Transcript Olivia`s Journey - Health Roundtable

Reflective
Presentation
Olivia’s Journey
Health Roundtable – Maternity Health
Improvement Group 2011
Victoria
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Metropolitan Region
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BMI Spread Over 8 Months
BMI >30 and Birth type
Sum of BabyNum
Data from 1/7/2010 to 2/3/2011
BMI
BirthType
30
31
32
33
Elective Caesar with Forceps
elective caesarean - labour
Elective caesarean - no labour
2
1
2
12
11
10
8
1
1
Emergency Caesar with Forceps
Emergency caesarean - labour
35
1
1
10
11
7
Emergency caesarean - no labour
2
6
1
3
Forceps
1
1
Normal
54
33
4
1
7
Total with BMI > 30
38
5
39
40
41
42
43
44
45
46
47
48
1
2
1
49
50
51
52
53
55
56
58
60
62
63 Grand Total
1
4
9
7
3
4
5
2
4
4
6
7
4
5
6
6
3
3
2
4
1
2
3
3
1
1
14
15
9
9
1
2
1
36
28
22
2
3
2
1
1
1
1
1
91
9
3
3
38
27
23
4
1
1
27
3
3
3
1
12
10
1
1
4
5
1
3
1
1
1
1
1
1
1
10
13
63
67
50
45
43
104
29
1
18
4
3
3
1
1
2
1
318
1
16
1
88
Total Births for period audited
37
1
Vaginal breech (assisted)
Grand Total
36
1
13
Vacuum extraction
34
1
23
22
22
17
17
9
6
8
4
1
8
2
1
1
4
1
1
1
1
1
1
593
2886
593
20%
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Background
•Sunshine Hospital is heading towards 4,500
births per year a 26% increase in 18 Months
•We have no dedicated high BMI program
•Use a case presentation to reflect on how we
could improve the client journey at Western
Health
•Share our deficiencies as a learning
opportunity
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Case Study
Olivia booked into Sunshine Hospital for
confinement of her first baby.
The following is a reflection of her journey and
the challenges experienced by both Olivia and
her Carers.
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Patient History
• 28 year old
• VSD repaired 09/12
• Obesity since early childhood (8yrs +)
• Morbid obesity weight 177kg, height 167cms, BMI 70
• Depression
• Smoker – ceased four years ago
• Vitamin D deficient
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Patient History
• Past Pregnancy/Obstetric
–
–
–
–
G1 P0
Implanon removed February 2009
Irregular menstrual cycle
EDD calculated by 1st trimester USS
• Medications
–
–
–
Elevit daily
Ostelin daily
Paracetamol PRN
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Patient History
• Surgical
–
Gastric Lap Banding 2003
• Family History
–
–
–
Mental illness – Mother schizophrenic
Diabetes
High blood pressure
• Social
–
–
Lives at home with Husband
Fulltime Carer for Mother – terminal cancer
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Patient History
• Hb 142
• Ferritin 98
• B12 and Folate NAD
• HepB, HepC and HIV negative
• GTT at 16 and 27 weeks NAD
• Varicella negative
• Thalassaemia NAD
• Syphilis NAD
• Urine MCS negative
• 1st trimester screening NAD
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First Antenatal Presentaion
• Attended at 13 weeks gestation with CMC
• Discussed high BMI and “difficulty with diet due to lap band” –
appointment with Bariatric Specialist three weeks time
• Referral made to Dietician, Medical OBS and Anaesthetics Department
• GTT order 16/40
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Second Antenatal Appointment
• Presentation at 16+6 weeks
• Reviewed by Bariatric Specialist – fluid removed from lap band
• Medical review attended – ECHO NAD
• Dietician review – diet plan
• Routine Morphology USS requested 20/40
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Ultrasound Limitations
• USS repeated twice due to incomplete morphology secondary to body
habitus
• Growth scans booked for 32 and 36 weeks NAD
• USS ordered again at 38 weeks due to midwives unable to auscultate
FHH
• O&G Registrar recommendation for Paed present due to family
history of congenital heart defects and limited morphology
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30 Weeks Pregnant
• Declined Social Work referral
• Declined CBE classes
• Numerous appointments DNA (documented drove to Hospital but
unable to park within close walking distance)
• Support by Palliative Care Services – Mother died
• Anaesthetic Team and O&G Medical Team review
• Normotensive
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Third Trimester Management
• Carpal Tunnel Syndrome symptoms
• Ankle Oedema
• 38 weeks HT 180/90 – headache, protein urea 2+, oedema, bloods
NAD. Commenced Labetolol
• Presented 39 weeks with decreased FM
• Presented PIH assessment – weekend Birthing Suite midwives unable
to detect FHH – USS attended
• Planned twice weekly CTG in PDSU
• Admitted to Maternity Ward 40 weeks PIH
• Non ambulant >38weeks - wheelchair
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41+5 IOL
• Admitted to Birthing Suite for IOL due to PIH and post maturity
• Prostin 2mg x 2 doses
• Documented difficulty with “monitoring fetal heart”
• Patient non ambulant
• IVC – FBE, E&E, SUA, LFT’s GS
• O&G Team aware of IOL
• Anaesthetic Team aware of IOL
• ARM and Syntocinon commenced following day by O&G Registrar
• Midwives unable to accurately assess contractions
• Patient requesting “early epidural”
• GBS positive HVS @ 36 weeks – antibiotic coverage intrapartum
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Intrapartum
• O&G plan “to deliver during the day”
• Epidural inserted, but catheter accidentally dislodged by patient
• Complaining of palmitations and noted IRR pulse – ECG NAD
• Discussed at “O&G handover 0800”
• Normotensive intraprtum
• Labour duration 7:41mins
• Failure to progress
• Emergency CS – general anaesthetic – Baby born 1641hrs
• Arterial line inserted in OT prior to surgery
• Four extra staff in OT to hold abdominal apron
• Baby 3780g – Apgars 6 @ 1min and 8 @ 5min
• Estimated blood loss 1200ml PPH
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Postpartum Care Plan
• Returned to Birthing Suite for 24/24 postpartum for 1:1 midwifery
care
• Clexane 40mg after 6hrs and then daily until discharge
• Routine pain management – Morphine PCA
• Pain Management Team
• TED Stockings too small
• IV antibiotics
• Physiotherapy referral
• Sleeping in chair
• Early mobilisation encouraged but “reluctant”
• Social work referral due to grief
• Discussed daily at O&G handover 0800hrs
• Daily O&G Registrar and Resident RV
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Postpartum Care
• Day 5
–
–
–
Discharged home – Clexane ceased
Domiciliary Care
Breastfeeding
• Day 10
–
–
Complaining of backache – non ambulant, wheelchair dependent
Abdominal wound moist – alternate sutures removed with remaining
for removal day 14
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Postpartum Care
• Day 16
–
–
–
–
–
–
–
–
–
–
Presented A&E – Hx bilateral aching calves and shoulder tip pain
Diagnosed Bilateral Pulmonary Embolus and Pleural Effusion
Respiratory Consultancy referral
Diagnosed Abdominal Wound Infection
Blood cultures under USS guidance by Anaesthetist due to numerous failed
attempts
Ceased breastfeeding
Transferred to Respiratory Unit – Footscray
Commenced Clexande 120mg
Returned to Recovery Room for removal of remaining abdominal
sutures
Commenced BD wound dressings
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Postpartum Care
• Day 16
–
–
–
Commenced oral antibiotics
Management plan ICU Liaison Nurse
Sleeping in chair
• Day 17
–
–
–
Physiotherapy referral
Complaining of constant backache, but unaided ambulation
Documented weight 200kg
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Postpartum Care
• Day 18
–
–
Occupational Therapy referral
Assessment, but nil follow up
• Day 19
–
Discharge HITH
• Day 21
–
–
Ongoing Physiotherapy referral – offered bariatric crutches to assist with
mobility in the community
Social Work referral due to grief following death of mother, but nil follow up
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Learnings
• Clinical
• Systems
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Obstetric Challenges in
the Obese Patient