Show
[9 MIN READ] Standardization is known for reducing variation and increasing consistency; it continues to be a recognized safeguard to decreasing liability and improving outcomes. High-quality postpartum care includes implementation of both standardized discharge processes and teaching that can improve maternal outcomes. AWHONN promotes postpartum discharge standardization and encourages that specific components of postpartum discharge teaching align with leading causes of maternal morbidity and mortality. While we previously outlined best practices in postpartum discharge teaching strategies, here we will discuss specific standardized teaching content that needs to be communicated to postpartum patients and their families at the time of discharge or sooner. Educating patients and their families to recognize important warning signs and symptoms and clearly understand normal healing versus abnormal symptomatology is strategic in reducing maternal morbidity and mortality. When to Seek CareIn 2012, Dr. Steven Clarke and Dr. Gary Hankins wrote a commentary for ACOG called “Preventing Maternal Death: Ten Clinical Diamonds.” It's an excellent read. They've identified specific recurring errors in a disproportionate share of maternal deaths. The errors are primarily related to pulmonary embolism, severe preeclampsia, cardiac disease and postpartum hemorrhage. The authors stated they were alarmed to see that a small number of errors continue to contribute to a large percentage of avoidable maternal deaths. Patients need to understand what is normal and what is abnormal for the postpartum period. Unfortunately, I have witnessed and cared for highly educated women who have experienced signs and symptoms of deteriorating health but didn’t initially seek care. A typical comment is, “I thought this was normal after having a baby.” In 2016, AWHONN outlined a discharge teaching conversation starter; it’s a great foundational script to initiate the discharge conversation with a patient:
In its POST-BIRTH Warning Signs Toolkit, AWHONN outlines the mnemonic POST BIRTH to help providers and patients remember the important warning signs and symptoms:
If patients have any of these signs/symptoms, they should seek immediate help. They should call their HCP; if not available, they should call 911 or go to the ED. AWHONN also provides a POST-BIRTH Warning Signs Discharge Education Checklist that addresses the leading causes of morbidity and mortality and the symptomology related to each. Each symptom requires review and confirmation of patient understanding using the teach-back method. It is vital that both patient and family understand where to go for help and what to do if symptoms are present. Signs & Symptoms of Health DeteriorationVenous ThromboembolismVenous thromboembolism (VTE) accounts for 9% of maternal deaths. At least half the VTE deaths studied had a strong chance of being prevented. HCPs should be familiar with the partnership for maternal safety VTE prophylaxis safety bundle.
Pulmonary EmbolismPulmonary embolism (PE), a blood clot that has traveled to the lung, is a complication of VTE; however, 30% of PE patients have no associated evidence of a VTE. It's a leading cause of preventable maternal death; however, in most cases, shortness of breath was not evaluated appropriately.
Infection
If you identify an infection, call your healthcare provider; if no response, go to the nearest ED or call 911. Cardiac DiseaseOne in three ICU admissions postpartum are related to cardiac disease. Cardiac disease accounts for 33% of all pregnancy-related deaths and has been cited as the leading cause of maternal mortality. Twenty five percent of these deaths could have been prevented if heart disease had been diagnosed sooner.
It is not normal to have chest discomfort or shortness of breath post-delivery. Your heart should not race and you should not feel faint. Any one of these signs or symptoms requires immediate attention. Call 911 or go to the ED immediately. Tell your HCP when you gave birth, then elaborate on your symptoms. PreeclampsiaPreeclampsia causes 60,000 deaths worldwide annually. There are 50 to 100 near misses for every patient death. Preeclampsia is a risk factor for stroke, seizure and future cardiovascular disease. Postpartum surveillance is required. Immediate postpartum follow-up as well as medication adherence is critical to improving outcomes; patients need to be educated on and understand the importance of continuing their medications post-delivery. Blood pressure control is the best intervention to prevent death related to stroke in women with preeclampsia. Early recognition of an elevated blood pressure is critical. Systolic pressures of >155-160 have been linked to cerebral hemorrhage and poor outcomes. Focus should be on reducing the time to treat. If a patient’s blood pressure remains elevated for 15 minutes, activate the hypertension algorithm. The key is to provide anti-hypertensive medications within a timely manner; i.e., within <60 minutes of documentation (preferably sooner). Critical blood pressure values of ≥160 systolic or ≥110 diastolic always require intervention. There should also be heightened attention to a diastolic of 105.
If you have any of these signs/symptoms, call your HCP; if no response, call 911 or go to the ED immediately. Twenty six percent of eclamptic seizures occur beyond 48 hours post-delivery. Most eclamptic seizures occur within one to seven days; however, they can occur up to six weeks post-delivery. Seventy-eight percent of these patients had no previous diagnosis of hypertension associated with pregnancy. Educate patients so they know what is normal and what is not normal, but any time a patient comes in complaining of a headache in the postpartum period, further investigation is necessary. The California Maternal Quality Care Collaborative(CMQCC) has developed preeclamptic post-discharge handouts. In addition to the symptoms noted, the CMQCC states that patients should seek immediate help if they experience blurry/double vision or see spots, or if they have gained more than three pounds in three days. Postpartum HemorrhagePostpartum hemorrhage (PPH) accounts for 12% to 13% of all maternal deaths. PPH is not a diagnosis; it is a clinical sign of an underlying cause. Making a diagnosis of PPH in a bleeding patient is like making a diagnosis of a fever in a septic patient; a definitive diagnosis ultimately needs to be made. PPH has a very short differential diagnosis; uterine atony is the leading cause. In a review of one million births, all the deaths related to postpartum hemorrhage were deemed to have been preventable with better care. Patients need to be able to communicate appropriately what they are experiencing so that an accurate and timely diagnosis with correct treatment can be achieved. Patients need to understand that they will have post-delivery bleeding, but they need to be able to differentiate normal bleeding from excessive bleeding. Use this next teaching point to explain what is normal and what is not.
If you have excess bleeding, contact your HCP; if no response, go to the ED or call 911 immediately. Suicide & Postpartum DepressionWhile suicide is not a leading cause of postpartum death, postpartum depression affects one in seven women. Use the Edinburgh Depression Scale to evaluate patients. If they score over twelve, they are at high risk and should be set up with counseling. Postpartum depression is a threat to the health of both mother and infant. Having multiple risk factors places the patient at highest risk. For example, the postpartum period itself is a risk factor for depression, but obesity is also a risk factor; the two risk factors together are a significant risk for depression. Heightened postpartum surveillance is indicated. Long-duration breastfeeding helps curb weight retention and decrease postpartum depression. HCPs need to promote breastfeeding as a way to protect women from depression.
Follow-UpOnce discharged, postpartum follow-up is an essential part of the pregnancy continuum of care. Ensure that your patients know they need to disclose their pregnancy any time they seek medical care within one-year of delivery. Confirming that patients have access to transportation helps ensure compliance with postpartum visits. SummaryWe need to work together to bring awareness to the leading causes of maternal mortality. Initiate postpartum teaching early; provide clear, concise messaging; and provide standardize teaching. While patients rely on the healthcare community to provide valuable lifesaving information, we rely on them to communicate timely and accurate information to us. Using standardized teaching tools and providing critical patient teaching points in postpartum discharge teaching empowers women to speak up and seek needed care in a timely manner. Evaluate your own organization’s postpartum discharge process. Seek to identify gaps and work collectively as a unit to make quality improvements and improve maternal outcomes. Related Content
ShareCategories: Labor & Delivery, Obstetrics, Patient Safety, Nursing What are the 4 most common causes of postpartum hemorrhage?The Four T's mnemonic can be used to identify and address the four most common causes of postpartum hemorrhage (uterine atony [Tone]; laceration, hematoma, inversion, rupture [Trauma]; retained tissue or invasive placenta [Tissue]; and coagulopathy [Thrombin]).
What are the signs of hemorrhage after birth?What are the symptoms of postpartum hemorrhage?. Uncontrolled bleeding.. Decreased blood pressure.. Increased heart rate.. Decrease in the red blood cell count (hematocrit). Swelling and pain in tissues in the vaginal and perineal area, if bleeding is due to a hematoma.. What are the risk factors for postpartum hemorrhage?The risk factors more strongly associated and the incidence of moderate postpartum hemorrhage in women with each of these factors were: retained placenta (33.3%), multiple pregnancy (20.9%), macrosomia (18.6%), episiotomy (16.2%), and need for perineal suture (15.0%).
What woman is at greatest risk for early postpartum hemorrhage?Who is at risk for postpartum hemorrhage?. Multiple-baby pregnancy.. High blood pressure disorders of pregnancy.. Having many previous births.. Prolonged labor.. Infection.. Obesity.. Use of forceps or vacuum-assisted delivery.. Being of Asian or Hispanic ethnic background.. |