1. Wisner, Kirsten MS, RNC-OB, CNS, C-EFM

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Hypertensive disorders of pregnancy are a leading contributor to maternal morbidity and mortality. Prompt and appropriate treatment can greatly reduce complications arising from these disorders (American College of Obstetricians and Gynecologists [ACOG], 2013). The following is a summary of the safety bundle released recently by the National Partnership for Maternal Safety on severe hypertension during pregnancy and postpartum (Bernstein et al., 2017). It is organized in four action domains: readiness, recognition and prevention, response, and reporting and systems learning.




* Create standards delineating early warning signs, diagnosis, monitoring, and treatment for women presenting with severe preeclampsia or eclampsia. These should include standardized order sets and algorithms. Align criteria with the ACOG Hypertension in Pregnancy Report (ACOG, 2013).


* Provide education about protocols via frequent interdisciplinary team-based simulation drills followed by debriefs to reinforce systems learning.


* Ensure timely assessment and triage of women presenting with hypertension during pregnancy or postpartum in all potential care areas, such as outpatient and emergency departments.


* Enable rapid, easy access to standardized, premixed medications commonly used to treat severe hypertension or eclampsia, as well as to reverse magnesium toxicity. Emergency boxes can be an ideal way to organize such medications along with necessary infusion supplies and brief instructions for dosing and administration.


* Develop an escalation plan that includes clearly defined triggers and processes for consultation and maternal transport.


Recognition and Prevention


* Implement standardized protocols for accurate blood pressure and urine protein measurement and assessment for women during pregnancy and postpartum along with staff education and skills monitoring.


* Implement systems for early detection of deterioration by creating a standard response to maternal early warning signs that includes prompt bedside evaluation.


* Make patient education resources available in all areas caring for pregnant and postpartum women about relevant signs and symptoms and appropriate follow-up.




* Develop standardized protocols for the management and treatment of severe hypertension, preeclampsia, or eclampsia in all areas caring for pregnant and postpartum women. Include checklists and escalation policies as well as defining blood pressure criteria, response time, seizure prophylaxis, onset and duration of magnesium sulfate therapy, and guidelines for managing magnesium toxicity. Clear strategies for educating women about care and follow-up postpartum should also be included in protocol development along with a verification process to ensure that women are seen within 1 to 2 weeks postpartum.


* For severe cases necessitating ICU admission, consider support needs for the woman, her family, and staff.


Reporting and Systems Learning


* Establish structured team huddles for high-risk patients and for postevent debriefs to identify areas of strength and opportunity.


* Implement a process for multidisciplinary review of all severe cases requiring an ICU admission to identify and respond to process and system issues.


* Routinely monitor and respond to structure, process, and outcome measures.


This and many other excellent safety bundles along with numerous resources to support their implementation are available at:




American College of Obstetricians and Gynecologists Task Force on Hypertension in Pregnancy. (2013). Hypertension in pregnancy. Retrieved from[Context Link]


Bernstein P. S., Martin J. N. Jr., Barton J. R., Shields L. E., Druzin M. L., Scavone B. M., ..., Menard M. K. (2017). National Partnership for Maternal Safety: Consensus bundle on severe hypertension during pregnancy and the postpartum period. Obstetrics and Gynecology, 130(2), 347-357. doi:10.1097/AOG.0000000000002115 [Context Link]