As we close out Women’s History Month, and I want to take this moment to discuss an issue that is not only dear to my heart but also takes the lives of more than 700 women each year—maternal mortality.

A maternal death is defined as the death of a woman during pregnancy or within one year of the end of pregnancy. The death is determined to be pregnancy-related if the cause of death is related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes.

Of the 5,259 deaths within a year of pregnancy completion that occurred during 2011–2013 and were reported to the Centers for Disease Control and Prevention (CDC), 38.2% were found to be pregnancy-related. In the United States, more than half of all maternal deaths occur after birth—often after discharge from the hospital. This doesn’t have to happen. In fact, at least half of all pregnancy-related deaths are preventable when the warning signs of pregnancy or childbirth complications emerge and a mom can get the timely care she needs from her healthcare providers. The reality is that many women do not receive consistent messages or adequate guidance on identifying the warning signs of complications, or instructions about when, and where to obtain necessary medical attention.

AWHONN has created specific instructions for acting on these warning signs called “SAVE YOUR LIFE: Get Care for These POST-BIRTH Warning Signs.” Here are the specific signs you should watch for and act on during the first year after birth:

• Pain in your chest
• Obstructed breathing or shortness of breath
• Seizures
• Thoughts of hurting yourself or your baby
• Bleeding that is 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 improve, even after taking medicine, or a bad headache with vision changes

For moms: If you are experiencing any of these post-birth warning signs, contact your health care provider or go to the nearest urgent care or hospital as soon as possible. For serious and potentially life threatening warning signs like pain in your chest, obstructed breathing, seizures, or if you have thoughts of hurting yourself or your baby, call 911. Let all responders know that you gave birth within the past year.

Recognizing and acting on these warning signs and complications that can lead to a mom’s death or injury is essential to reducing maternal deaths in the United States. Share this information with pregnant women you care for. AWHONN is committed to working together with nurses and moms to reduce maternal mortality rates. Let’s help women to be aware and to recognize the signs of post-birth complications in order to begin reversing this alarming trend.

Additional resources:

• Discharge Education on Maternal Morbidity and Mortality Provided by Nurses to Women in the Postpartum Period (JOGNN)
• Improving Postpartum Education About Warning Signs of Maternal Morbidity and Mortality (Nursing for Women’s Health)
• FOR CONSUMERS: Learn These Post-Birth Warning Signs (Healthy Mom & Baby)

Jennifer Doyle is the 2018 AWHONN President and a women’s health nurse practitioner with nearly 25 years of experience in obstetrics. She is the APN of the Women’s Service Line at Summa Health in Akron, OH, as well as faculty and coordinator of the WHNP program at Kent State University in Kent, OH.

It’s staggering to think that 54 to 93 percent of maternal deaths related to postpartum hemorrhage (PPH) could be avoided.

So what can we do on our units to reduce the number of women with complications, or even death, from an obstetrical hemorrhage?

I have taken part in many discussions about high tech simulation and drills, and we are always asking ourselves:

• How can we have effective drills without a simulation lab and simulation models?
• Can low tech simulation play a beneficial role in decreasing obstetrical hemorrhage?

I recently took part in a pilot program that the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN)  trialed on postpartum hemorrhage risk assessments, evidence-based oxytocin orders, and hemorrhage drills and debriefing based upon a variety of settings.

Here are a few ideas that I have implemented without utilizing a simulation lab. These easy suggestions may help every obstetrical unit  raise awareness of obstetrical hemorrhage and contribute to decreased maternal morbidity and mortality.

First, have a mock code on your unit using your own crash cart.  You may be surprised to find out how many nurses are uncomfortable with finding key items in your crash cart.  Use a pillow to simulate a gravid uterus and have one nurse demonstrate left uterine displacement while other nurses deliver compressions and ventilations.  Additional nurses may find supplies, IVs, and medications in the code cart.

Second, devise a scavenger hunt and ask your staff to find the closest location of items needed during an obstetrical hemorrhage.  In many units the OB techs check the hemorrhage cart and the nurses may be less familiar with the items on the cart.  They may be leaving the room to get supplies and medications that are already on the cart.  In a true emergency this will use up valuable time.

Third, consider efficiencies. Do you have your medications locked in a Pyxis or Omnicell?  Do nurses have to remove the uterotonics one at a time? Due to the awareness raised by our hospital’s participation in AWHONNs postpartum hemorrhage project,  the day after our medication administration system was installed our pharmacy was notified that we needed a postpartum hemorrhage kit.  Now with one selection we retrieve ergonovine maleate (methergine), misoprostol (cytotec), carboprost (hemabate) and oxytocin (pitocin).

Fourth, how do you drill? What about drills in an empty patient room?  Have a drill in a patient room with nothing more than a mannequin.  Change the scenarios and include the less common situations.  With a type and screen being completed on most admitted labor and delivery patients it is not common to be ordering uncrossedmatched blood.  I use a scenario that includes a woman presenting to L&D with an obvious hemorrhage. This scenario presents the opportunity to review how and when to retrieve uncrossmatched blood.  What is your procedure?  Is there special paperwork or forms?  During one drill we strongly stressed the time element including how quickly we could generate a medical record number and how much time would be lost if an OB tech was sent for the blood. In our institution uncrossmatched blood may only be released to a physician or nurse.  Take the scenario further and include your massive transfusion protocol.  Review when and how to initiate the protocol.

Lastly, practice quantification of blood loss until it becomes routine.  Use scales, work sheets, and a variety of scenarios to keep staff informed and interested.  These can be presented by a charge nurse on any shift without preplanning.  It is just one more way to keep obstetrical hemorrhage on the forefront of everyone’s mind.  The more awareness we raise the better chance we have of early recognition and intervention. The goal is to have a healthy mother and healthy family.

Donna is a Perinatal Clinical Specialist at JFK Medical Center in NJ.  She has always loved OB nursing and also enjoys teaching.  She is currently an adjunct instructor at Kaplan University and Walden University.  She was the Hospital Lead for AWHONN’s PPH Project.

Citations

Berg, C. J., Harper, M. A., Atkinson, S. M., Bell, E. A., Brown, H. L., Hage, M. L., . . . Callaghan, W. M. (2005). Preventability of pregnancy-related deaths: Results of a statewide review. Obstetrics & Gynecology, 106, 1228–1234.doi:10.1097/01.AOG.0000187894.71913.e8

California Department of Public Health. (2011). The California pregnancy-associated mortality review. Report from 2002 and 2003 maternal death reviews. Sacramento, CA: Author. Retrieved from http://www.cdph.ca.gov/data/statistics/Documents/MO-CA-PAMR-MaternalDeathReview-2002-03.pdf

Della Torre, M., Kilpatrick, S. J., Hibbard, J. U., Simonson, L., Scott, S., Koch, A., . . . Geller, S. E. (2011). Assessing preventability for obstetric hemorrhage. American Journal of Perinatology, 28(10), 753-760.doi:10.1055/s-0031-1280856

Resources

Get free postpartum hemorrhage resources from AWHONN.

Learn more about AWHONN’s Postpartum Hemorrhage Project

For more in-depth info and to learn more about how to reduce clinician errors associated with obstetric hemorrhage mortality and morbidity, join AWHONN’s newest implementation community on Postpartum Hemorrhage.

As a charge nurse on a busy Labor & Delivery unit I am responsible for the nurses on my team that work each day with me. On one particular day we had a patient who was scheduled for a repeat cesarean section for her second baby. Everything was going fine with her recovery in PACU, until I heard an unfamiliar alarm sounding on the unit.

I looked up at the fetal monitor board to see if the monitors indicated anything wrong. I saw that the patient in room 202, who was also in PACU, had a blood pressure of 70/40 and a heart rate of 160. I ran into the room and asked the nurse if she had seen the monitor.

She stated that she had just given the patient IV pain medication and that was why her heart rate was high and blood pressure was low. I said that is unusual for that to happen, it looks more like she is going into shock. I told her to start a second IV line and open both line wide. I checked her fundus to find out that her uterus was boggy and when massaged a mountain of clots came out.

I rang the call bell and asked OB tech to get the scale to weigh the clots and had another nurse, who had since come into the room, to call the doctor and get me an order for methergine. Methergine was given and in 15 minutes more clots were expressed and weighed. By this time we had weighed a total of 1200-1300 mls, not including the 800 mls she had lost in the OR. I asked the nurse to call the doctor back and when she did she said to prep the patient and take her to the OR, the doctor was on her way to the hospital. The patient was taken to the OR and given several units of blood and FFP.

Her uterus was saved for the time being and she was sent to the ICU for the night to be closely monitored. Two days later when she returned to our unit she told me her side of the story. She stated that while everything was happening to her she felt like she was above the room looking down and then she saw her grandparents sitting on a park bench. She told them that she wanted to stay with them and they told her she had to return to take care of her little girls. When she left she told me that we were her angels and we had saved her from death and she appreciated all we did for her and her family.

Later that day the doctor thanked me for “catching” the change in vital signs before she had gotten any worse and that I had probably saved her life. It makes be proud to be able to save someone’s life and reaffirms to me that I made the right career choice many years ago. I love what I do.

Photo: Jennifer Doyle assessing and caring for fellow colleague Amy Burkett, MD, FACOG.

Somewhere in a Labor and Delivery unit, a woman gives birth.  A family is born. A nurse remains at the bedside.  A sentinel, who assesses, plans, and intervenes.  The nurse is equipped with knowledge and skills to holistically care for mom and baby.  The nurse’s primary focus is to promote bonding and breastfeeding. However, despite a safe birth, risk remains.  Postpartum hemorrhage (PPH) is a leading cause of maternal morbidity and mortality.  It is often preventable.

As a labor and delivery staff nurse, there were countless occasions when I held vigil at the side of my patients after they gave birth.  I was prepared with an array of resources to treat PPH. In part, this included uterine massage, oxytocin, methylergometrine, carboprost, and misoprostol.   As a nurse caring for a woman in the immediate postpartum period, my goal was to assess maternal bleeding and avoid PPH, or treat early if it occurred.  I would often stand at the bedside, pondering how much oxytocin I should administer to this new mother, and for how long.

For years, I have wondered about postpartum oxytocin administration.  How much is too much?  Are we as nurses administering enough?  What is the optimal dosage to prevent PPH without causing negative side effects?

I know that I am not alone in my contemplations.

There continues to be a dichotomy between postpartum oxytocin administration and healthcare’s current climate of standardization of practice, checklists, and evidence-based practice.  Typically, diluted oxytocin is administered intravenously during the postpartum period based on what is left ‘in the bag’ after birth.  Example, if there is 200 ml ‘in the bag’, the woman receives 200 ml.  If there is 900 ml ‘in the bag’, the woman may receive 400, 700, or 900 ml.  Additional oxytocin administration may occur if increased vaginal bleeding is noted after delivery, but amount and duration of administration is almost always variable.

Currently, no standardization exists with respect to dosage or duration of oxytocin postpartum¹.  Further, very little evidence exists to validate optimal dosage and duration for the prevention of postpartum hemorrhage².  A team at my institution has embarked on a project to address this clinical quandary. 

In 2011, our multidisciplinary team developed a standardized postpartum oxytocin administration protocol to prevent postpartum hemorrhage (PPH).  Our protocol was based on the limited evidence available at that time.  A multidisciplinary team reviewed several trials’ data in which 10 units to 80 or more units of oxytocin were given postpartum for a duration of <1 to 12 hours^3-7.   Our protocol is a “middle of the road’’ approach in which a total of oxytocin 60 U is administered intravenously post-delivery via infusion pump.  Our protocol is as follows:  a bolus of oxytocin 15 U in 250 mL of lactated Ringers solution (LR) at delivery followed by an additional oxytocin 15 U in 250 mL LR over the next hour, then oxytocin 30 U in 500 mL LR at a rate of 125 mL/hr for the following 4 hours. Thus, the total time for oxytocin administration post-delivery is 5 hours.

We have since performed a retrospective quality improvement assessment comparing PPH rates at 6-months pre-protocol (n = 1267) with rates at 6-months post-protocol (n = 1440) implementation. PPH was defined as PPH treatment by pharmaceutical, mechanical, or surgical methods. Inclusion criteria included all births at greater than 23 weeks’ gestation from April 2012 to March 2013. Patient characteristics for both cohorts were similar for race, age, parity, gestational age, delivery type, and neonatal weight.

The PPH rate decreased 37% after protocol implementation (adjusted relative risk [ARR], 0.63; 95% confidence interval [CI], 0.46–0.91). Administration of misoprostol, carboprost, methylergonovine maleate, and blood products decreased post-protocol implementation by 36%, 38%, 32%, and 22%, respectively. The PPH rate for women with a vaginal delivery decreased significantly after protocol implementation (5.9% pre-protocol vs 3.8% post-protocol; P = .03). The PPH rate for women undergoing cesarean delivery increased, but not significantly, after protocol implementation (6.9% pre-protocol vs 8.6% post-protocol; P = .34).  We did not control for some PPH risk factors, including abnormal insertion of placenta, preeclampsia, and multiple gestation. Despite this limitation, our PPH rate for women undergoing cesarean delivery is lower than other published rates.^8,9

These findings were a preliminary step.  Based on our 6 month pre/post outcomes, our team was very enthusiastic about performing a larger analysis to see if we would confirm these initial findings.   However, a lack of funding prevented data retrieval and analysis.  Our health system’s management supported the expansion of the project, if we could obtain funding. AWHONN seemed the perfect fit for our project’s aims.  AWHONN’s  PPH Project is a national model for PPH quality improvement. Our team responded to AWHONN’s  call for grant applications and  were extremely honored when we were notified that our  project:  Evaluation of a Standardized Protocol for Oxytocin Administration to Prevent Postpartum Hemorrhage, was selected as the 2015 Hill-Rom, Celeste Phillips Family-Centered Maternity Care Award Recipient!

This $10,000 award provides the funding necessary to complete a full 2 year pre/post review, which is now underway!

We believe that the results of our full 4 year review will be of great  interest and value to nurses practicing at the bedside.  We believe our project and subsequent results will have widespread implications for any multidisciplinary team caring for women in the postpartum period.  Personally, I hope that the protocol study and results will help my fellow nurses who find themselves at the bedside, just as I have, wondering about the dose and duration of oxytocin to prevent PPH.  Preventing maternal morbidity and mortality through reduction of PPH is a timely topic of extreme importance.

We are thankful to AWHONN, AWHONN’s Research Advisory Panel, and Hill Rom for the award.  We hope that our findings lead to better outcomes and increased safety for the women and families that we serve.

Jennifer Doyle, MSN, WHNP-BC
Jennifer Doyle, a member of AWHONN’s Board of Directors and is also the perinatal outreach educator/APN for the Women’s Service line at Summa Health System’s Akron City Hospital in Ohio. Jennifer leads multiple research and quality improvement projects within her facility and across the state of Ohio. Many of her projects focus on intrapartum safety.

References

1.Harvey, C. and Dildy, G. Obstetric Hemorrhage.  Practice Monograph.  Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN).  2012.

2. AWHONN. Practice Brief: Clinical Management for Women’s Health and Perinatal Nurses: Oxytocin administration for management of third stage of labor. May, 2014. (2).
3. Tita AT, Szychowski JM, Rouse DJ, et al. Higher-dose oxytocin and hemorrhage after vaginal delivery: a randomized controlled trial. Obstet Gynecol. 2012;119(2 pt 1):293–300.
4. Munn MB, Owen J, Vincent R, Wakefield M, Chestnut DH, Hauth JC. Comparison of two oxytocin regimens to prevent uterine atony at cesarean delivery: a randomized controlled trial. Obstet Gynecol. 2001;98(3):386–390.
5. Murphy DJ, MacGregor H, Munishankar B, McLeod G. A randomised controlled trial of oxytocin 5IU and placebo infusion versus oxytocin 5IU and 30IU infusion for the control of blood loss at elective caesarean section: pilot study. ISRCTN 40302163. Eur J Obstet Gynecol Reprod Biol. 2009;142(1):30–33.
6. King KJ, Douglas MJ, Waldmar U, Wong A, King RAR. Five-unit bolus oxytocin at cesarean delivery in women at risk of atony: a randomized, double-blind, controlled trial. Anesth Analg. 2010;111(6):1460–1466.
7. Gungorduk K, Asicioglu O, Celikkol O, Olgac Y, Ark C. Use of additional oxytocin to reduce blood loss at elective caesarean section: a randomized control trial. Aust N Z J Obstet Gynaecol. 2010;50(1):36–39.
8. Dagraca J, Malladi V, Nunes K, Scavone B. Outcomes after institution of a new oxytocin infusion protocol during the third stage of labor and immediate postpartum period. Int J Obstet Anesth. 2013;22(3):194–199.
9. Sheehan SR, Montgomery AA, Carey M, et al. Oxytocin bolus versus oxytocin bolus and infusion for control of blood loss at elective caesarean section: double blind, placebo controlled, randomised trial. BMJ. 2011;343:d4661. doi:10.1136/bmj.d4661.