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Review all maternal deaths at your institution.1 Participate in Levels of Maternal Care designation.9 Implement bundles: hemorrhage, hypertension, etc.3 Have all perinatal stafftake implicit bias training.6 Have clear severe hypertension treatment guidelines posted and treat acute severe hypertension within 30 minutes.12 Debrief after each adverse event.8 Have a massive transfusion protocol and hemorrhage kit on L+D. Participate in multidisciplinary simulations in the L+D unit and in testing areas.10 Expand community outreach for better access for Medicaid and others.11 Screen for VTE risk and treat appropriately.7 Utilize toolkits.4 Review all cases of severe maternal morbidity (ICU admissions and/or transfusions of 4 or more units of red blood cells.2 REFERENCES 1. Berg C, Danel I, Atrash H, Zane S, Bartlett L.Strategies to reduce pregnancy-related deaths:from identification and review to action. Reduction of severe maternal morbidity from hemorrhage using a state perinatal quality collaborative.

Maternal mortality is rising in the USA. The pregnancy-related maternal mortality ratio increased from 10/100,000 to 17/100,000 live births from the 1990s to 2012. A large proportion of maternal deaths are preventable. This review highlights a national approach to reduce maternal death and morbidity and discusses multiple efforts to reduce maternal morbidity, death and improve obstetric safety. These efforts include communication and collaboration between all stake holders involved in perinatal health, creation of national bundles addressing key maternal care areas such as hemorrhage management, call for all obstetric hospitals to review and analyze all cases of severe maternal morbidity, and access to contraception. Implementation of interventions based on these efforts is a national imperative to improve obstetric safety.

Background and Objectives Labetalol is frequently prescribed for the treatment of hypertension during pregnancy; however, the influence of pregnancy on labetalol pharmacokinetics is uncertain, with inconsistent findings reported by previous studies. This study examined the population pharmacokinetics of oral labetalol during and after pregnancy in women receiving labetalol for hypertension. Methods Data were collected from 57 women receiving the drug for hypertension from the 12th week of pregnancy through 12 weeks postpartum using a prospective, longitudinal design. A sparse sampling strategy guided collection of plasma samples. Samples were assayed for labetalol by high-performance liquid chromatography. Estimation of population pharmacokinetic parameters and covariate effects was performed by nonlinear mixed effects modeling using NONMEM. The final population model was validated by bootstrap analysis and visual predictive check. Simulations were performed with the final model to evaluate the appropriate body weight to guide labetalol dosing. Results Lean body weight (LBW) and gestational age, i.e. weeks of pregnancy, were identified as significantly influencing oral clearance (CL/ F ) of labetalol, with CL/ F ranging from 1.4-fold greater than postpartum values at 12 weeks’ gestational age to 1.6-fold greater at 40 weeks. Doses adjusted for LBW provide more consistent drug exposure than doses adjusted for total body weight. The apparent volumes of distribution for the central compartment and at steady-state were 1.9-fold higher during pregnancy. Conclusions Gestational age and LBW impact the pharmacokinetics of labetalol during pregnancy and have clinical implications for adjusting labetalol doses in these women.

When infants are at risk of being born at a very premature gestation (22-25 weeks), parents face important life-support decisions because of the high mortality for such infants. Concurrently, providers are challenged with providing parents a supportive environment within which to make these decisions. Practice guidelines for medical care of these infants and the principles of perinatal palliative care for families can be resources for providers, but there is limited research to bridge these medical and humanistic approaches to infant and family care. The purpose of this article is to describe how parents at risk of delivering their infant prior to 26 weeks gestation interpreted the quality of their interpersonal interactions with healthcare providers. Directed content analysis was employed to perform secondary analysis of data from 54 parents (40 mothers and 14 fathers) from the previously coded theme \"Quality of Interactions.\" These categorized data described parents' encounters, expectations, and experiences of interactions that occurred prenatally with care providers. For this analysis, Swanson's theory of caring was selected to guide analysis and to delineate parents' descriptions of caring and uncaring interactions. Parents' expectations for caring included: (a) respecting parents and believing in their capacity to make the best decisions for their family (maintaining belief); (b) understanding parents' experiences and their continued need to protect their infant (knowing); (c) physically and emotionally engaging with the parents (being with); (d) providing unbiased information describing all possibilities (enabling); and (e) helping parents navigate the system and creating a therapeutic environment for them in which to make decisions (doing for). Understanding parents' prenatal caring expectations through Swanson's theory gives deeper insights, aligning their expectations with the palliative care movement.