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Most Maternal Deaths Occur Post-Birth

Posted By Institute for Perinatal Quality Improvement, Thursday, August 17, 2017
Updated: Wednesday, August 16, 2017

Author: Debra Bingham, DrPH, RN, FAAN

Tara Hansen, a 29-year-old elementary school special education teacher from New Jersey, experienced a normal, healthy first pregnancy and gave birth to a healthy baby boy in March 2011. When Tara didn’t feel well after giving birth, the health care providers she sought help from assumed that the symptoms she described were simply the ordinary “expected' postpartum symptoms. She was considered a healthy postpartum patient and sent home.

Six days after Tara gave life, she died of a postpartum infection. Tara had tried to get help and knew she didn’t feel right, but she also did not have sufficient information about postpartum symptoms that are considered red-flag warnings of life-threatening conditions.

Her death could likely have been prevented had she received timely, effective treatment, but the clinicians she asked for help did not take her symptoms seriously enough. The tragedy of Tara’s death led Ryan, her devoted husband, and his family to form the Tara Hansen Foundation. They tell the story of Tara’s death because they want her death to motivate change and improve outcomes for all mothers.

The findings of a recent study, "Nurses’ Knowledge and Teaching of Possible Postpartum Complications,"  which surveyed 372 Registered Nurses who care for women during postpartum indicates that nurses would benefit from greater education about postpartum risks. Forty-six percent of the nurses surveyed were not aware that maternal mortality rates have increased in the last decade, and the majority did not know that most maternal deaths occurred postpartum.

Two-thirds of the nurses surveyed reported spending 10 minutes or less teaching about warning signs of potential postpartum complications prior to new mothers being discharged from the hospital, which may or may not be enough time to ensure comprehension of such important information. Many women, like Tara, leave the hospital unable to adequately determine if the symptoms they notice after birth are normal and expected, or abnormal requiring urgent or emergency medical attention.Another important factor is ensuring that women are not discharged home from the hospital too early and receive adequate discharge education.

Our goal at the Institute for Perinatal Quality Improvement (PQI) is to support leaders in developing and implementing Quality Improvement (QI) projects that save lives. One example of a QI project Dr. Debra Bingham, developed and implemented when working as Vice President of Research, Education, and Practice at the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) was the "Empowering Women to Obtain Needed Care" pilot project. This pilot project was possible due to support from the Merck for Mothers program. The goal of the AWHONN pilot project was to increase women's access to quality information about risks for post-birth complications, especially before discharge from the hospital but after giving birth.

The program was designed to better equip women, their partners with information that would help them recognize health changes or warning signs of postpartum complications. The tools created for this project included a Discharge Education Checklist (for nurses to use when teaching all women to recognize warning signs of postpartum complications that could occur after discharge) and a Patient Handout titled "Save Your Life," that included 9 symptoms that use the acronym "Post-Birth". The emergency symptoms that require calling 911 spell out POST:

  • Pain in the chest
  • Obstructed breathing or shortness of breath
  • Seizures
  • Thoughts of hurting yourself or your baby

 The symptoms that require the urgent attention of one's health care provider spell out the word BIRTH:

  • Bleeding, soaking through one pad per hour, or blood clots the size of an egg or bigger, or an
  • Incision that is not healing,
  • Red or swollen leg that is painful or warm to touch,
  • Temperature of 100.4 degrees Fahrenheit, or higher
  • Headache that does not get better, even after taking medicine, or bad headache with vision changes.

These tools and a description of this program were published in the peer-reviewed journal Nursing for Women’s Health. New mothers need to be encouraged to reach out to their health care provider if they have these or other symptoms that concern them. We cannot predict which women will have a post-birth complication. That is why ALL new mothers need to be encouraged to reach out to their healthcare provider if they have these or other symptoms that concern them.  The AWHONN “Save Your Life” handout and the education she received from a nurse before discharge, helped 27-year-old Abigail (not her real name) save her own life. In her second week postpartum, Abigail experienced some of the symptoms, including "shortness of breath," listed as important warning signs on the patient handout under "Call 911 if you have."  Abigail was taken immediately to the emergency room, where she was diagnosed with a pulmonary embolus in her right lung. Abigail believes the post-birth education and handout she received before discharge saved her life.

Nurses may hesitate to teach women about these signs and symptoms of potential complications because they don't want to scare anyone. However, every new mother needs to be taught which post-birth symptoms are emergencies and which ones are urgent. Start the conversation by saying something like, "Although most new mothers do not experience life threatening complications, I want to make sure that you are aware of the 9 most common warning signs. I also want you to trust your instincts, if you think something might be wrong, seek care." Teaching a new mother this information could save her life!

Find links to other related facts and resources here and let PQI know if you would be interested in joining the Postpartum Discharge Education PQI Action Community.

Sign-up as a Basic (FREE) or Premium PQI Subscriber and pin your postpartum discharge education or other perinatal QI projects on our QI Project Maps. The Institute for Perinatal Quality Improvement (PQI) is honored to have received support from the Tara Hansen foundation to launch the New Jersey Quality Improvement Project Maps pilot program.  Thanks to this generous gift, New Jersey is the first state to work with PQI and launch a state-wide PQI Mapping effort.

Register to attend PQI's free education on: Improving Postpartum Education about Potential Maternal Complications. 


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Tags:  maternal morbidity  maternal mortality  Postbirth  postbirth warning signs  postpartum  postpartum complications  quality improvement 

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