- Postpartum hemorrhage and complications from preeclampsia account for over 50,000 maternal deaths per year (Karrar, 2024).

-CDC (2024) reports that over 80% of pregnancy and post-pregnancy-related deaths are preventable, but continue to happen due to factors such as educational deficits, rushed assessments by nurses, and missed early intervention.

Quick Facts:

-Preeclampsia is a disorder of pregnancy with new-onset hypertension that can develop severe features such as seizures or coma, which can then be described as actual eclampsia (Karrar, 2024).

-Postpartum hemorrhage occurs with a blood loss of 500ml or more in vaginal births or a blood loss of 1000ml or more with cesarean sections (Ricci, 2017).

• Following birth, mothers at risk for postpartum hemorrhage (PPH), are not receiving adequate prophylactic treatment, resulting in a 27% contribution to maternal death (Gallos et al., 2023).

• Many mothers are also not educated on what signs and symptoms to look for post-discharge that would indicate they need to seek medical care (Lowe, 2022).

Who is affected?

• Patients are directly affected by this issue and suffer consequences such as unnecessary medical complications and/or death.

• Nurses are also affected as they need to advance to more complex and immediate interventions. This can increase their workload and make it harder to care for their other patients.

• Families are affected since unexpected complications of their loved one's health can cause trust issues between family members and the healthcare team.

Where and When?

• This can occur during hospitalization after delivery or after the patient is discharged home

Why is this important?

• Mothers require well-timed assessments, interventions, and effective nursing judgment to improve their care outcomes.

Did you know?

• Women of color are three times more likely to die from maternal complications than white women.

• This can be attributed to implicit bias by physicians and nurses, genetic predispositions such as preeclampsia, and lack of access to prenatal care related to socioeconomic backgrounds (Lister, 2019).

The Solution

• Standardized protocols should be implemented for the type and frequency of early interventions such as fundal checks, safe administration of magnesium for dangerously high blood pressure in moms with preeclampsia, and possibly a programmed system within EPIC to flag a certain combination of symptoms, similar to a Sepsis Alert.

• An example of this could include subjective data from the patient such as feeling lightheaded/dizzy, a section as opposed to a vaginal delivery, a large amount of blood loss from birth, high heart rate with low blood pressure. The system would identify the data in the patient's chart and prompt the nurse with an alert to identify the risk of hemorrhage.

• Mothers face challenges regarding a healthy birth related to non-medical factors as well, some of the common risks for maternal health related to subpar care, can occur before the first prenatal visit.

• Medical vs Non-medical risk factors: Medical risk factors include conditions mentioned above such as Preeclampsia, postpartum hemorrhage, and preexisting health conditions like cardiovascular disease (Joseph et al., 2024).

• Non-medical risk factors can include things like diet, location & access to care, abusive relationships, and unaddressed mental illness- which can be linked to higher incidences of postpartum depression and/or suicide (CDC, 2024).

• Implicit racial bias by the healthcare team also presents an additional problem for mothers, leading to poorer outcomes in care and pain management (Saluja & Bryant, 2021).

Why does this matter?

• Risk factors for maternal death and complications do not start and stop with medical complications.

• It's important to know that the health and safety of mothers aren't limited to their time in the hospital. As nurses, it is our job to advocate for our patient's foreseeable needs during our bedside care.

• This can include things like offering Telehealth services for mothers who have limited access to care and have concerns about postpartum complications, offering domestic violence resources so mothers have a safe, non-dangerous to return home and recover, and being aware of any implicit bias the patient has or will receive during their hospital stay, and how we can combat that.

• Nurses assess mothers for appropriate bleeding after birth, provide depression screening before discharge, monitor for signs and symptoms of impending hemorrhage, and educate mothers on what level of bleeding and clotting is appropriate following delivery, and at what intervals they are appropriate.

What nurses are not doing

• Nurses often rely on Estimated Blood Loss (EBL) as opposed to Quantitative Blood Loss (QBL) which is widely recognized to be inaccurate and underestimates blood loss (Ayala et al., 2023).

• Lack of communication between nurses about retained placental fragments during delivery and how this can contribute to excessive clotting (Ricci, 2017).

• Inconsistencies in hospital policies concerning different protocols for care and frequency of assessments.

• Delayed treatment of uterotonic drug therapy (Gallos et al., 2023).

How this affects the issue

• Without timely intervention or prophylactic treatment of PPH, maternal risk of death dramatically increases. A 2023 international study by The New England Journal of Medicine asserts that only 53% of women who suffered from postpartum hemorrhage received care with a uterotonic drug such as oxytocin, carbetocin, ergometrine, or misoprostol(Gallos et al., 2023).

• Inconsistencies in policy result in mothers receiving different levels of care, when all care should be based on the most up-to-date EBP.

• If nurses are misinformed about the patient's total blood loss, they may be unprepared for the potential challenges ahead (Gallos et al., 2023).

How nurses can improve the situation

• Nurses can strive to use the QBL method when recording blood loss post-delivery by weighing blood-soaked items on a scale (Ayala, 2023).

• Nurses can also advocate for standardized policies regarding early intervention and medication administration for PPH.

• Nurses spend the most time with recovering mothers who are at their most emotionally and mentally vulnerable.

• This time is crucial for assessment, intervention, and education.

How nurses can help

• Nurses can join committees in hospitals to advocate for consistent policies based on evidence-based practice

• Nurses should prevent missed vital information in their assessments, especially in the first 24 hours after delivery as mothers are at highest risk for PPH during this time.

• Mothers should also be educated on what warning signs to look for and ways to promote health post-delivery.

• Warning signs include passing clots larger than a plum or golf ball, blurry vision, sudden fast heartbeat accompanied by feeling dizzy or completely saturating a pad in blood in one hour or less after the first few hours of delivery (Joseph et al., 2024).

• Mothers should be educated on the benefits of breastfeeding, when possible, to promote uterine contractions and decrease bleeding as well as emptying a full bladder so the uterus does not become displaced and have a difficult time contracting (CDC, 2024)

Why it matters:

• Standardizing treatment ensures equity in care throughout all healthcare systems.

• Accurate data and information is needed to set the foundation for appropriate treatment.

• The education received, especially by new mothers, will help them for the months to come after discharge. By helping mom stay healthy, we are helping baby too.

• Lack of adequate staffing/large patient load. Nurses sometimes rush through patient assessments and miss vital cues of impending hemorrhage (Haddad, 2023).

• Disorganization and chaos in the delivery room make it difficult to gather all blood-soaked pads and weigh them, which is probably why EBL seems to be the standard for recording blood loss (Ayala et al., 2023).

• Communication gaps between staff related to limited timing and nurse burnout during shift changes (Haddad, 2023).

Solutions:

• Adequate staffing and reasonable patient load so nurses have sufficient time to go thorough assessments.

• Better organization in delivery rooms and ORs when it comes to collecting blood items for measuring.

• Nurses provide written reports with important details gathered throughout the night to ensure important facts are not accidentally skipped during verbal reports due to fatigue, especially for night shift nurses.

• Nurse-patient ratios must be realistic in terms of what care the nurse will be able to provide considering the workload at hand.

• Essential care that can negatively be affected by time restraints includes education, thorough assessments with ample time to chart when necessary, and the timing for early intervention.

Having ample staffing and specialty staffing when appropriate (Haddad, 2023).

• An example of this would be having a lactation consultant when needed; nurses must be skilled enough to educate new moms on breastfeeding, however, this can be a lengthy process that takes the nurse away from other time-sensitive matters.

Maintaining organization despite a fast-paced environment (Ricci, 2017).

• Many essential details can be missed or charted at later times, which leaves room for misremembering events and information. I believe that nurses should be offered verbal recording devices or have a scribe in the delivery room, for example. This would alleviate the stress of having to juggle so many different roles and would, in turn, provide more accurate, reliable information. The nurses could listen to the verbal recording at a calmer time and chart events as needed.

• Prophylactic care is essential. Illness is much easier to manage when primary intervention plays a role. For maternal care, this can include things such as prenatal visits, a healthy diet with the supplementation of vitamins when necessary to support the baby's growth, and blood pressure medication adherence for mothers at high risk for preeclampsia or eclampsia.

• Patient education can be the most beneficial care of all. As nurses, we care for our patients in the hospital setting without thinking, while that type of care is undoubtedly important, providing patients with the knowledge to care for themselves at home and what resources to seek help from post-discharge, can arguably be more important as it empowers the patient with the autonomy needed to be an advocate for their treatment and care, throughout their life span.

• Consistency in care is key to being able to measure areas for improvement or policy adjustments as needed. Consistency in care can almost be observed as the Control of nursing. It allows nurses to easier visualize any deviations from treatment plans and why certain adjustments do or don't work.

During my time at Sentara College, I have understood these concepts both in a theoretical and clinical setting. Understanding these concepts has prepared me for leadership for multiple reasons. Understanding and valuing preventive care will help me think proactively rather than reactively, which is a key leadership trait. Leaders are not just problem-solvers; they are forward-thinkers who anticipate needs and reduce risks before issues escalate. Patient education requires effective communication, empathy, and teaching skills. Teaching patients how to manage their care means the nurse understands that our job is to not only care for patients in a hospital setting but to ensure they will be in charge of their entire wellness trajectory. Finally, consistency in care will encourage me to look towards EBP when adhering to policy or potentially revising policy to create an enhanced healthcare experience for all patients in the future.

One of the most impactful strategies in promoting maternal health is patient education. This knowledge allows patients to advocate for themselves, recognize potential warning signs, and seek timely medical attention when necessary.

Despite the clear benefits, nurses often face considerable challenges in implementing these interventions. Like many other areas within the healthcare system, maternal healthcare suffers from a nationwide nursing shortage. This shortage places a heavy burden on existing staff, limiting the personalized care and education they can provide. Additionally, disorganization within hospital systems and inconsistent policies can further hinder the ability of nurses to carry out their roles effectively.

To overcome these barriers, research emphasizes the importance of consistent, evidence-based hospital policies, improved communication among care teams, and adequate staffing levels. These elements are essential to creating an environment where nurses can deliver high-quality care and education without unnecessary constraints.

Ultimately, we must shift our focus beyond bedside treatment and consider the long-term well-being of our patients. Proactive education and empowerment are just as vital as medical intervention. As nurses, it is our responsibility to ensure that every patient leaves our care not only healthier but more informed and prepared for the future.

Ayala, M., Nookala, V., Fogel, J., & Fatehi, M. (2023). Visual estimation of blood loss versus quantitative blood loss for maternal outcomes related to obstetrical hemorrhage. Baylor University Medical Center Proceedings, 36(3), 341–345. https://doi.org/10.1080/08998280.2023.2187248

CDC. (2024, September). Preventing pregnancy-related deaths. Centers for Disease Control and Prevention. https://www.cdc.gov/maternal-mortality/preventing-pregnancy-related-deaths/index.html#:~:text=More%20than%2080%25%20of%20pregnancy%2Drelated%20deaths%20are%20preventable.

Gallos, I., Devall, A., Martin, J., Middleton, L., Beeson, L., Galadanci, H., Alwy Al-beity, F., Qureshi, Z., Hofmeyr, G. J., Moran, N., Fawcus, S., Sheikh, L., Gwako, G., Osoti, A., Aswat, A., Mammoliti, K.-M., Sindhu, K. N., Podesek, M., Horne, I., … Coomarasamy, A. (2023). Randomized trial of early detection and treatment of postpartum hemorrhage. New England Journal of Medicine, 389(1), 11–21. https://doi.org/10.1056/nejmoa2303966

Haddad, L. M. (2023, February 13). Nursing shortage. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK493175/

Joseph, K. S., Ananth, C., Schisterman, E., Brandt, J., Mehrabadi, A., Chan , W., Sabr, Y., John, S., Razaz, N., Muraca, G., Boutin, A., & Lisonkova, S. (2024, April). Maternal mortality in the United States: Are the high and rising rates due to changes in obstetrical factors, maternal medical conditions, or maternal mortality surveillance? - american journal of obstetrics & gynecology. Maternal mortality in the United States: are the high and rising rates due to changes in obstetrical factors, maternal medical conditions, or maternal mortality surveillance? https://www.ajog.org/article/S0002-9378(24)00005-X/fulltext

Karrar, S. A. (2024, February 25). Preeclampsia. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK570611/

Lister, R. L. (2019). Black maternal mortality-the elephant in the room. World Journal of Gynecology & Womens Health, 3(1). https://doi.org/10.33552/wjgwh.2019.03.000555

Lowe, G. (2022, April 1). Exploring Risk Factors for Maternal Mortality: A Qualitative Study. https://ecommons.udayton.edu/cgi/viewcontent.cgi?article=1361&context=uhp_theses

Ricci, S. S. (2017). Essentials of maternity, newborn, and women’s Health Nursing. Wolters Kluwer.

Saluja, B., & Bryant, Z. (2021). How implicit bias contributes to racial disparities in maternal morbidity and mortality in the United States. Journal of Women’s Health, 30(2), 270–273. https://doi.org/10.1089/jwh.2020.8874