Preeclampsia is one of the leading causes of mortality and morbidities caused by pregnancy in both developed and developing countries. Postpartum preeclampsia (PPP) is a rare condition that occurs after delivery of a newborn. The current PPP diagnosis is limited to elevated blood pressures and elevated protein in the urine. PPP is not understood as well as prenatal preeclampsia. The methodology for diagnosing prenatal preeclampsia is by checking for elevated blood pressure that may cause damage to other organs and patients may present with these signs and symptoms. The treatment for prenatal preeclampsia is delivery of the newborn. (Site 5). Much attention has been given to prenatal preeclampsia which has lowered its occurrence. PPP is much less understood and may be its own disease separate from prenatal preeclampsia because treatment of the later is delivery of the newborn which is not the same for PPP. (cite 4)
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Existing literature has an extensive amount of information about prenatal preeclampsia. There is a gap in research about PPP, the occurrence rate, what factors put a person at highest risk, and the most common signs and symptoms. The risk factors for those who are most likely to develop PPP are not thoroughly understood, although there are studies out there working on these determinants. (cite 4) Newer studies have shown that PPP may account for 0.3-27.5% of documented preeclampsia. It is believed that PPP can lead to stroke, brain damage, HELLP syndrome and seizures, if left untreated. These conditions are not only devasting to the patient but also the family system. Also, mothers that go home sooner than 48 hours may be at a higher risk of developing PPP, as PPP is believed to occur 48 hours after delivery but can occur up to six weeks after a mother gives birth to her newborn. (#1) Some of the presumed signs and symptoms (s/s) of PPP include high blood pressure, protein in the urine, a headache that does not get better with medicine, difficulty seeing, nausea, vomiting, upper right abdominal pain, weight gain, and edema. These s/s are very similar to those seen in mothers with prenatal preeclampsia. If mothers are not properly educated about PPP, these signs and symptoms may be missed.
Prenatal visits with a pregnant patient’s obstetrician, which includes the time frame of conception until birth, averages fourteen to sixteen visits. In comparison, only one postpartum visit is scheduled. (cite 3) The American College of Obstetricians (ACOG), which is a nonprofit organization of physicians that advocate for the highest standards of women’s health, previously recommended women follow up within the first 6 weeks. New guidelines established in 2018 recommend mothers have their first postpartum exam sooner than six weeks. However, up to forty percent of mothers miss their six-week follow up exam. (cite 2). PPP may also be missed by this lack of follow up post birth.
It is hard to determine who will be at risk for PPP. Women who have PPP, do not typically have prenatal preeclampsia. A newer study reported that PPP is a separate disease from prenatal preeclampsia. PPP differs in demographic, the s/s that manifest, and laboratory findings. In this study, it is found that PPP affects older patients, mothers that have multiple children and those that come from a lower socio-economic background. The s/s most commonly associated with PPP in this study were headache, changes in vision, nausea and vomiting, seizures, shortness of breath, and laboratory markers that corresponded to hypertension. It has been found that higher level of education in the mother and the number of children the mother has, may determine how well mothers will self-report PPP symptoms. ( cite 4)
There are many factors that go into the best time to educate a mother of the signs and symptoms of PPP. During labor and delivery, mothers may be in pain, or anxious among many other factors contributing to a diminished ability to understand the importance of or retain the information from instruction on PPP. At discharge, mothers are usually exhausted and anxious about taking home a newborn, which can affect how much information is retained. It has been reported that the amount of discharge information mothers are given is overwhelming. Mothers receive information on their own postpartum care and on the care of a newborn. Nurses have a hard time prioritizing which discharge information is of most importance. The discharge instructions across institutions also vary. It has been found that discharge instructions are often inconsistent and are not based on evidence-based practice. (cite 6) At some institutions, there is one single line in the literature about possible PPP, which includes instruction to call the healthcare provider if you have a headache. Furthermore, if women know the warning signs of PPP and react promptly, they can be adequately treated. Overall, there is a gap in educating mothers of possible post birth complications in their own health.
One of the newer models for discharge education being used is POST BIRTH warning signs and is a pneumonic device of when to seek emergency health. It is a one-page paper developed by AWHONN, which is the Association of Women’s Health, Obstetric and Neonatal Nurses. AWHONN support nurses caring for mothers and newborns through research, education and advocacy. Hospitals that have a maternity floor try to follow AWHONN guidelines (cite 7)
POST BIRTH stands for “P-pain in chest, O- obstructed breathing or pain in the chest, S- seizures, T- Thoughts of hurting yourself or baby, B- bleeding through a pad in one hours, large clots, I- incision is not healing, R redness or swelling in leg, T temperature is greater than 100.4, H headache that does not get better with pain medications or change in vision.” (site 6). This pneumonic device is becoming the new gold standard for discharge instructions. It is precise and educates mothers on warning signs that could be potentially life threatening. Patients are told to go home and hang this discharge sheet on their fridge or somewhere everyone in the house can see it, so these symptoms are less likely to be ignored. However, if a patients first language is not English speaking or if the patient is illiterate, the patient may not remember these warning signs. It’s also imperative that the patient puts this in an area where they can be reminded of the warning signs on a daily basis. Otherwise, patients are having to recall from their memory what the warning signs are. As mentioned above, many factors play a role in how much information will be retained at the time of discharge.
The Preeclampsia Foundation has a pictorial guide, the Preeclampsia Symptoms Tear Pad, for the s/s of preeclampsia. It lists the main s/s of preeclampsia with a visual representation next to it. The signs and symptoms include, edema, change in vision, weight gain, headache, and gastrointestinal distress. Although this guide is not meant for PPP, it still may be used to educate mothers for PPP. It has been found to effectively educate mothers, including those who may have poor reading skills. Using this pictorial guide at every prenatal visit may help knowledge retention postpartum. There would be more visits, as mentioned above, fourteen-sixteen opportunities, to educate mothers about the s/s of PPP. These frequent visits coupled with the pictorial Preeclampsia Symptoms Tear Pad, may help mothers respond quickly to PPP. Therefore, mothers that receive prenatal education, as opposed to only postpartum discharge instructions about postpartum preeclampsia (PPP) will be better educated about the signs and symptoms of PPP and when to seek emergent medical attention.
I have been lucky enough to have worked at a community hospital and a teaching hospital. The teaching hospital that I worked at was University Hospitals (UH) MacDonald’s Women’s Hospital. Both the community hospital and the latter have areas that they excel at within the maternity department. I have been able to see areas of opportunity for education in both of these hospital settings and this is the reason why I have chosen to set up my methods section the way I have. This study is attempting to show that frequent exposure to PPP s/s during the whole prenatal period will be more beneficial when compared to only limited education in the discharge teaching. This will be done by having a control group that receives routine prenatal care and education. The experimental group will have mothers that receive extra teaching about PPP.
Women in the experimental group would have an extra five minutes at the end of each one of the prenatal visits where education is performed by a trained registered nurse using the Preeclampsia Symptoms Tear Pad. They will learn the difference of when to call their obstetrician versus when they should go to the emergency room. The patients would then demonstrate the knowledge retained by using the teach back method. Women that have more frequent education in the form of verbal education and a pictorial guide will remember s/s of PPP at one, two, three and four-week periods when compared to those who did not receive this extra teaching. All teaching methods and sessions will be documented to ensure all patients are receiving the same length and type of education. The hope is that being more familiar with the s/s of PPP will in turn help mothers who are experiencing PPP to seek the needed emergent medical attention.
All members of the control group and experimental group would be selected through convenience sampling. Mothers would then be randomly selected into two groups. The mothers selected would be mothers that have one or more children and are twenty-eight to forty years old. These criteria are based on the newer PPP study that found that multiparous mothers that are older are at higher risk for developing PPP. Any mothers who have previously suffered from pregnancy induced preeclampsia or PPP would not be enrolled in this study to prevent previous pregnancy knowledge of preeclampsia. Exclusion criteria would also include any mothers that develop preeclampsia throughout the pregnancy. These mothers tend to be followed more closely and will receive much information about preeclampsia warning signs throughout pregnancy. They will also be more likely to experience the s/s related to preeclampsia.
The patient population for this study would come from University Hospital’s (UH) MacDonald’s Women’s Hospital. I would choose this hospital because they have approximately four thousand births per year, giving a larger patient population to work with. UH MacDonald’s Women’s Hospital also deals with a higher risk pregnancy population, when compared to local community hospitals, which may also put these moms at a higher risk for developing PPP. I would want a total of one hundred and fifty people to participate in the pilot study. Seventy-five people for the control group and seventy-five people for the experimental group. This large population would allow for attrition rates. As mentioned above, sixty percent of women do not go to their postpartum six week follow up exams, which make obtaining information post birth difficult.
UH MacDonald’s Women’s Hospital also currently uses the POST BIRTH discharge instruction sheet, which as mentioned above, is the gold standard for postpartum discharge teaching instructions. Comparing the gold standard of discharge education with a newer form of education would give valuable information on how the postpartum education can be built upon. By understanding how mothers can learn best about warning signs of PPP that come after their babies are born can hopefully save lives and improve quality of life for these families.
Measurements & Data Collection
Mothers from both the experimental and control group would receive a phone call at one, two, three, and four weeks post birth of their baby. On the phone call the patients would be given a series of questions verbally by a registered nurse. This questionnaire would be easy to answer and follow-up on the patient’s understanding of the s/s of PPP. Furthermore, the questionnaire would be multiple choice and fill in the blank so that biases in answers between the control and experimental groups would be limited. The answer would help to differentiate between the efficacy of calling the patients obstetrician and going to the emergency department. A literature search does not show a readily available questionnaire in this format so one may need to be developed and tested before this study could take place.
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Phone calls would be chosen over office visits to avoid high attrition rates. When setting up the experiment, I would also want a backup phone number, preferably a support person to the mother that will be available in case the mother does not answer. The phone call would be performed by a trained registered nurse who is familiar with the questionnaire. I would also want the nurse to be trained in postpartum care. Having a trained postpartum nurse make the phone call would allow the registered nurse can guide the mother to seek the appropriate medical attention if the mother is experiencing any issues.
The preferred statistical test to process the results from this study would be an ANOVA test. This is chosen because it is ideal for determining the statistical difference of multiple treatment methods on groups. The control group and experimental group would be given the same questionnaire at the same interval postpartum and the test results would be compared. The control group’s score on the questionnaire would serve as the baseline from which the experimental procedure, additional prenatal training about PPP, would be judged for efficacy in retaining information on the s/s of PPP.
The ANOVA test, compared to a T-Test, would enable the data to be compared in a more meaningful way if follow on studies were performed with more specific population or if the data of the initial experiment were divided into smaller populations.
With PPP, it is vital that mothers are aware of
Mom’s tired and anxious
Can’t absorb information
Postpartum preeclampsia different illness
Lack of education in prenatal period
Reasons why education is not covered
Rates of postpartum preeclampsia
Future education- ERs need to be properly educated on warning signs so that these don’t get missed.
- Carlozzi, N. E., Kallen, M. A., Sander, A. M., Brickell, T. A., Lange, R. T., French, L. M., Ianni, P. A., Miner, J. A., & Hanks, R. (2019). The Development of a New Computer Adaptive Test to Evaluate Anxiety in Caregivers of Individuals With Traumatic Brain Injury: TBI-CareQOL Caregiver-Specific Anxiety. Archives of Physical Medicine & Rehabilitation, 100, S22–S30. https://doi.org/10.1016/j.apmr.2018.05.027
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