[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 Care
In 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:
“Although most women who give birth recover without any problems, any woman can have complications after the birth of a baby. Learning to recognize these post-birth warning signs and knowing what to do can save your life. I would like to go over these with you now so you will know what to look for and when to call 911 or your healthcare provider. Please share this information with your family and friends and post the ‘Save Your Life’ handout in a place where you can get to it easily, like your refrigerator or microwave.”
- Nursing for Women’s Health, Jan 2017
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:
- Pain in the chest
- Obstructed breathing
- Seizures
- Thoughts of harming yourself or your baby
- Bleeding that soaks through one pad per hour or clots larger than the size of an egg
- Incision that is nothealing
- Red swollenleg that is painful or warm to touch
- Temperature ≥100.4˚F (38˚C)
- Headache that doesn’t go away or get better after taking medications, or a bad headache with vision changes
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 Deterioration
Venous Thromboembolism
Venous 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.
- Critical Patient Teaching Point: VTE is a blood clot in the leg, usually in the calf area. Leg pain is not a normal side effect of giving birth, even with an epidural. Urgent attention is required for a calf that is red and swollen – perhaps warm or burning – or tender to the touch, or if there is more swelling in one leg than the other. If recognized, call your HCP immediately; if no response, call 911 or go to the emergency department.
Pulmonary Embolism
Pulmonary 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.
- Critical Patient Teaching Point: It is not normal to have chest pain or shortness of breath after having a baby. If you are experiencing shortness of breath, shallow rapid respirations, chest pain that worsens with cough, or change in level of consciousness, call 911 or go to the ED immediately.
Infection
- Critical Patient Teaching Point: Infection is an invasion of bacteria with the potential to spread throughout your system. It requires immediate medical attention in order to prevent severe and systemic illness. To identify an infection, look for:
- Temperatureof ≥4˚F (38˚C)
- Foul-smelling blood or discharge from the vagina
- Increased redness or discharge from an episiotomy
- C-section incision that is red, tender to touch, swollen, bleeding or draining, or has odor
If you identify an infection, call your healthcare provider; if no response, go to the nearest ED or call 911.
Cardiac Disease
One 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.
- Critical Patient Teaching Point: Signs and symptoms of cardiac disease include:
- Shortness of breath
- Chest pain
- Heart palpitations
- Discomfort in the chest
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.
Preeclampsia
Preeclampsia 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.
- Critical Patient Teaching Point: The following are the signs and symptoms related to hypertension and preeclampsia:
- Severe headache that does not respond to rest, medication, hydration
- Constant headache
- Vision changes – seeing spots or flashing lights
- Swelling of hands, face, legs
- Change of consciousness
- Pain in the right upper abdominal area
- Seizures – call 911 Immediately
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 Hemorrhage
Postpartum 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.
- Critical Patient Teaching Point: The following are all considered to be excess bleeding:
- Bleeding >1 sanitary pad/hour
- Passing 1 or more clots the size of an egg or larger
- Clot characteristic is bright red or dark red, for example
If you have excess bleeding, contact your HCP; if no response, go to the ED or call 911 immediately.
Suicide & Postpartum Depression
While 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.
- Critical Patient Teaching Point: Patients can experience postpartum depression as early as one week and up to one year after giving birth; it requires medical attention. Look for the following signs:
- Thinking of harming yourself or your baby
- Feeling loss of control, unable to care for self or baby
- Feeling sad most of the day or every day
- Having trouble sleeping or sleeping too much
- Having trouble bonding with your baby
- Experiencing extremes of behavior
Follow-Up
Once 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.
Summary
We 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.
