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Planning for high-risk maternity patients

A new approach

Hollander, Jennifer MSN, RN; Lamonica, Kelly DNP, RNC-OB, EFM

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doi: 10.1097/01.NURSE.0000669232.30502.70
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AS MATERNAL morbidity and mortality continue to rise across the US, hospitals are being challenged to identify high-risk maternity patients sooner than ever so a thorough plan of care can be developed in advance.1 Studies have shown that quality prenatal care can improve maternal outcomes. Having a plan in place before the expectant mother comes in to deliver is the first step toward quality care.

At Penn Medicine Princeton Medical Center in Plainsboro, N.J., a multidisciplinary team of providers recently came together to launch an initiative that ensures high-risk patients are identified early and that a concrete plan is in place for their care months ahead of their delivery date.

“The Pink Paper”

In 2015, the Center for Maternal and Newborn Care at Princeton Medical Center was transformed from a special care nursery into a neonatal ICU. The nursing team expected to see an increased volume of sick newborns, but it also meant that the unit began seeing more pregnant women with preeclampsia and other comorbidities. In response, the medical center's Perinatal Committee—which includes obstetricians, midwives, neonatologists, anesthesiologists, perinatologists, nursing leadership, a perinatal nurse, and clinical nurses—created a form for scenarios in which an expectant mother is experiencing a health problem. The form provides a written account of the patient's condition before they arrive in the labor and delivery department. However, the team quickly realized that the form needed to include greater detail about the patients and their pregnancies. This would allow for the development of a more thorough plan of care in advance so the entire care team would be prepared when a high-risk patient arrived at the hospital. That led to the development of “the Pink Paper.”

The committee developed the Pink Paper using information from a healthcare training program called Team Strategies and Tools to Enhance Performance and Safety, or TeamSTEPPS. (See What is TeamSTEPPS?) Printed on pink paper to stand out, the new form was designed to provide a detailed explanation of the expectant mother's health problem along with a thorough plan of care and a checklist to identify the consults that are needed or that have been completed. Each patient's Pink Paper includes an estimated date of delivery, health history, and a plan of care, and it lists everyone involved in planning and any specific patient healthcare needs.

The form is completed during the Perinatal Committee meeting in which high-risk patients are presented and discussed. The patient may be presented by the perinatologist who sees the patient or, in some cases, an obstetrician. If necessary, the ICU intensivist and representatives from cardiology and/or pharmacy are invited to participate in the discussion.

The discussion enables the team, especially the nursing staff, to identify areas in which they may need more education to provide appropriate care for the patient. For example, the unit once cared for a woman whose newborn twins had twin reversed arterial perfusion (TRAP) sequence, a rare condition in monochorionic twin pregnancies.2 In these cases, an “acardiac twin” with no heart or a rudimentary heart is wholly dependent on its co-twin for circulatory support. The upper body and head are often poorly developed or not developed at all, and an acardiac twin cannot survive ex utero. Due to the circulatory burden of supporting the acardiac twin, the co-twin is at risk of developing heart failure and other complications that may lead to preterm birth or death without intervention.2

This was the first such case the unit had seen, so the nurses needed education on what to expect and best care practices. Once a plan is agreed upon, the perinatal nurse completes the form and the entire team signs off on it. The form is then placed on top of the prenatal patient medical record so it is immediately identifiable and available when the patient arrives. An internal tool, the form is separate from and not included in the patient's electronic medical record. After the patient delivers, the team holds a debriefing session to determine how well the plan worked.

An evolution

Once the Pink Paper was developed and reviewed by the multidisciplinary Perinatal Committee, it was rolled out at the obstetrics department meeting for all providers. Nurses were educated on the form at huddles and staff meetings, and the health system's maternal fetal medicine department was also educated. In addition, the Perinatal Committee met with representatives from outside maternal fetal medicine groups to educate them about the form and impress upon them the importance of sending their high-risk patients for review.

As the nursing team began using the Pink Paper, the committee continued to make changes to maximize its usefulness. It was important to us, however, to keep the form to one page in order to maintain a laser-like focus on the most pertinent patient information. The committee did revise the form so that it now specifies whether a hospital intensivist will be needed as part of the team managing the patient. Hospital intensivists usually do not attend Perinatal Committee meetings, but there may be circumstances in which the committee would need to discuss a potential patient and would invite the intensivist to participate in the discussion.

Process is working

The Pink Paper has helped identify and plan for high-risk patients since its introduction about 2 years ago. A few barriers were encountered during this project; for example, the obstetricians who use perinatologists from outside of the hospital's maternal fetal medicine group would forget to present high-risk cases to the Perinatal Committee from time to time. A few patients who should have been presented were not. Representatives from the Perinatal Committee spoke at the obstetrics department meeting and reminded the physicians of the need. The physicians were also told that they can provide the patient's name to the perinatal nurse and he or she will bring the Pink Paper to the meeting for discussion. The Perinatal Committee now reviews between one and four cases per month.

The Pink Paper has enabled us to involve the entire care team early on and know what the patient will need before she arrives. As a result, the nursing team is better prepared for high-risk patients as it continues to see more complex patients. For example, the team recently cared for a patient with a cardiac disorder. Because her case was reviewed and the Pink Paper was used in advance of her arrival, the nursing team prepared by having telemetry ready and alerting the ICU about her potential need for intensive care after delivery. The team also had a cardiologist on standby if needed, made sure the code cart was readily available, and conducted a debriefing after the patient delivered the baby.

Because of its demonstrated commitment to improving and maintaining the health of newborns and their mothers, Penn Medicine Princeton Health in 2018 was one of only 4 healthcare organizations in New Jersey and 54 in the nation to have earned The Joint Commission's Gold Seal of Approval for advanced certification in perinatal care.

What is TeamSTEPPS?3

Developed by the Department of Defense's Patient Safety Program in collaboration with the Agency for Healthcare Research and Quality, TeamSTEPPS is an evidence-based teamwork system that aims to improve patient safety and optimize outcomes by improving communication and teamwork skills among healthcare professionals. The system is based on five key principles: team structure, communication, leadership, situation monitoring, and mutual support. TeamSTEPPS offers healthcare systems ready-to-use materials and a training curriculum to integrate teamwork principles into a variety of settings. For more information, see


1. Centers for Disease Control and Prevention. Reproductive health: pregnancy mortality surveillance system. 2020.
2. Miller R. Diagnosis and management of twin reversed arterial perfusion (TRAP) sequence. UpToDate. 2020.
3. Agency for Healthcare Research and Quality. TeamSTEPPS.

maternal morbidity; maternity; neonatal care; perinatal care; Pink Paper; TeamSTEPPS

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