Part of a multi-column series focused on Maternal and Infant Health in Southeast Arkansas.

Becoming a parent is intimidating, but I don’t want national news stories about maternal death rates to concern you or your loved ones unnecessarily. In my last column on maternal health, I discussed the progress our state has made in identifying barriers to providing optimum care for new mothers- specifically in the areas of post-partum hemorrhage and hypertensive emergencies. Through the UAMS program we helped pilot, POWER (Perinatal Outcomes Workgroup by Education and Research), several hospitals including our own, Drew Memorial, have implemented “safety bundles” to combat these two issues. The bundles are a collection of best practices and resources that we transitioned to over a year ago, and since implementing them, the results in our facility have been impeccable. I’ll explain more about what these bundles mean for our local patients and what other practices are in place to improve the experience for expectant and new mothers.

Our greatest two local concerns are the same aforementioned concerns at the state and national level: Post-partum hemorrhage (bleeding excessively after delivery, which can be very gradual) and hypertensive emergencies (a severe increase in blood pressure that can lead to stroke).

Nearly all post-partum hemorrhage deaths are preventable. If appropriate treatment begins early, there is no reason to be concerned that a hemorrhage will be life-threatening. That’s why our Labor & Delivery and Post-Partum staff members undergo special training in identifying a hemorrhage before it becomes serious.

Before a mom delivers in our hospital, we screen her for risk factors. About 60 percent of those who experience a post-partum hemorrhage (PPH) have one or more of the following attributes: pre-pregnancy BMI of greater than 50 (considered obese); suspected placental previa (when the placenta partially covers the cervix); diagnosed bleeding disorders; prior C-section; if mom has given birth more than four times previously; prior post-partum hemorrhage; low blood or low platelet count. We watch these mothers even more closely for hemorrhage, but keep in mind that still 40% of those who experience one do not exhibit these symptoms prior to delivery.

Significant blood loss leads to the patient death, and it can happen after either a vaginal or C-section delivery. However, the gradual nature of blood loss sometimes makes identifying a PPH difficult. Of course some blood loss is normal, so the cumulative blood loss over time has to be monitored. Research shows that monitoring quantitative blood loss (not estimating) by using graduated drapes during delivery and weighing any padding contributes to being able to quickly identify a PPH.

After delivery, our concern is with monitoring mom for signs of PPH. We have a special post-partum hemorrhage “crash cart” in our Labor & Delivery unit, a practice that began as part of implementing the PPH safety bundle. The cart is kept fully stocked with instruments and materials needed to save a patient who is suspected to be experiencing a hemorrhage. We also have a minimized version of this cart- called a “PPH crash tray” – in our post-partum unit. Our patient care team also follows protocols for regular, cumulative weighing of that padding, even if the patient has moved from Labor & Delivery to the Post-partum recovery floor.

It’s important that our annual hands-on skills training includes reviews of these practices and continued attention on monitoring post-partum vital signs. Staff at many credentialed levels take vital signs- not just RNs – so we review how a gradual change in vital signs can be indicative of a gradual hemorrhage. We also host UAMS on-site each quarter for Obstetric Emergency Training for our staff.

Our post-partum monitoring of subtle changes in vitals and bleeding patterns, as I mentioned, helps us identify PPH, but it is also one of the best ways we can identify hypertensive emergencies before mom is at an elevated risk of having a stroke. RNs check patient vitals frequently to make sure post-partum moms fall into normal ranges. Moms who are at a higher risk for hypertensive emergencies are also screened upon admission to the hospital – a patient may be overweight, have high blood pressure or have been diagnosed with preeclampsia, or she could have other lab or vital sign indicators.

We are grateful for a clinical staff that is very willing and capable of improving and updating best practices to improve our patient outcomes. Since implementing a number of focused trainings and processes, our hospital has seen no patient deaths resulting from post-partum hemorrhage. We have also continued to have no serious post-partum hypertensive emergencies that result in death. While we are extremely proud of these outcomes, as a country we need to continue to make strides toward ending preventable maternal death. The UAMS POWER group has enabled a number of hospitals in our state to begin using these practices, and we are grateful for the successes we can attribute to their recommendations.

In the next column, I will talk about how prenatal care contributes to a healthier delivery, and I’ll also explain how other hospital best practices lead to improved outcomes for both our mom and infant patients.

Kristen Smith, a registered nurse, is the director of labor & delivery, nursery, and education at Drew Memorial Health System in Monticello.

Previous columns:

Introduction

Statewide Attention on Maternal Mortality