Maternal Early Warning Signs

by Lisa-Marie S. Cook BSN, RNC-OB, C-EFM, ICCE, CD

Taylor* returned to the hospital three days after leaving with her baby girl. It was the first baby for their little family. “I’m not feeling so great,” she said. “I don’t know if I’m just tired, but I’ve had this headache that won’t go away.” The OB on-call recommended that she come to the hospital now.

When she arrived, she was triaged in the emergency room.  “I told them that I just had a baby, so they sent me up to labor and delivery,” she said almost apologetically. Her first blood pressure on my monitor was 192/ 112.  I took it again.  It was 202/119.  I called the doctor, but not before her eyes closed and she began to seize.  I pressed the emergency button.  This wasn’t a drill; it is every Labor and Delivery nurse’s dreaded nightmare.  I called the rapid response team, Taylor was experiencing an eclamptic seizure.  Preeclampsia can impact the kidneys, liver, uterus, and brain, and is more than just high blood pressure.  It’s an inflammatory response from increased blood volume, and, right now, it was causing Taylor to seize.

May is often the month known to celebrate Mothers. For 861 families in 2020, Mother’s Day was a time of loss and grief as complications from the pregnancy caused an unexpected death also known as “Maternal Mortality.” Somehow, “mortality” doesn’t sound as daunting as “death,” but the fact remains, it happens. The number of Maternal Deaths continues to rise in the United States, compared with 754 deaths in 2019. The maternal mortality rate for 2020 was 23.8 deaths per 100,000 live births compared to the rate of 20.1 in 2019–that is 861 families impacted by a loss. As childbirth workers, we cannot gloss over these facts.  Awareness is key to addressing this issue.

The United States has the highest rate of Maternal Mortality and Morbidity among industrialized countries worldwide. While the United States’ maternal death rate is the highest despite the amount of healthcare available, a bigger concern is “severe maternal morbidity.”

Severe maternal morbidity is defined by the U.S. Centers for Disease Control and Prevention as “unexpected outcomes of labor and delivery that result in significant short- or long-term consequences to a woman’s health.”  It affects a staggering 50,000 to 60,000 women each year.

Here are some notable facts:

  • More than half of recorded maternal deaths occur the day after birth (52%)
  • Causes of death vary widely. Cardiomyopathy) (11%), blood clots (9%), high blood pressure (8%), stroke (7%), and a category combining other cardiac conditions (15%).  Infection (13%) and severe postpartum bleeding (11%) are leading causes of complications.
  • During pregnancy, hemorrhage and cardiovascular conditions are the leading causes of death. At birth and shortly after, infection is the leading cause.  In the postpartum period, once parents are out of the hospital and beyond the traditional six- or eight-week post-pregnancy visit, cardiomyopathy (weakened heart muscle) and mental health conditions (including substance use and suicide) are identified as leading causes.
  • These are Severe Morbidity Diagnosis that have been identified during pregnancy and after birth: Myocardial Infarction, aneurysm, acute renal failure, adult respiratory distress syndrome, amniotic fluid embolism/thrombotic embolism, cardiac arrest, conversion of cardiac rhythm, DIC disseminated intravascular coagulation, eclampsia, cerebrovascular disorders, pulmonary edema/ acute heart failure, anesthesia complications, sepsis, shock, sickle cell crisis, blood product transfusion, hysterectomy, tracheostomy, and ventilation.

Disparities Exist:

  • The maternal death ratio for Black women (37.1 per 100,000 pregnancies) is 2.5 times the ratio for white women (14.7) and three times the ratio for Hispanic women (11.8).
  • A Black mother with a college education is at 60 percent greater risk for a maternal death than a white or Hispanic woman with less than high school education.

A study reported widely disparate pregnancy-related mortality ratios for each group, specifically: Black (40.8%), American Indian/Alaska Native (29.7%), Asian Pacific Islander (13.5%), White (12.7%), and Hispanic (11.5%).

As with maternal deaths, many cases of maternal morbidity can be avoided.

How can we, as Childbirth Educators and Doulas, address this issue and provide the best care to clients and their families? The answer is two-fold: education and follow-up.

Education

We tiptoe and skirt around this issue.  It’s difficult to talk about maternal mortality or morbidity in childbirth classes, and hard to discuss as a doula. Maternal complications—it’s not supposed to happen. How do we educate without causing anxiety or fear of birth?   And how important is it, really, to provide information on maternal mortality and morbidity?  Studies show that poor awareness of obstetric danger signs is a major contributing factor to delays in seeking care and leads to high maternal mortality and morbidity worldwide.  The lack of knowledge is a cause of severe complications and outcomes.  We CAN make a difference here!

Awareness of maternal warning signs and symptoms requiring care is a start.  To educate the public and decrease rates of complications, the Alliance for Innovation on Maternal Health, Center for Disease Control, and AWHONN (Association of Women’s Health, Obstetric, and Neonatal Nurses) have provided free information for education.  See the links to the free resources below.

Warning Signs in Pregnancy require notification to your health care provider to receive help right away. If you are unable to reach your provider, go to an emergency room. Symptoms include:

Headache that won’t go away after taking medicine, or gets worse over timeTrouble breathing or shortness of breath when at restVaginal bleeding or fluid leaking during pregnancy
Dizziness or fainting, or seizures/ “blacking out”Chest pain or fast-beating heartBad smelling vaginal bleeding or fluid leaking after pregnancy
Thoughts of hurting yourself, someone else,  or your babySevere belly pain that doesn’t go awaySwelling, redness in your leg that is painful to touch
Fever- Temperature greater than 100.4’ FBaby’s movements slow down or stop during pregnancyOverwhelming tiredness
An incision that is not healingAny signs of infection-redness or pus-from your vaginal laceration or cesarean incision

Additional tips for using this list:

  • This list is not meant to cover everything you might be experiencing. If you feel like something just isn’t right, it’s always best to tell your provider and get the help you need.
  • Always remember to say that you’re pregnant or have been pregnant within the last year when getting help.

Follow-Up

Postpartum follow-up is another way to decrease poor outcomes following birth. A large proportion of maternal deaths and complications occur after childbirth. Too many women are losing connections to health care after giving birth. Increasing attendance at postpartum visits is a developmental goal for Healthy People 2020.

Currently, only 60% of women attend their postpartum visits. Missed postpartum visits increase the risk for missed medical complications, the onset of chronic health conditions, and access to effective contraception. The importance of a postpartum visit following birth must be stressed, so that identification of those requiring continued care is accomplished.  This is where the doula and the postpartum doula come in! We are on the front lines, often times, when it comes to noticing concerning postpartum symptoms sooner than the 4-6 week follow-up appointments.

Taylor received medications to stop the seizure and stabilize her blood pressure. The stress of preeclampsia caused her kidneys severe damage requiring a stay in the ICU for days and several weeks in the hospital until she recovered enough to go home. Long-term care now includes dialysis and rehabilitation. She survived, but with complications that continue to this day.

The families you instruct and care for depend on you for your wisdom, expertise, and guidance. Please inform them—you may save a life and protect a family.

*Taylor’s* name has been changed to protect the patient, their family, and the providers who cared for them.

Free Resources and Handouts:

Resources

ACOG Committee Opinion. Number 736. Optimizing Postpartum Care. May, 2018. Reaffirmed 2021.Accessed May 22, 2022.

CDC.Maternal Mortality Rates in the United States, 2020  . Accessed May 22, 2022.

https://www.commonwealthfund.org/publications/issue-brief-report/2020/dec/maternal-mortality-united-states-primer Accessed May 17, 2022.

Howell, Elizabeth A. MD, MPP; Egorova, Natalia N. PhD, MPH; Janevic, Teresa PhD, MPH; Brodman, Michael MD; Balbierz, Amy MPH; Zeitlin, Jennifer DSc, MA; Hebert, Paul L. PhD Race and Ethnicity, Medical Insurance, and Within-Hospital Severe Maternal Morbidity Disparities, Obstetrics & Gynecology: February 2020 – Volume 135 – Issue 2 – p 285-293.

Joseph, K. S. MD, PhD; Boutin, Amélie PhD; Lisonkova, Sarka MD, PhD; Muraca, Giulia M. MPH, PhD; Razaz, Neda MPH, PhD; John, Sid MSc; Mehrabadi, Azar PhD; Sabr, Yasser MD, MHSc; Ananth, Cande V. PhD, MPH; Schisterman, Enrique PhD Maternal Mortality in the United States, Obstetrics & Gynecology: May 2021 – Volume 137 – Issue 5 – p 763-771

Nkamba, D.M., Wembodinga, G., Bernard, P. et al. Awareness of obstetric danger signs among pregnant women in the Democratic Republic of Congo: evidence from a nationwide cross-sectional study. BMC Women’s Health 21, 82 (2021). https://doi.org/10.1186/s12905-021-01234-3

Petersen, Emily E., et al., “Racial/Ethnic Disparities in Pregnancy-Related Deaths — United States, 2007–2016,” Morbidity and Mortality Weekly Report 68, no. 35 (Sept. 6, 2019): 762–65. Accessed May 22, 2022.

Ukah, U. Vivian MPH, PhD; Dayan, Natalie MD, MSc; Potter, Brian J. MDCM, SM; Ayoub, Aimina MSc; Auger, Nathalie MD, MSc Severe Maternal Morbidity and Risk of Mortality Beyond the Postpartum Period, Obstetrics & Gynecology: February 2021 – Volume 137 – Issue 2 – p 277-284.