6. Cardiopulmonary Arrest** - Transfer the patient for definitive treatment. **Additional Information:** - The quantification of blood loss remains a challenge (often visually estimated.) - It's essential to improve estimations of blood loss. - Valid tools to help estimate blood loss include pictograms, which can be implemented in healthcare settings. - Pictograms are a visual guide for estimating blood loss in obstetric hemorrhages. (See Figure 2).