[8 MIN READ]

Unprecedented maternal mortality and morbidity rates nationwide have pushed healthcare providers and obstetric experts to closely examine all areas of perinatal and obstetric health. Specifically, the postpartum period is a time of heightened patient vulnerability and is fraught with maternal risk. Sixty-one percent of pregnancy-related deaths occur in the postpartum period, making it potentially more hazardous to a woman’s health than the actual pregnancy itself.

Increasing awareness of the postpartum period as one of substantial risk has made it clear that postpartum discharge is in desperate need of our attention. Celebrities such as Adele, Chrissy Teigen and Serena Williams have brought national attention to this area of healthcare by sharing their personal health struggles surrounding childbirth and the postpartum period on social media.

The national organizations ACOG and AWHONN have worked to establish recognition of the importance of the postpartum period and the postpartum discharge process with a focus on standardization. Standardization of obstetrical processes has historically improved outcomes and provider workflow. By applying it to the postpartum discharge process, we can be strategic in teaching postpartum patients the most critical warning signs and symptoms of health deterioration as well as where and when to seek help.

Postpartum Challenges

In 1970, the C-Section rate in the U.S. was five percent. Today, one in three patients is delivering via C-section. With the increased number of C-sections comes a greater risk of surgical complications. A study analyzing births from 1998 to 2008 reported a 75% increase in post-birth complications and a 183% increase in women receiving blood transfusions post-delivery. Compared to 50 years ago, patients are sicker with multiple comorbidities, and they are older and heavier. We also have higher oxytocin rates, higher cervical ripening rates, and higher epidural rates. All these women become at-risk patients who are vulnerable to a multitude of health issues in the postpartum period.

Since most U.S. women deliver in a hospital, initial postpartum oversight for these patients is delivered by the inpatient healthcare team. However, as they transition to home, those responsible for postpartum health oversight are family, friends and the patient herself. There are four things that women need to master for successful postpartum transition and fourth trimester adaptation: social support, self-efficacy, positive coping, and realistic expectations. Successful transition requires a collaborative approach and the support of a multidisciplinary team that includes the physician, healthcare team, family and patient.

Postpartum challenges of sleep deprivation, pain, fatigue, stress or mental health complexities are barriers to adaptation. Poor maternal adaptation leads to a decrease in breastfeeding, a decrease in childhood immunizations, poor behavior of children, and the inability of the mom to care for other children. All these difficulties may prove to be obstacles to the patient’s understanding and grasp of important concepts at the time of discharge. Her lack of focus on her own health during this period poses a huge risk.

Optimizing Postpartum Discharge

ACOG’s 2018 paper “Optimizing Postpartum Care” emphasizes comprehensive woman-centered care planning and the idea of on-going care addressing physical, social and psychological well-being. AWHONN has promoted that in addition to the routine and customary discharge requirements, discharge should also include standardized discharge teaching. Every patient and family member needs to be educated on the serious warning signs and symptoms of health deterioration as well as potential post-delivery complications. Additionally, ACOG highlights the importance of patient access to support resources at the time of discharge, including help with breastfeeding, and the need to be sure a return visit is scheduled for the infant three to five days post-discharge per AAP recommendation. Timing of the postpartum visit should be individualized, but all women should have contact with their ob-gyn care provider within 1-3 weeks postpartum, followed by a comprehensive visit no later than 12 weeks postpartum. This appointment is critical to review current pregnancy adverse outcomes as well as future pregnancy implications.

Barriers to Teaching

Poor staffing, limited time, and lack of patient interest are all significant barriers to quality postpartum discharge teaching and retention. Additionally, laboring patients take top unit priority, but leading causes of maternal morbidity and mortality offer a new, important perspective on the postpartum period. Due to the heightened risk in this period, discharge teaching should not be viewed as a mundane task; rather, it should be embraced as an opportunity to provide life-saving information to our patients.

Anticipatory Teaching

Many women report not receiving adequate information at the time of discharge. Additionally, 40% of patients do not return for a postpartum visit. Important life-saving facts need introduction prior to the postpartum period. Anticipation of maternal complexities that occur in the postpartum period highlight the importance of sharing this crucial information with women throughout the continuum of pregnancy and into the postpartum period. It is recommended to integrate postpartum discharge teaching into the prenatal plan of care to ensure the opportunity for repetition and retention of important information.

It is also critical to identify patient challenges early on and prepare for them in advance. If your patient is high-risk or might have transportation issues getting to the postpartum visits, you should plan ahead to ensure they have access to healthcare post-delivery. Make sure they understand how crucial follow-up care is to their health.

Best Practices for Postpartum Discharge Teaching

1) Consider a Discharge RN.

Some hospitals have discharge RNs or discharge teams of nurses. This ensures quality and consistency of discharge teaching. These nurses can also make postpartum phone calls 24 to 48 hours post-discharge to home. Discharge RNs can also encourage patients to submit questions via email or a patient portal, which will then be addressed in a timely manner by this dedicated team.

2) Use standardized teaching and checklists.

Convene a group of champions within your organization and determine what your standards will be. Create a checklist incorporating AWHONN and ACOG recommendations for postpartum discharge. Make sure that all important points will be addressed with every patient. Ensure your messaging is consistent, especially when using descriptor terminology for what constitutes abnormal bleeding or clots.

3) Evaluate the risk of your patient.

All patient and family situations are unique and require our respect and consideration. Identify high-risk patients prenatally with the anticipation that you will need to adapt your teaching style to their unique needs and situations. Work as a team with the clinic coordinators to know which patients will require additional time at discharge due to comorbidities, limited resources, language barriers, lack of transportation, limited education or difficulty with comprehension, domestic issues, family complexities or any behavioral identifications. These issues not only impact maternal transition and outcome, but also infant care and future pregnancies. High-risk patients will demand more of your time and patience, so prepare in advance to ensure appropriate time is allotted and teaching is adapted.

4) Consider your target audience.

Evaluate your patient’s pre-existing knowledge base so that you can build upon it. Use age-appropriate principles of teaching and learning. Consider language and cultural implications. You may want to use a hospital interpreter to assist with teaching to ensure a clear message. Approach topics like literacy with sensitivity. Adjust the pace of your teaching as necessary. Be repetitive or use pictures to help facilitate comprehension. Most childbirth education materials are written at a fifth- to sixth-grade level, but you may need to adjust as necessary for each patient.

5) Incorporate co-parents, family and social network.

Both ACOG and The Joint Commission recommend active family engagement in teaching. Incorporating the father or co-parent is important because they might see or remember things from teaching the mother forgets. Father engagement has been proven to mitigate infant mortality rate, and perhaps it can impact maternal outcomes as well.

6) Educate normal versus abnormal.

I have frequently witnessed well-educated patients mistake abnormal symptoms for normal symptoms post-childbirth. It is crucial that every patient understand the difference between expected norms and what is “not normal.” What may seem so blatantly obvious to you as the teacher can be completely misunderstood by the learner. Simplifying and reinforcing information with repetition is imperative to comprehension. Ensure your patients comprehend what you are teaching by using the “Ask Me 3” and “teach-back” methods.

7) Allow time for patient and family questions.

Not only should you validate your teaching with either the “Ask Me 3” or the “teach-back” method, but make sure to leave time for mothers (and family members) to ask questions.

8) Empower mothers to speak up on their own behalf.

Women tend to be better caregivers for others than themselves. They don’t always allow themselves the time or permission to take care of their own needs because they tend to be busy putting others first. We can empower patients to speak up, voice their concerns, and seek appropriate care. Encourage them to listen to their own bodies and report when something isn’t right. Sometimes something just as vague as something “doesn’t feel right” needs to be addressed.

9) Emphasize follow-up.

Ensure that women understand that the postpartum period is a continuation of pregnancy in which their bodies are in a state of healing. The body doesn’t immediately return to pre-pregnancy baseline physiology; thus, postpartum visits are just as important as they were prenatally. Women also need to understand that the postpartum period remains one of high risk. Provide documentation of all follow-up appointments, including date and time, follow-up provider and appointment location. Accurate phone numbers, addresses and directions are essential to continuity.

10) Disclosure of recent pregnancy when seeking care.

It is a critical risk and safety issue for a woman to disclose a recent pregnancy to all healthcare providers. Many pregnancy-related complications can mimic other disease processes. To ensure accurate and timely diagnosis, pregnancy within the past year needs to be known. Patient scenarios of postpartum women showing up in the ED without disclosure of recent pregnancy have ultimately led to tragic outcomes that could have been avoided had a recent pregnancy been revealed.

Reducing Communication Failures

Communication failure between health providers is a root cause of maternal morbidity, mortality and sentinel events. Communication failure between the healthcare team and patient can also cause harm. Failure to educate our patients can lead to unintended consequences that impact maternal and infant outcomes. Let’s prioritize postpartum discharge, recognizing that it can indeed be life-saving.

Do you have other best practices you’ve incorporated into your postpartum discharge time-out teaching? Share them with us and we can add them to this post.

You might also be interested in:

• 6 Common Errors in Fetal Heart Monitoring (FHM)
• Nurses: Standardize Patient Education with These Postpartum Warning Signs
• Framework for an Obstetrics Training Program
• 5 Strategies to Improve Maternal Mortality Rates
• Measuring Clinical Performance Improvement in Obstetrics

Resources

• Agostino, M. et al. Identifying Potentially Preventable Elements in Severe Adverse Maternal Events. Dec 2016, Volume 45, #6.
• ACOG Committee Opinion OB Practice, Optimizing Postpartum Care, May 2018, #736.
• AWHONN Patient Discharge Education, Post Birth Warning Signs and Symptoms, June 2016.
• AWHONN Patient Discharge Education, Save your Life, June 2016.
• Bingham, D. &Cornell, A. Expert Panel to Track Nurses’ Effect on Maternal Morbidity & Mortality. Dec 2016, Volume 45, #6.
• Brennan, R. & Keohane, C. How communication among members of the Health Care Team Affects Maternal Morbidity & Mortality. JOGNN, Dec 2016, Volume 45, #6.
• Callaghan WM, Creanga AA, Kuklinar EV (2012) Severe maternal morbidity among delivery and postpartum hospitalizations in the US. OBGYN, 120(5) 1029-1036. Heep://dx.doi.org/10.1097/APG.)b)13e31826d60c5
• Creanga AA, Berg CJ, Syverson C et al. (2015) Pregnancy-related mortality in the US 2006-2010. OBGYN, 125-5-12. http://dx.doi.org/10.1097/AOG.0000000000000564
• D’Oria, R. et al. Strategies to Reduce Maternal Mortality During the First Year After Birth. Dec 2016, Volume 45, #6.
• Fahey, J. & Shenassa, E. Understanding and meeting the needs of women in the postpartum period: The perinatal maternal health promotion model. Journal of Midwifery & Women’s Health. Nov/Dec 2013, Vol 58 #6.
• Kassebaum, N. Global, Regional, and National levels and causes of Maternal Mortality during 1990-2013. The Lancet. Volume 384, Sept 2014.
• Kleppel, L. et al. National Initiatives to Improve Systems for Postpartum Care. Springer Science & Business Media. New York, August 16, 2016.
• Logsdon, Cynthia. Nursing Strategies to address Maternal Morbidity and Mortality. Dec 2016, Volume 45, #6.
• Suplee, et al. Improving postpartum education about warning signs or Maternal Morbidity and Mortality. Nursing for Women’s Health. Jan 2017, Volume 20, issue