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November 2017 Vol. 4 No. 10

In This Issue 

Preventing Maternal Morbidity and Mortality: Improving Post-Birth Warning Signs Education

Kara Johnson, DNP, RNC-OB, CNS

Many of us were shocked by the NPR story released last Spring on Lauren Bloomstein, a NICU nurse that died of HELLP syndrome and hemorrhagic stroke soon after giving birth at the hospital where she worked. The healthcare team failed to recognize and intervene when she developed RUQ pain and severe hypertension. Lauren’s story is one of many stories of women with pregnancy-related deaths in 2016 in Propublica’s Lost Mothers (2017).

As of 2013, the U.S. has one of the highest rates of maternal mortality of all developed countries at 17.3 per 100,000 live births (CDC, 2016). In Oregon, the maternal mortality rate is 13.2 per 100,000 live births (United Health Foundation, 2016). Major health disparities among racial and ethnic groups persist, with Black women experiencing a three to four-fold increase in maternal mortality compared to White women (CDC, 2016). Access to care, health insurance, poverty, and education impact outcomes. These racial and ethnic disparities suggest that system-wide improvements are needed so that all women receive high quality care. For every maternal death a much larger number, about 50,000 women a year (D’Alton, Main, Menard, & Levy, 2014), experience severe morbidity in the U.S. Maternal morbidity includes physical or psychological conditions that result from or are aggravated by pregnancy and have an adverse effect on a woman’s health (CDC, 2016).

The leading causes of pregnancy-related deaths are non-cardiovascular disease (15.3%), cardiovascular disease (14.3%), infection or sepsis (12.7%), hemorrhage (11.3%), cardiomyopathy (10.8%), thrombotic pulmonary embolism (9.0%), and hypertensive disorders of pregnancy (7.6%) (CDC, 2016). Seventy percent of obstetric hemorrhage and 60% of preeclampsia deaths were reviewed as preventable (Main, McCain, Morton, Holtby, and Lawton, 2015). Provider, hospital, and patient contributing factors varied by cause of death supporting implementation of patient safety bundles.

More than 50% of maternal deaths occur

during the postpartum period.

Twenty-five percent of maternal deaths occur intrapartum or immediately following delivery. More than 50% of maternal deaths occur during the postpartum period (Kleppel, Suplee, Stuebe, & Bingham, 2016). Two factors that have contributed to maternal mortality are lack of patient knowledge and a delay in seeking care. A majority of women report that they did not receive adequate guidance for postpartum health concerns (Kleppel, Suplee, Stuebe, & Bingham, 2016). Many patients are only scheduled a single postpartum visit six weeks after hospital discharge with their obstetric provider and as many as 40% never attend a postpartum care visit (ACOG, 2016).

Nurses provide the majority of postpartum discharge education. Many hospitals have a postpartum discharge teaching checklist in the electronic medical record, but have wide variation in content related to maternal warning signs. It is unclear how nurses determine content and what education needs to be provided verbally and what education can be reviewed at home. Many women have expressed that the amount of information they receive in the hospital is overwhelming. With high maternal mortality rates, high rates of women not attending postpartum visits, and wide variation in postpartum education, a standard, evidence-based approach is needed for post-birth warning signs to prevent maternal morbidity and mortality.

AWHONN developed a patient teaching handout with warning signs to promote awareness and understanding of critical signs and symptoms of post-birth complications that can be used for all postpartum women. The handout is available in both English and Spanish and can be printed free of charge if the handout is being used for patient care or educational purposes. A standardized checklist was also developed to guide nurses on post-birth warning signs.

A standard, evidence-based approach is needed for

post-birth warning signs education, such as

AWHONN's "Save Your Life" handout.

Many postpartum complications can be treated if identified quickly and the woman receives prompt medical care. The handout is divided into three sections: when to call 911, when to call a healthcare provider, and descriptions of warning signs that can become life-threatening if prompt medical attention is not received. There is also an important reminder to make sure she tells her healthcare providers that she recently had a baby so that providers are aware the symptoms may be pregnancy related. The intent of this handout is for postpartum women to keep in a place where they can easily access and review. Partner and family education on post-birth warning signs is also strongly encouraged. The discharge teaching checklist was developed for nurses as a reference tool for providing education by defining potential complications, listing specific signs and symptoms, and explaining when and where to seek medical attention (Kleppel, Suplee, Stuebe, & Bingham, 2016).

The U.S. currently has high maternal mortality rates during the postpartum period. A standard, evidence-based approach is needed for post-birth warning signs education, such as AWHONN’s “Save Your Life” handout and checklist to prevent maternal morbidity and mortality. Implementation of standardized patient education program on post-birth warning signs by nurses that care for postpartum women has the potential to save many lives.

For more information and to access AWHONN’s “Save Your Life” patient handout, checklist, and education course visit:


American College of Obstetricians and Gynecologists (ACOG). (2016). Optimizing postpartum care: Committee Opinion no. 666. Obstetrics and Gynecology, 127, e187-e192.

doi: 10.1097/AOG0000000000001487

Centers for Disease Control (CDC). (2016). Pregnancy mortality surveillance system. Retrieved from

D’Alton, M.E., Main, E.K., Menard, M.K., & Levy, B.S. (2014). The National Partnership for Patient Safety.

Obstetrics & Gynecology, 123, 973-977. doi: 10.1097/AOG.0000000000000219

Kleppel, L., Suplee, P.D., Stuebe, A.M., & Bingham, D. (2016). National initiatives to improve systems for postpartum care. Maternal Child Health Journal, 20, 566-570.

Main, E.K., McCain, C.L., Morton, C.H., Holtby, S. & Lawton, E.S. (2015). Pregnancy-related mortality in California: Causes, characterisitics, and improvement opportunities. Obstetrics & Gynecology, 125, 938-947. doi: 10.1097/AOG.0000000000000746

Martin, N., Cillikens, E. & Freitas, A. (2017). Propublica: Lost mothers. Retrieved from

Supplee, P.D., Kleppel, L., Santa-Donato, A., & Bingham, D. (2017). Improving postpartum education about warning signs of maternal morbidity and mortality. Nursing for Women’s Health, 20, 552-557.

doi: 10.1016/j.nwh.2016.10.009

United Health Foundation. (2016). America’s health rankings: Oregon. Retrieved from

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Congratulations and Welcome to Our 2018 Leadership Team

A hearty congratulations to Becky Moore and Donna Talain for their election into the Chair and Secretary/Treasurer positions, respectively, for the 2018-2020 term!

A great big Thank You to our outgoing Conference Co-Chairs, Nancy Alt and Robin Cothrell-Tubbs, for all their hard work through the years bringing you amazing Fall Conferences every year! We know it's a lot of work putting together quality conferences and they've done a spectacular job.

A warm welcome to our new Conference Co-Chairs, Sara Mosher and Sue Walden! With the help of the entire Conference Committee, we have the utmost confidence that this year's Oregon AWHONN Fall Conference will be the best yet. Are you interested in helping to plan our 2018 Oregon AWHONN Fall Conference? Contact the Co-Chairs at [email protected] and [email protected].

Finally, another welcome to Nancy Alt who is taking over the Legislative Coordinator role! Are you passionate about what's going on in healthcare today? Want to learn how you can help shape healthcare on a local level? Contact Nancy at [email protected].

Upcoming Events

Mid-Willamette Valley Chapter Meeting

Oregon AWHONN Abstract Writing Webinar

Wednesday, Jun 9 at 5:00 PM - 6:00 PM

An investment in knowledge pays the best interest.

Benjamin Franklin