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Improving POSTPARTUM EDUCATIOJl

About Warn i ng Signs of

MATERNAL MORBIDITY and MORTALITY

PATRICIA D. SUPLEE LISA KLEPPEL

ANNE SANTA-DoNATO DEBRA BINGHAM

Maternal mortality or pregnancy-related death is the death of a woman from compli-

cations of pregnancy and childbirth occurring up to 1 year postpartum. In a report

using data from 2010, the United States ranked 49th out of 184 countries for mater-

nal mortality (Central Intelligence Agency, 2016); it is one of eight countries where

maternal mortality rates have been on the rise in recent years (Hogan et aI., 2010; Kassebaum et aI., 2014).

Abstract: Maternal morbidity and mortality rates remain high in the United States compared with other developed countries. Of par- ticular concern is the rise in postpartum deaths, because many of the risk factors for complications associated with maternal morbidity and mortality may not be clearly identified before a woman's discharge after birth. Although nurses provide some form of postpartum discharge education to all women who give birth, the information women receive on common potential complications is nat always consistent or evidence based. By improving postpartum education, nurses may be better poised to teach women how to recognize and respond to warning signs. This article describes a project intended to increase women's access to predischarge education about the risks for postbirth complications. http://dx.doi.org/ 10.1016/j.nwh.20 16.10.009

Keywords: maternal morbidity I maternal mortality I postpartum complications I postpartum education I pregnancy-related death

Although the most current u.s. pregnancy-related mortal- ity rate shows a slight decrease in maternal deaths, from

17.8 deaths per 100,000 live births in 2011 to 15.9 deaths per

100,000 live births in 2012 (Centers for Disease Control and

Prevention [CDC], 2016), this rate is more than double the

1987 rate of 7.2 deaths per 100,000 births. However, research-

ers working to better understand the measurement limitations

of maternal mortality trends found that the CDC estimates may

underreport maternal mortality rates. Recently, MacDorman,

Declercq, Cabral, and Morton (2016), using adjusted models,

reported an estimated maternal mortality rate for 2014 of 23.8

per 100,000 live births (included 48 states and the District of

Columbia). During this same time period, the rates of mater-

nal mortality in other developed countries decreased (Hogan et

aI., 2010). In addition to maternal mortality, the rates of severe

maternal morbidity in the United States have more than dou-

bled since 1998 (Callaghan, Creanga, & Kuklina, 2012).

The seven leading causes of pregnancy-related deaths for

2011 and 2012 in the United States are noncardiovascular dis-

eases 05.3%; not specifically described by the CDC), cardiovas-

cular diseases 04.7%), infection or sepsis 02.7%), hemorrhage

01.3%), cardiomyopathy (10.8%), thrombotic pulmonary

embolism (9.0%), and hypertensive disorders of pregnancy

(7.6%; CDC, 2016). Although any woman can experience one

of these complications during pregnancy or childbirth, women

with chronic conditions such as cardiac disease, obesity, or high

blood pressure are at higher risk of dying or nearly dying from

these complications.

Health disparities among racial and ethnic groups in the

United States have been well documented in the literature

(Elo & Culhane, 2010), and eliminating these disparities is an

overarching goal of Healthy People 2020 (U.S. Department of

Health and Human Services, 2016). In obstetrics, these dispari-

ties persist and are clearly evident in reported rates of mater-

nal morbidity and mortality. During 2011 and 2012, the CDC

reported the deaths per 100,000 live births as 1l.8 for White

women, 4l.1 for Black women, and 15.7 for women of other

races (CDC, 2016). These data show that maternal mortality

rates are approximately three to four times higher for Black

women compared with White women.

Understanding the timing of maternal deaths and their

possible preventability can help guide the development of

improvement efforts. In 2013, an international review of

Patricia D. Suplee PhD, RNC-OB, is an associate professor in the School of Nursing-Camden at Rutgers University in Camden, NJ. Lisa Kleppel, MPH, PMp, is a project manager at AWHONN in Washington, DC. Anne Santa-Donato, MSN, RNC, is director of obstetric programs at AWHONN in Washington, DC. Debra Bingham, DrPH, RN, FAAN, is a perinatal consultant and founder of the Institute for Perinatal Quality Improvement in Silver Spring, MD. The authors report no conflicts of interest or relevant financial relationships. Address correspondence to: suplee@camden.rutgers.edu.

maternal mortality found that, on average, nearly 25% of deaths

occurred antepartum, another 25% occurred intrapartum or

immediately postpartum, and almost 50% occurred in the

postpartum period up to 1 year (Kassebaum et aI., 2014). Cre-

anga et ai. (2015), using more recent U.S.-only data, found that

of the maternal deaths reported, 39% of women died before or

on the day of birth and 61% died in the postpartum period.

These data make it clear that postpartum deaths are not just an

international issue but are also a problem in the United States.

Researchers estimate that 40% to 50% of U.S. maternal deaths

are preventable (Bacak, Berg, Desmarais, Hutchins, & Locke,

2006). When focusing on obstetric hemorrhage alone, 54% to

70% of these maternal deaths are estimated to be preventable

(Della Torre et aI., 2011; Main, McCain, Morton, Holtby, &

Lawton, 2015).

POSTPARTUM CARE AND EDUCATION Within hospital systems, establishing guidelines to optimize

and improve postpartum care is important. Recently the Amer-

ican College of Obstetricians and Gynecologists (2016) pub-

lished a Committee Opinion on optimizing postpartum care.

In addition, the Alliance on Innovation in Maternal Care is a

multidisciplinary national program convened to reduce severe

maternal morbidity and maternal mortality and is supported

by the Maternal and Child Health Bureau/Health Resource Ser-

vices Administration. The Alliance on Innovation in Maternal

Care is developing two postpartum safety bundles to be used

by all types of providers (medical, nursing, social service, and

public health) to address the basic elements of postpartum care

(Kleppel, Suplee, Stuebe, & Bingham, 2016). This first bundle

will cover the first 6 weeks postpartum, and the second bun-

dle will focus on interconception care and health up to 1 year

postpartum.

Nurses are the health care providers who perform the most

postpartum education in the United States. Thus, it is critical

that nurses work to improve discharge education so that the

information they provide is efficient, timely, and evidence

based. When women are discharged after birth, nurses playa

vital role in providing them with education on self-care and

infant care and a plethora of information related to transition-

ing home and caring for a newborn. Authors have reported

that the amount of information women receive is overwhelm-

ing (Alden, Lowdermilk, Cashion, & Perry, 2012; Murray &

McKinney, 2014). It is not clear how nurses currently decide

which information is a priority to provide face-to-face educa-

tion on and which information can be given to a woman to read

at home. Many hospitals require the discharging nurse to com-

plete some sort of checklist that includes a list of educational

topics. However, there is wide variation in discharge education

related to information on warning signs of maternal morbidity

nwhjournal.org

and mortality (Suplee, Bingham, & Kleppel, 2016). This holds

true for women being discharged from birth centers as well.

For rates of postpartum maternal morbidity and mortality

to be reduced, it is vital for women who have just given birth to

be instructed on specific warning signs so that they know what

to look for, when to call a health care provider, or when to go to

the nearest emergency department. Many of the complications

women experience can be successfully treated if they are identi-

fied quickly and women receive prompt medical attention. To

that end, below we describe the findings from the implemen-

tation phase of a pilot project of the Association of Women's

Health, Obstetric and Neonatal Nurses (AWHONN) entitled

"Empowering Women to Obtain Needed Care" and discuss

implications for clinical practice.

WHY POSTPARTUM DISCHARGE EDUCATION NEEDS IMPROVEMENT The United States Agency for Healthcare Research and Qual-

ity defines quality health care as "doing the right thing, at the

right time, in the right way, for the right person-and having

the best possible results" (2003, p. 1). For

the past few decades, postpartum education

has evolved around maternal self-care and

infant care (Alden et aI., 2012; Murray et aI.,

2014). We conducted a literature review in

CINAHL and found no studies that focused

on educating women about specific potential

complications after birth. One recent study

(Suplee et aI., 2016) found a lack of standard

information and approaches to how nurses

meet the challenge of educating women who

are considered at risk for maternal mortal-

ity, as well as for all women at risk simply on

the basis of their postpregnancy health sta-

tus. National leaders have stated that earlier

recognition of warning signs by postpartum

women and earlier interventions by health

care providers may lead to a decrease in the

current growing maternal morbidity and

mortality rates in the United States (D'Alton,

Main, Menard, & Levy, 2014; The Joint Com-

mission, 2010).

Comprehensive improvement efforts to

advance postpartum education fOCUSing

specifically on potential risks for maternal

morbidity and mortality are needed. Future

education programs should include infor-

mation for both at-risk and healthy women,

because complications may not be clearly

identified or apparent before a woman's dis-

charge after birth.

Dec ember 2016 I January 2017

THE "EMPOWERING WOMEN TO OBTAIN NEEDED CARE" PROJECT With support from the Merck for Mothers program, a 10-year initiative focused on improving the health and well-being of

women during pregnancy and childbirth, AWHONN initiated

the "Empowering Women to Obtain Needed Care" project.

Researchers estimate that 40% to 50% of lJ .S. maternal

deaths are preventable

The goal of this pilot project was to increase women's access

to quality information about risks for postbirth complications,

especially before discharge from the hospital after giving birth.

Accurate and consistent information provided to all women

who give birth can better equip them to recognize health

changes or warning signs of postpartum complications. Early

recognition of postbirth warning signs enables women to seek

Nursing for Women's Health 555

and obtain health care for these potentially life-threatening

complications. The project was divided into two phases (see

Figure 1).

PHASE 1: BASELINE ASSESSMENT Baseline assessment included a comprehensive literature

review, a review of postpartum discharge materials currently

used by nurses to educate women about warning signs, and

focus groups with nurses held at selected hospitals to assess

what was currently taught to postpartum women and how the

education was delivered. Findings showed that inconsistent

information was provided to women about postbirth warning

signs and what they should do if they experienced any of these

signs once discharged (Suplee et aI., 2016) .

PHASE 2: IMPLEMENTATION The implementation phase included two components. First,

standardized evidence-based educational materials and dis-

charge teaching talking points were designed for nurses to use

when educating women about maternal morbidity and mor-

tality. Second, these educational materials were pilot tested in

four designated hospitals to identify barriers and facilitators to

FIGURE 1

implementation and to evaluate postpartum nurses' satisfac-

tion using the materials.

The education materials were designed to be easy to use and

to have the ability to be integrated into current teaching tools

used by nurses across the country. The leading causes of mater-

nal morbidity and mortality in the United States formed the

basis of what was included by the Expert Panel on the educa-

tional tools before pilot testing in 2015. What follows is a report

of the results of the implementation phase (Phase 2).

METHODOLOGY Sample Four of the six hospitals from the baseline assessment (Phase

1) agreed to participate in the implem entation portion (Phase

2) . Hospitals chosen for this pilot project reflected diverse

populations of postpartum women in terms of race, ethnicity,

and socioeconomic status. Among the hospitals participating

in this project, African American and Hispanic women were

reported to make up 25% to 65% of the total birth demograph-

ics for 2012. In the same year, Medicaid-reimbursed births in

these hospitals ranged from 25% to 75% of their total births.

Although it was not possible to capture the exact number of

Phases of the Empowering Women to Obtain Needed Care Pilot Project

Phase One: Baseline Assessment

IV outcomes

556 Nursing f o r Wom e n 's Hea lt h

Phase Two: Implementation

• Design educational checklist tool for nurses

• Design patient education tool • Design nurses' evaluation tool • Design audit tool • Review all tools with

Expert Panel • Train/orient nurse leaders • Pilot tools in 4 hospitals • Conduct & analyze health

records audit • Analyze nurse evaluations • Redesign tools based

on feedback

V o lume 2 0 Issue 6

women who received postpartum education using the pilot

project tools, a cumulative estimated calculation of births over

a 3-month period included more than 3,000 women. In addi- tion, approximately 150 nurses were involved in providing the

education to the postpartum women before discharge.

Procedure

After recruiting nurse site leaders from the four hospitals, the

project manager sent copies of all of the tools to them. A con-

ference call was held to introduce the nurse site leaders to the

program tools and to explain how they should be implemented

and how to train staff nurses to use them. The education for

for nurses to use when beginning the conversation with new

mothers: Although the majority of women who give birth do not

have complications once they go home, all women are potentially

at risk. Knowing these postpartum warning signs can save your

life as many signs can indicate a life-threatening condition and

require immediate medical care.

Patient Handout The handout for women to take home, titled "Save Your Life"

(see Figure 3), includes sections on when to call 911, when

to call one's health care provider, and descriptions of warn-

ing signs that could become life-threatening if women do not

Education ~rams should include information for both at-risk and healthy women, because complications may not be clearly

identified or aD-parent before a woman's discharge after birth

nurses included background information on statistics related to

rising rates of maternal mortality to ensure that all of the nurses

participating in the pilot program had accurate and current

information to share with their staff. The pilot implementation

took place from October through December 2015. During this

time, nurse site leaders from all four hospitals reported that the

nurses who provided postpartum education at their hospitals

were using the new forms with all women after birth and before

discharge. Monthly conference calls were held to discuss real

and potential issues encountered with the use of the program

materials and to share feedback among the nurse site leaders.

PROJECT TOOLS Four tools were created by the principal investigators, project

manager, an expert panel of nurses and health professionals on

the basis of information gleaned from the literature review and

focus groups held with nurses from six hospitals in New Jer-

seyand Georgia. Two teaching tools were developed-one for

nurses to use when teaching women about potential warning

signs of maternal morbidity and mortality (see Figure 2) and

another for women to take home (see Figure 3).

Discharge Education Checklist

The Post-Birth Warning Signs: Postpartum Discharge Educa-

tion Checklist (see Figure 2) was deSigned to provide nurses

with a tool they could use when teaching all women to rec-

ognize warning signs of postpartum complications that could

occur after discharge. The hospitals were given permission to

integrate the checklist into their electronic health record. The

checklist defines each potential complication, lists specific signs

and symptoms, and explains where and when a woman should

seek medical attention. It also includes this suggested script

December 20161 January 2017

obtain prompt medical attention. The other important message

included in this handout is a reminder for women to tell pro-

viders caring for them during the first year after giving birth,

I had a baby on [specific date] and I am having the following

specific symptoms . ... This message is intended to alert provid-

ers that a woman's symptoms could be related to a recent preg-

nancy. Nurses instructed each woman to keep the handout in a

place where she could access and review it easily, such as on her

refrigerator. Women were also encouraged to include a partner

or family member in the discharge education sessions before

discharge so that they could also hear the education to support

earlier identification of warning signs and symptoms and help

mobilize timely care.

Education Evaluation Tool

Additional tools were designed by the AWHONN project team

to be used for data collection by the site leader and evaluation

of the teaching tools by the nurses. The Postpartum Education

Evaluation Tool was an online survey distributed to all post-

partum nurses at the participating hospitals. Nurses were asked

to describe the facilitators and barriers to using the discharge

checklist and patient handout by responding to open-ended

questions. They were also asked to rate six statements using

a Likert scale (strongly agree to strongly disagree) focusing on

such elements as satisfaction, ease of use, ease of understand-

ing, assistance with teaching, and their assessment of women's

abilities to understand the warning signs and describe when to

obtain needed care.

Audit Tool A quality improvement health record audit tool was devel-

oped to be used by nurse site leaders when performing 30

Nursing for Women 's Health 557

FIGURE 2 Discharge Education Checkl ist (Full-sized PDF version of Figure 2 appears online as Supplemental Figure 51.)

POST-BIRTH WARNING SIGNS: POSTPARTUM DISCHARGE EDUCATION CHECKLIST

This checklist is a teaching guide for nurses to use when educating all women about the essential warning signs that can result in maternal morbidity and/or mortality.

Instructions:

POST- BIRTH

WARNING SIGNS

• Instruct ALL women about all of the following potential complications. All teaching should be documented on this form or in your facility's electronic medical record.

• Focus on risk factors for a specific complication first; then review all warning signs. • Emphasize that women do not have to experience ALL of the signs in each category for them to seek care. • Encourage the woman's significant other or her designated family members to be included in education

whenever possible.

The information included on this checklist is organized according to complications that can result in severe maternal morbidity or maternal mortality. Essential teaching points should be included in all postpartum discharge teaching.

The parent handout, "Save Your Life", is designed to reinforce this teaching. This handout is organized according to AWHONN's acronym, POST-BIRTH, to help everyone remember the key warning signs and when to call 911 or a health provider. A portion of this handout is below for reference.

Call your healthcare provider if you ha ve:

( If you can 't reach your healthcare provider, ca ll 9 11 or go to an emergency room)

o P ain in chest

o O bstructed breathing or shortness of breath

o S eizures

o T houghts of hurting yourself or your baby

o B leeding, soaking through one pad/hour, or blood clots, the size of an egg or bigger

o I ncision that is not healing

o R ed or swollen leg that is painful or warm to touch

o T emperature of 100.4°F or higher

o H eadache that does not get better, even after taking medicine, or bad headache with vision changes

Below is a suggested conversation-starter: "A lthough most women who give birth recover without problems, any woman can have

complications after the birth of a baby. Learning t o recognize these POST- BIRTH warn -

ing signs and knowing what to do can save your life . I would like to go over these POST-

BIRTH warning signs with you now, so you will know what to look for and when to call

9 77 or when to call your healthcare provider.

Please share thiS with family and f riends and post the "Save Your Life" handout in a place where you can get to it easily (like your refngerator). JJ

(continued)

558 Nursing for Women 's Health Volume 20 Issue 6

FIGURE 2 Discharge Education Checklist continued ••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• j

POST-BIRTH Warning Signs: Postpartum Discharge

Education Checklist

Pulmonary Embolism Essential Teaching for Women

What is Pulmonary Emboli sm? Pulmonary embolism is a blood clot that has traveled to your lung.

Signs of Pulmonary Embolism • Shortness of breath at rest (e.g., tachypneic shallow, rapid respirations) • Chest pain that worsens when coughing • Change in level of consciousness

Obtaining Immediate Care Ca ll 91 1 or go to nearest emergency room RIGHT AWAY.

RN initials ______________________ Date Family/support person present? YES / NO

Cardiac (Heart) Disease Essential Teaching for Women

What is Cardiac Disease? Card iac disease is when your heart is not working as well as it should and can include a number of disorders that may have different signs and symptoms.

Signs of Potential • Shortness of breath or difficulty breathing Cardiac Emergency • Heart palpitations (feeling that your heart is racing)

• Chest pain or pressure

Obtaining Immediate Care Call 911 or go to nearest emergency room RIGHT AWAY.

RN initials ______________________ Date Family/support person present? YES / NO

Hypertensive Disorders of Pregnancy Essential Teaching for Women

What is Severe Hypertension? Hypertension is when your blood pressure is much higher than it should be.

Signs of Severe Hypertension • Severe constant headache that does not respond to over-the-counter pain medicine, rest, and/or hydration

What is Preeclampsia/Eclampsia? Preeclampsia is a complication of pregnancy that includes high blood pressure and signs of damage to other organ systems. Eclampsia is the convu lsive phase of preeclampsia, characterized by seizures.

Signs of Preeclampsia • Severe constant headache that does not respond to pain medicine, rest, and/or hydration • Changes in vision, seeing spots, or flashing lights • Pa in in the upper right abdominal area • Swellin g of face, hands, and/or legs more than what you wou ld expect • Change in level of consciousness

Signs of Eclampsia • Se izures

Obtaining Immediate Care Ca ll 911 for seizures. Ca ll healthcare provider immed iately for any other signs. If symptoms worsen or no response from provider/clinic, call 911 or go to nearest emergency room.

RN initials ______________________ Date Family/support person present? YES / NO

Obstetric Hemorrhage Essential Teaching for Women

What is Obstetric Hemorrhage? Obstetric hemorrhage is when you have an excess amou nt of bleeding after you have delivered your baby.

Signs of Obstetr ic Hemorrhage • Bleeding through more than 1 sanitary pad/hour • Passing I or more clots the size of an egg or bigger • Character of clots/differentiation of bright red bleed in g from dark with clots

Obtaining Immediate Care Call healthcare provider immediately for signs of hemorrhage. If symptoms worsen or no response from provider/clinic. call 911 or go to nearest emergency room.

RN initials ______________________ Date Family/support person present? YES / NO

(con tinued)

December 20161 January 2017 Nursing for Women's Health 559

FIGURE 2 Discharge Education Checklist continued

POST- BIRTH Warning Signs: Postpartum Discharge

Education Checklist

Venous Thromboembolism Essential Teaching for Women

What is Venous Thromboembolism? Venous thromboembolism is when you develop a blood clot usua lly in your leg (ca lf area).

Signs of Venous Thromboembolism • Leg pain, tender to touch, burning or redness, particu larly in the ca lf area • Swell ing of one leg more than the other

Obtaining Immediate Care Ca ll healthcare provider immediately for above signs of venous thromboembolism. If symptoms worsen or no response from provider/clinic, call 911 or go to nearest emergency roolTI.

RN initia ls _____________________ _ Date _________ _ Fami ly/support person present? YES / NO

Infect ion Essential Teac hi ng for Women

What is Infection? An infection is an invasion of bacteria or viruses that enter and spread through your body, making you ill.

Signs ofInfection • Temp is 2100.4°F (238°C) • Bad smelling blood or discharge from the vagina • Increase in redness or discharge from episiotomy or C-Section site or open wound not healing

Obtaining Immediate Care Call hea lthcare provider immediately for above signs. If symptoms worsen or no response from provider/clink, ca ll 9 11 or go to nearest emergency room.

RN init ials _____________________ _ Date _________ _ Family/support person present? YES / NO

Postpartum Dep ress ion Essent ial Teach ing for Women

What is Postpartum Depression Postpartum depression is a type of depression that occurs after childbirth. PPD can occur as early as one week (PPD)? up to one year after giving birth.

Signs of Postpartum Depression • Thinking of hurting yourself or your baby • Feeling out of control, unable to care for self or baby • Feel ing depressed or sad most of the day every day • Having trouble sleepi ng or sleeping too much • Having trouble bonding with your baby

Obtaining Immediate Care Call 911 or go to nearest emergency room if you feel you might harm yourself or your baby. Ca ll healthcare provider immediately for other signs of depression (sadness, withdrawn, difficulty coping with parenting).

RN initials _____________________ _ Date _________ _ Family/support person present? YES / NO

Essential Teaching for Women

• Discuss importance of follow-up visit with doctor, nurse practitioner or midwife in 4-6 weeks (or sooner if

Follow- Up health status warrants it) • Provide correct phone number for appointment

AppO intment • Emphasize importance to notifying all healthcare providers of delivery date up to one year after birth of baby

• Confirm date for postpartum appointment prior to discharge

RN initials _____________________ _ Date _________ _ Family/support person present? YES / NO

The patient received the POST-BIRTH Warning Signs education and a copy of the "Save Your Life" handout.

Nurse Initials and Signature: __________________________ Date/Time:

@AW H O N N 2016: A ll Rig ht s Rese rved

16001 Page 2 of 2

POS T- BIRTH Wa rn ing Sig ns: AW H O N N's Pos t pa rtum Di sc harge Ed ucatio n Project

560 Nursing for Women's Health Volume 20 Issue 6

FIGURE 3 Patient Handout (Full-sized PDF version of Figure 3 appears online as Supplemental Figure 52.)

SAVE YOUR LIFE:

Call your healthcare provider if you have:

( If you can't reach your healthcare provider, ca ll 911 or go t o an emergency room)

"Trust 'lour instincts. ALWA'IS get ",edical

care if yoU are oot fee\il"g we\\ or

"a"e questtons or concerns .

Get Care for These POST-BIRTH Warning Signs Most women who give birth recover without problems. But any woman can have complications after the birth of a baby. Learning to recog nize these POST-BIRTH warning signs and knowing what to do can save your life.

o P ain in chest

POST- BIRTH

WARNING SIGNS

o O bstructed breathing or shortness of breath

o S eizures

o Th oughts of hurting yourself or your baby

o B leeding, soaking through one pad/hour, or blood clots, the size of an egg or bigger

o I ncision that is not healing

o R ed or swollen leg that is painful or warm to touch

o T emperature of 100.4°F or higher

o H eadache that does not get better, even after taking medicine, or bad headache with vision changes

Tell 911 or your healthcare provider:

"I had a baby on ___ =,,---___ and (Date)

I am having __ ....,.".---.,..,,....--,---,--,-__ ' (Specific warning signs)

These post-birth warning signs can become life- threatening if you don't receive medical care right away because : Pain in chest, obstructed breathing or shortness of breath (trouble catc hin g yo ur breath) may mea n yo u have a blood clot in yo ur lung or a hea rt problem

Seizures may mean yo u have a condition ca lled eclampsia

Thoughts o r feelings of wanting to hurt yourself or your baby may mean yo u have postpartum depression

Bleeding (heavy) , soak ing more t ha n one pad in an hour or pa ssing an egg-sized clot or bigger may mean you have an obstetric hemorrhage

Incision that is not healing, increased redness or any pus from ep isiotomy or C -sect ion si te may mean yo u have an infect io n

Redness, swelling, warmth, or pain in the calf area of yo ur leg may mean you have a blood clot

Temperature of IOO.4°F o r higher, bad smelling vaginal blood or discharge may mean you ha ve a n infection

Headache (ve ry painful), vision changes, or pain in the upper r ight area of your belly may mean you have high blood pressure or post b irth p reeclampsia

GET MyHealthcareProvider/Clinic: ________________ Phone Number: _________ _ HELP Hospital Closest To Me: ______________________________ _

16002 ©20 16 Associat ion of Women's Health, Obstetric, a nd Neonatal Nurses. All rig hts reserved.

Requests for permission to use or reprod uce should be directed to permissions@awhonn.org.

December 20161 January 2017 Nurs ing for Women's Health 561

When implementing change in any health care setting, it is vital

to incllJde nurse site leaders and champions to facilitate the change

within the setting and to engage them in the review and evaluation process

health record audits per month. Audit topics included type of

birth; family support present during teaching; and education

provided about pulmonary embolism, obstetric hemorrhage,

severe hypertension, venous thromboembolism, infection,

postpartum depression, and follow-up care.

ANALYSIS AND RESULTS The nurse survey and audits were analyzed using descriptive

statistics. Site leaders used different methods to educate the

nurses at their hospitals on the project and on how to use the

project tools. Primarily, education of the staff nurses occurred

during staff meetings; however, the site leaders also met indi-

vidually with small groups and one on one for those who could

not attend. The site leaders were responsible for addressing any

questions nurses had regarding the project. It was beyond the

scope of the project to determine which methods were most

effective for orienting nurses to the program and the tools.

The exact number of nurses who used the tools for educat-

ing women about potential warning signs could not be captured

562 Nursing for Women's Health

during the pilot because of limitations in funding. The hospital-

based nurse site leaders estimated that 150 nurses performed

discharge education at their hospitals during the pilot period.

Of these, 52 nurses responded to the online survey, resulting in

a 33% response rate. This percentage is fairly consistent with that

reported in the literature for survey completion (Watt, Simp-

son, McKillop, & Nunn, 2002). Most nurses who completed the

survey indicated that the discharge education checklist and the

patient handout were easy to use, that the checklist would assist

them with their teaching about postpartum complications, that

they were satisfied with the amount of information on the tools,

and, finally, that women were able to understand what was being

taught to them about warning signs and were able to describe

when they should seek care (see Table 1).

In addition to nurses' comments about the use of the tools,

there were additional questions focusing on the potential bar-

riers and facilitators nurses experienced when they used the

tools. The main barrier reported was that the patient hand-

outs were available only in English, thereby preventing nurses

from distributing handouts to non-English-speaking patients.

Handouts were translated into Spanish to eliminate this barrier.

The main facilitator reported by nurses was the accessibility of

the form on the chart.

DISCUSSION When implementing change in any health care setting, it is vital

to include nurse site leaders and champions to facilitate the

change within the setting and to engage them in the review and

evaluation process. The Post-Birth Warning Signs: Postpartum

Volume 20 Issue 6

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TABLE 1 Postpartum Education Evaluation Survey Results (n = 52) .................................................................................................................................................................

Statement Strongly Agree, Undecided, Disagree, Strongly Agree, % (n) % (n) % (n) % (n) Disagree, % (n)

I found the Maternal Mortality Checklist easy to use. 25.0 (13) 53.9 (28) 9.6 (5) 3.9 (2) 7.7 (4)

I feel that the Maternal Mortality Checklist will assist me when teaching all women about warning signs of possible postpartum complications. 36.5 (19) 48.1 (25) 5.8 (3) 5.8 (3) 3.9 (2)

I found the Save Your Life handout easy to use when teaching women. 38.5 (20) 40.4 (21) 13.5 (7) 3.9 (2) 3.9 (2)

I was satisfied with the amount of content found on the Save Your Life handout provided to the women. 40.4 (21) 46.2 (24) 3.9 (2) 7.7 (4) 1.9 (1)

I felt that women were able to understand the importance of postpartum warning signs that were discussed with them. 38.5 (20) 48.1 (25) 9.6 (5) 3.9 (2) 0(0)

The women were able to describe to me when to seek and obtain needed care related to all of the warning signs presented on the handout. 28.9 (15) 63.5 (33) 3.9 (2) 1.9 (1) 1.9 (1)

Discharge Education Checklist and the Save Your Life hand-

out were purposely designed in tandem and with consistent

content to enable nurses to teach the content in a standardized

format while women followed along using the handout. Nurses'

perceptions of satisfaction with and ease of use of both of these

tools were overall positive in this pilot project.

The exact teaching method used by the nurses for teaching

about or reinforcing maternal warning signs education was not

measured. However, in the focus groups during Phase 1, many

nurses reported using the teach-back technique, which would

be appropriate to use when teaching about potential complica-

tions of pregnancy and childbirth. The checklist also included

documentation of whether a support person was available dur-

ing the education.

Nurses were asked to discuss the barriers and facilitators of

incorporating these teaching tools into their clinical practice.

December 20161 January 2017

Although not all nurses provided responses to these questions,

many did, and the primary barrier identified was lack of a Span-

ish-language version of the handout; this led the project team

to create a Spanish version for nurses to use as a handout dur-

ing this phase of the project. In the future, it will be important

to validate these Spanish-language teaching tools. These tools

need to be reliable, and the content must be culturally appropri-

ate. The main facilitator of incorporating these tools into clini-

cal practice was reported by the nurses to be the accessibility

of the form on the chart. One aspect of having nurses test new

patient education tools is that a balance of time versus pur-

pose must be reached. As nurses gained additional knowledge

themselves about postpartum maternal mortality, there was an

increased appreciation for the importance of their role in pro-

viding education to all women on recognizing warning signs of

postpartum morbidity and mortality.

Nursing for Women's Health 563

The site leaders themselves were also asked about barriers

and facilitators to implementation to assist with future project

design. Their reported barriers and facilitators are listed in Box 1.

PRACTICAL IMPLICATIONS FOR CLINICIANS Indeed, our recommendations are consistent with the findings

that a lack of recognition or understanding of warning signs for

pregnancy complications by health care providers and fami-

lies contribute to preventable maternal mortality (Main et ai.,

2015). Therefore, implementation of standardized education by

nurses who care for women during the postpartum period has

the potential to playa significant role in decreasing maternal

morbidity and mortality. To help achieve this goal, it is essential

to engage all postpartum women (and their support persons

whenever possible) in focused discussions about potentially

life-threatening post-birth complications as a routine compo-

nent of discharge education. One of the challenges for nurses

and other health care professionals is to present this education

in a manner that is informative and that fosters empowerment

without instilling unnecessary fear in women. In fact, this chal-

lenge was reported as a concern by some of the nurse site lead-

ers and resulted in inclusion of additional scripting and talking

points to help nurses engage with women when they were dis-

cussing the components outlined on the Post-Birth Warning

Signs: Postpartum Discharge Education Checklist. Although

it might seem daunting to discuss potentially life-threatening

postbirth complications, especially with women for whom

pregnancy and birth were normal, engaging women and their

families in this critical conversation in an objective and sup-

portive manner may save lives. Because of the alarmingly high

percentage of maternal deaths that occur in the immediate

postpartum period and through the first year after birth (Cre-

anga et ai., 2015; Kassebaum et ai., 2014), the potential benefits

of having the conversation clearly outweigh the potential risks

of not doing so.

Equally critical is the need to help women understand the

importance oflistening to their own bodies and acting on signs

that do not seem normal to them. Women experience a myriad

of signs and symptoms associated with the normal physiologic

and psychosocial changes occurring during the postpartum

period. Therefore, it is important to help them understand nor-

mal signs and symptoms and the ways to differentiate those

that are normal from those that are not. Women also need to

know why it is necessary and appropriate to proactively seek

and obtain care when they are not feeling well and how urgently

they should obtain this care on the basis of the types of symp-

toms they are experiencing. Armed with information about

and understanding of the postbirth warning signs, women can

be empowered to act immediately rather than wait and suffer

potentially devastating consequences.

564 Nursing for Women's Health

BOX 1 Barriers and Facilitators to Postpartum Education Implementation as Reported by Nurse Site Leaders

BARRIERS Duplication of documentation left some nurses frustrated with extra work. Given the short pilot period, most hospitals were unable to integrate all documentation into the electronic health record.

Competing priorities or inadequate staffing did not allow some sites to participate in pilot implementation after participation in Phase 1 of project.

Tight time lines and inadequate lead time from initial orientation to implementation made it difficult for some sites to obtain administra- tive approval and to train nurses .

Inconsistent methods of data collection among sites made it difficult for the project team to compare implementation across sites.

FACILITATORS

Ease of use by nurses with information provided in one tool.

Commitment to the project by hospital leaders and! or administration.

Availability of staff with time to devote to implementation and problem solving.

Authority and decision-making capabil- ity of hospital leaders to respond to issues in a timely way.

Regular support and communication throughout the project via group phone calls to discuss challenges and brainstorm solutions .

Positive working relationships with hospital site leaders contributed to the ease with which this project could gear up for implementation.

Designating specific staff in leadership roles in implementation motivated these nurses to succeed and ultimately contributed to project success.

Volume 20 Issue 6

Although the window of opportunity for discharge plan-

ning and teaching postpartum women is small and the volume

of information to be relayed is large, the necessity to provide

this critical information cannot be overstated. Nurses can

EXEMPLAR One of the AWHONN project principal investigators con-

ducted an interview with a woman who received the postbirth

warning signs education before she was discharged from the

One of the challenges for nurses and other health care professionals is to present this education in a manner that is informative

and that fosters empowerment without instilling unnecessary fear in women

work together within their maternity services to strategize and

develop best practices to ensure that essential maternal and

newborn discharge teaching is accomplished in the most effi-

cient and effective manner possible. One strategy may be to plan

discharge teaching over the course of the woman's postpartum

stay rather than waiting for day of discharge. Another strategy

may be to include this education as part of prenatal education.

And finally, incorporating a checklist and patient education tool

(such as the AWHONN tools) into hospital electronic health

record systems and the discharge education process will pro-

vide nurses with a resource handout to use when providing

evidence-based care education.

December 20161 January 2017

hospital and who subsequently experienced a complication.

Her story (see Box 2) aptly illustrates the value in providing

this education to all women and empowering them to obtain

needed care.

LIMITATIONS The AWHONN project team identified limitations to this

project. First, the sample size was small (four hospitals par-

ticipated from two distinct geographic regions), and the data

collected over 3 months were not necessarily reflective of dis-

charge practices across the nation, making the authors cautious

about the results. Second, there was a retention issue: two of

Nursing for Women's Health 565

the original six hospitals withdrew from Phase 2. One facility

withdrew related to its lack of resources to execute the project,

and in the other facility, a decision was made that another pro-

ject had priority over this one. This, unfortunately, is the reality

for many health care facilities that are challenged to simul-

taneously orchestrate multiple projects without additional

resources . Lastly, there was a lack of consistency in how hospi-

tal leaders chose to train staff on the implementation and doc-

umentation of the education. Site leaders reported that nurses

received the training during staff meetings, in small groups, or

one on one. An audit tool was designed by the project team to

be used by nurse site leaders for monthly chart reviews; how-

ever, there was inconsistency among the leaders on how data

were obtained and recorded in the audit form . Thus, data from

these audits were determined to not be reliable.

CONCLUSION The overall goal to streamline and improve the education that all

postpartum women receive regarding warning signs of compli-

cations is a lofty but necessary one. The results of this pilot pro-

ject are promising. Future research should include interviewing

women to explore how they perceive the educational tools and

information they received about this content from their nurses,

testing the educational tools and education methods for teach-

ing staff and new mothers in multiple facilities with a larger

sample of nurses and postpartum women, and monitoring

readmission rates resulting from women using and reporting

warning signs after discharge from the hospital and returning

to the hospital to obtain needed care. Further investigation

and evaluation have the potential to demonstrate that hospital

readmission for identified warning signs is the right thing to

do to facilitate early intervention for postpartum complications

and that obtaining needed postpartum care will be the result

of improved education and awareness of the postbirth warning

signs. Thus, providing consistent education to all women in the

postpartum period before discharge has the potential to reduce

severe maternal morbidity and to save lives. NWH

Acknowledgments This project was supported by AWHONN, and the activities

described in this article were supported by funding from Merck,

through its Merck for Mothers program, and are the sole responsi- bility of the authors. Merck for Mothers is known as MSD for Moth- ers outside the United States and Canada. The authors would also like to acknowledge the following members of the Expert Panel

who assisted with the Empowering Women to Obtain Needed

Care Project: Jennifer L. Barkin, PhD, MS, Joan Rosen Bloch,

PhD, CRNp, Helen M. Hurst, DNP, RNC-OB, APRN-CNM, and

Mimi Pomerleau, DNP, WHNP-BC, RNC-OB, CNE.

~ Cross~ark

566 Nursing f o r Wom e n 's Hea lt h

BOX2 Interview With a Woman in the Postpartum Period Who Experienced a Complication

Abigail (not her real name) is a 27-year-old woman who had an uneventful prenatal course without risk factors or complications and had a vaginal birth. Be- fore discharge, the postpartum nurse caring for Abi- gail educated her about the most common postbirth warning signs, gave her the Save Your Life handout, and reviewed the handout with her. During her second postpartum week, Abigail developed and was treated for mastitis. Within a few days of starting antibiotic therapy for the mastitis, she began to feel progressively worse, stating, "I just didn't feel like myself." In the interview, she described symptoms that included a "rapid heart rate, racing, like palpita- tions" and that her breathing was "off," explaining that when she would take a breath "in" she would start coughing. She reported remembering the Save Your Life handout, referring to it, and seeing the words "shortness of breath" and "call 911" on it. She turned to her mother, showed her the handout, and said, "Something isn't right, we're going in [to the emergency departmentl." In the emergency depart- ment of her local hospital, Abigail's heart rate was 163, and she was still short of breath. She recalled being very frightened, stating that her greatest fear then was "not knowing if I'd ever hold my baby again." Abigail was diagnosed with a small pulmo- nary embolus in her right lung, was admitted to the hospital, and was successfully treated on a unit where her baby could stay with her and continue to breastfeed.

As she reflected on this emergency, Abigail was thankful that the physicians and nurses in the emergency department identified her pulmonary embolus, and she shared that, having received the information about postbirth warning signs, she was able to immediately act on what she read on the basis of the symptoms she experienced. Abigail explained that she now knows how important it is to be on the lookout for signs that do not seem nor- mal, even when pregnancy and birth are uneventful. She is grateful to have had the Save Your Life hand- out available. She stated during the interview that she believes the postbirth education and handout she received before discharge saved her life.

V o lume 2 0 Issue 6

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Supplementary Material

Note: To access the supplementary material that accompanies this article, visit the online version of Nursing for Women's Health at http://nwhjournal.org and at http://dx.doi.org/10.1016/j.nwh.2016.10.009 .

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