Continuing Education Module—The Childbirth Educator's Role in Teaching Post-Birth Warning Signs

Abstract

The U.S. maternal mortality rate has doubled in the past 25 years and has risen despite improvements in health care and an overwhelming global trend in the other direction. Forty-five countries have lower maternal mortality rates than the United States (CIA World Factbook, 2018). For a country that spends more than any other country on health care and more on childbirth-related care than any other area of hospitalization, this is a shockingly poor return on investment. After prolonged attention during pregnancy and birth, there is relatively little attention to the mother's health and well-being in the postpartum period. Yet more than half of childbirth-related deaths occur during this time (Muza, 2017). To minimize complications leading to maternal mortality, childbirth educators need to teach mother and families to identify and respond promptly to warning signs of postpartum complications.

The United States is the only developed nation with rising maternal mortality rates. Global maternal death rates fell by more than a third from 2000 to 2015. During this time the U.S. maternal mortality rate has doubled (Tavernise, 2016). Death rates from hemorrhage or eclampsia rates have remained stable. The increase in mortality in recent years is due to heart problems and other chronic conditions which have increased sharply in the population (Centers for Disease Control and Prevention [CDC], 2018; Tavernise, 2016).

DEFINITIONS RELATED TO MATERNAL DEATH

A maternal death is death of a woman while pregnant (or within 42 days of termination of pregnancy) regardless of duration or site of pregnancy. Accidental or incidental causes of death are not classified as maternal deaths. Direct deaths are those related to obstetric complications during pregnancy, labor, or postpartum (6 weeks) or resulting from any treatment received during this time. Indirect deaths are those associated with a disorder, the effect of which is exacerbated by pregnancy. Late maternal deaths are those occurring more than 42 days but less than 1 year after the end of pregnancy (Payne, 2016). Maternal mortality ratio refers to maternal deaths per 100,000 live births. Maternal mortality rate is deaths per 100,000 women aged 15 to 45 (World Bank, 2018).

MATERNAL MORTALITY IN THE UNITED STATES

Annually an estimated 1,200 women in the United States suffer fatal complications during pregnancy or childbirth, and another 60,000 suffer near-fatal complications (Appold, 2017). The World Health Organization (WHO) identified factors that contribute to the upward trend in maternal morbidity and mortality in the United States (2018). One factor is inconsistent obstetric practices, with significant variability in the resources available to patients dealing with critical emergencies. Improving training for health-care professionals, standardizing care, and developing referral networks would be significant steps to alleviate this factor. More pregnant women with chronic conditions and women bearing children later in life when chronic health conditions are more prevalent are other contributing factors (Appold, 2017; Fretts, 2017; Kenny, Lavender, McNamee, O'Neill, & Mills, 2013). There needs to be more coordination between primary care and obstetrical providers, nurses, childbirth educators, and other health-care professionals who care for women during pregnancy.

According to the CDC Pregnancy Mortality Surveillance System (2018), the number of reported pregnancy-related deaths in the United States steadily increased from a ratio of 7.2 to 18.0 from 1987 to 2014. Causes included cardiovascular diseases (15%), non-cardiovascular diseases (14.7%), infection or sepsis (12.8%), hemorrhage (11.5%), cardiomyopathy (10.3%), pulmonary embolism (9.1%), cerebrovascular accident (7.4%), and hypertensive disorders of pregnancy (6.8%) (CDC, 2018).

DISCHARGE TEACHING ABOUT MATERNAL COMPLICATIONS

In the Listening to Mother's Survey (Declercq, Sakala, Corry, Applebaum, & Herrlich, 2013), new mothers described the time after giving birth as exhausting, emotionally charged, and physiologically draining. Mothers are tired and overwhelmed with the care of the new baby. They reported inadequate support and lack of knowledge of how to cope with fluctuating hormones, lack of sleep, and recovery from birth. Much emphasis on education and anticipatory guidance is given regarding care of the newborn. However, after prolonged attention during pregnancy and birth, there is relatively little attention to the mother's health and well-being in the postpartum period. Mothers need to monitor their own health and recognize what is normal and what is not. They need to know who to call or where to go if they see warning signs. The sooner the health-care provider identifies the warning signs, the sooner they can make the diagnosis and provide necessary care. The American College of Obstetricians and Gynecologists (ACOG) acknowledge the importance of redefining postpartum care in a Committee Opinion #736 that reinforces the importance of the “fourth trimester” and supports anticipatory guidance beginning in pregnancy (ACOG, 2018).

Suplee, Bingham, and Kleppel (2017) surveyed maternity nurses regarding time spent specifically teaching women about warning signs of postpartum complications. That time ranged from less than 5 minutes to over 30 minutes with the majority of nurses spending less than 10 minutes teaching warning signs. Topics most likely to be discussed were postpartum depression, hemorrhage, and infection. Topics least likely to be discussed were potential for a cardiac event and pulmonary embolism.

According to the WHO (2018), 60% of maternal deaths are preventable. To prevent mortality from obstetric complications, women must know possible complications, how to recognize their symptoms, the difference between the need for prompt attention and immediate care, and how to obtain the appropriate care in a timely manner. The Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN), The ACOG, and United States Department of Health and Human Services (USDHHS) support efforts to improve postpartum education. AWHONN recommends standardized education about post-birth warning signs at hospital discharge to ensure that all mothers receive vital information about maternal complications.

They have identified signs of potentially life-threatening postpartum complications that need to be identified and promptly reported. This information is summarized in POST-BIRTH Warning Signs (Figure 1) (AWHONN, 2017a). This information is intended to be given to mothers as part of standardized comprehensive postpartum discharge planning and education.

Figure 1.

POST-BIRTH Warning Signs.

The Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN), developed the acronym POST-BIRTH as a way to remember the warning signs and know which steps to take. The POST-BIRTH Warning Signs are: Pain in chest Obstructed breathing or shortness of breath Seizures Thoughts of hurting yourself or someone else - Bleeding, soaking through one pad/hour, or blood clots the size of an egg or bigger Incision that is not healing Red or swollen leg, that is painful or warm to touch Temperature of 100.4°F or higher Headache that does not get better, even after taking medicine, or bad headache with vision changes If you see a sign in the POST section, call 911. If you see a sign in the BIRTH section, call your health-care provider. If you can't reach them, call 911 or go to the emergency room. Inform anyone you call—911, emergency room, urgent-care provider, or your health-care provider—that you have given birth in the last year. Copyright 2016. AWHONN. Washington, DC. Care providers can download the AWHONN POST-BIRTH warning signs flyer, translations of the flyer, magnets, and online education for CNE credit from the www.AWHONN.org website at https://www.awhonn.org/page/POSTBIRTH

The first serious post-birth complications identified by AWHONN are cardiovascular. Hormonal changes in the cardiovascular system in pregnancy puts an extra workload on the heart. Plasma volume and cardiac output increase by 50% along with an increased resting heart rate (Franklin, Benton, & Parekh, 2011). Women with congenital heart conditions of advancing maternal age and risk factors such as hypertension and pre-eclampsia are at higher risk of a cardiac event (Elkayam, Goland, Pieper, & Silversides, 2016). Shortness of breath, difficulty in breathing, chest pain, and palpitations are signs that require immediate attention such as calling 911 or going to an ED (AWHONN, 2017b).

Another cardiovascular complication is hypertension, which is higher than normal blood pressure. Severe headaches, which occur with hypertension, may not respond to over-the-counter pain medications and hydration (AWHONN, 2017b). Severe hypertension that is unchecked could result in organ damage. When hypertension is accompanied by protein in the urine and edema of the face, hands, and lower extremities it is called preeclampsia. Other changes that may occur with preeclampsia are severe headaches, visual disturbances such as spots before the eyes or seeing halos around lights (Ricci, 2017). The mother may also experience pain in the right upper quadrant of the abdomen and have changes in her level of consciousness. If seizures occur with hypertension, it is called eclampsia and requires calling 911 immediately. For other symptoms, the mother or her family should call the health-care provider (AWHONN, 2017b).

Postpartum depression can occur from one week to 1 year after giving birth. New mothers, or their families, must recognize the signs of depression. The mother might think about hurting herself or her baby, or feel out of control or unable to care for herself or her newborn. She may be sad or depressed much of every day and either have trouble sleeping or sleep too much. And she may have trouble bonding with her newborn. If the mother thinks she might harm herself or her newborn, she should call 911 or go to the ED. For other symptoms of depression such as sadness, withdrawal, or difficulty coping with parenting, she should call her health-care provider (AWHONN, 2017b).

Activation of clotting factors around the time of birth makes the mother more prone to having a blood clot. If a clot travels to the lungs, it is called a pulmonary embolism. Symptoms would include shortness of breath even at rest, and fast, shallow, rapid respirations. The mother may have chest pain that gets worse when coughing and may have a change in her level of consciousness. For any of these warning signs she should call 911 or go immediately to the ED (AWHONN, 2017b).

Another common site for a blood clot in the post birth period is in a vein in the calf of the leg. A venous thromboembolism will cause pain, swelling, burning or redness in the affected leg, and the leg will be tender to touch. The mother should report any of these signs of venous thromboembolism to her health-care provider (AWHONN, 2017b).

Most women know there will be vaginal bleeding after birth but they need to be able to recognize when bleeding is excessive. The uterus must stay contracted to prevent an excessive amount of bleeding. Emptying her bladder, massaging her uterus, and putting her baby to breast can help to contract the uterus and provide mechanical hemostasis to compress bleeding blood vessels (Belfort, 2017). Postpartum hemorrhage is defined as bright red bleeding that saturates more than one sanitary pad per hour, or passing clots the size of an egg or larger. With either of these signs of hemorrhage, the mother should call the health-care provider immediately (AWHONN, 2017b).

Postpartum infection is caused by the entry of bacteria into the uterus that can then spread to the whole body. Procedures performed during labor and delivery can introduce infection into the uterus (Jansen, Gibson, Bowles, & Leach, 2016). Signs of infection would include a temperature of above 100.4 degrees Fahrenheit, tachycardia, foul smelling discharge from the vagina, and lower abdominal pain (Chen, 2017). Episiotomy, perineal lacerations, or cesarean surgery incisions that exhibit redness or discharge could also indicate an infection. For any of these signs the mother should call her health-care provider (AWHONN, 2017b).

Whenever the recommendation is for the mother to report to her health-care provider, it is imperative that if she does not get a prompt reply from the physician or clinic, she should call 911 or go to the ED at the nearest hospital. She should not delay action waiting for a delayed return phone call.

IMPLICATIONS FOR CHILDBIRTH EDUCATORS

With the emphasis of childbirth education on preparation for childbirth and care of the infant, it is important for childbirth educators to emphasize that mothers pay more attention to their own recovery, recognize signs of danger and promptly seek medical assistance. Over half of maternal deaths occur in the first month after childbirth (Muza, 2017). Even healthy mothers are at risk at this time. Although the AWHONN POST-BIRTH tool is intended for use at hospital postpartum discharge, childbirth educators can introduce the topic in the prenatal period when expectant parents are more receptive to information. They can emphasize the importance of mothers, and their families, recognizing warning signs and promptly and appropriately reporting them. Given new mothers vulnerability after the birth, childbirth educators must also discuss the importance of keeping routine follow-up visits with their health-care provider. Mothers should display the POST BIRTH warning signs, the correct telephone numbers of their health-care provider, and their appointment dates and times in a prominent place in the home. Family members should be encouraged to be present for this discussion because for some of these complications, the mother may not be able to make decisions or act on her own. When calling 911 or registering in the ED it is also important for the mother or her family to emphasize that she has just given birth and that she is experiencing one of these identified warning signs.

Having established rapport with the childbearing family in the prenatal period, childbirth educators are in a unique position as members of the health-care team to introduce the subject of postpartum maternal care and the recognition of warning signs that need prompt or immediate care. Whenever possible they could make postpartum follow-up phone calls or host support groups to inquire about the mother's status and reinforce this vital information. By involving the family as important members of the health-care team, childbirth educators can empower them to recognize and report these early warning signs, report and respond appropriately, and reduce the possibility of a tragic maternal death.

Biographies

BETTY CARLSON BOWLES is Associate Professor of Nursing at Midwestern State University in Wichita Falls, Texas. In the summer she teaches Public Health at Queen Mary University in London. As a Lamaze Certified Childbirth Educator she taught childbirth classes for 25 years.

MARTY GIBSON is Associate Professor of Nursing with over 25 years experience in nursing and nursing education. She teaches nursing at Springhill College in Mobile, Alabama, and teaches online courses for Midwestern State University. In the summer she teaches Public Health at Queen Mary University in London.

LAUREN JANSEN is Associate Professor of Nursing with over 25 years experience in nursing and nursing education. She teaches nursing at Midwestern State University and coordinates all of the maternal–newborn nursing courses. All three authors regularly publish together in referred journals and present at conferences including recent presentations in Toronto, Paris, and Athens.

DISCLOSURE

The authors have no relevant financial interest or affiliations with any commercial interests related to the subjects discussed within this article.

FUNDING

The author(s) received no specific grant or financial support for the research, authorship, and/or publication of this article.