Date of Award
Projects: SPU Access Only
Doctor of Nursing Practice (DNP)
Dr. Gloria Nam, PhD, ARNP, FNP-BC
Dr. Heidi Monroe, PhD, MSN, RN, CPN
Globally, between 2003-2009, hemorrhage, sepsis, and hypertensive disorders were responsible for more than half of all maternal deaths recorded (Say et al., 2014). According to the Centers for Disease Control (CDC), 700 women die each year in the United States from pregnancy-related complications; 36% of these deaths occurred at delivery or within a week after birth, and 33% also happened one week to one year postpartum (CDC, 2019). In the United States, postpartum mothers experience fragmented care and navigate the healthcare system independently until the first appointment with a primary care provider, which occurs between four to six weeks postpartum (American College of Obstetricians and Gynecologists [ACOG], 2018). Within this period, strokes, infections, and hemorrhage, which are some of the leading causes of maternal deaths, according to the CDC, can occur. Furthermore, most of these deaths are largely preventable if the warning signs are promptly identified (CDC, 2019). Pediatric nurse practitioners, who are in frequent contact with the mother-baby dyad during well-child visits, are primely positioned to identify these postpartum complications. However, they are not adequately equipped with screening tools to enable the timely identification of these complications.
Additionally, besides the availability of tools and recommendations to screen for depression in the postpartum mother in the pediatric setting, there are no such recommendations for identifying mothers with complications during well-child visits. Thus, a gap exists in the literature regarding the care of the postpartum mother. Without specific guidelines and strategies for pediatric nurse practitioners, postpartum mothers are at risk for preventable morbidity and mortality.
The goal of the Doctor of Nursing Practice (DNP) project was to create a tool for pediatric nurse practitioners/providers to identity postpartum mothers with symptoms of preeclampsia-hypertension, infection, and depression to aid in the prompt referral of the mothers to an appropriate level of care.
The project's participants included three pediatric nurse practitioners and twenty-two postpartum mothers, and the project was conducted in a pediatric clinic in Washington State. The DNP student reviewed hypertension guidelines, sepsis criteria, and current recommendations for postpartum depression screening and generated a screening tool incorporating these recommendations. The pediatric nurse practitioners received training on the use of the tool in the clinical setting, and it was piloted in the clinic for four weeks. After the piloting phase, the pediatric nurse practitioners were interviewed for feedback on the performance of the tool, the tool's ease of use, difficulties, and recommendations.
All three of the clinic's nurse practitioners participated in the screenings every week except in week four when one was unable to due to scheduling. Twenty-two new postpartum mothers participated in the screenings. Of this number (N=22), two of the mothers (8%) required a referral, one to the gynecologist and the other for counseling; however, the pediatric providers did not indicate the reason for the referral or the triggers. Some of the difficulties reported by the nurse practitioners included the absence of a plan for depressed mothers, absence of crisis centers or resources provided to streamline maternal referrals; and the mothers lack awareness of some portions of their medical history. There was also a reluctance by some mothers to disclose personal history in the presence of a current partner. Overall, the nurse practitioners thought the tool was easy to use, and also made them more aware of the signs and symptoms to assess for in postpartum mothers during well-child visits.
The tool can be used in a pediatric clinic setting with adequate staffing and a high volume of postpartum mothers. The tool needs to be transformed into a mobile application in this era of technological advancement for both providers and mothers to communicate concerns before arriving at the clinic. Primary care providers may also benefit from the timely information provided through the screenings to help in caring for the postpartum mother. Furthermore, to facilitate screenings, policymakers, and insurance companies must consider reimbursing pediatric nurse practitioners for these services.
Implications for Nursing
The project has demonstrated that pediatric nurse practitioners can play a pivotal role in addressing complications that occur in mothers through timely screenings and referrals, although their role is child-centered. Additionally, the nursing profession must prioritize postpartum maternal health by providing teachings and educational materials at every postpartum encounter, and also offer mothers community resources and links. Nursing organizations and healthcare institutions must dedicate resources to researching new ways to improve maternal health in other settings and tap into the world of health care technology and applications to bring about positive changes that are currently needed in maternal care.
American College of Obstetrics and Gynecology (2018). Optimizing postpartum care. Retrieved from https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Optimizing-Postpartum-Care?IsMobileSet=false
Centers for Disease Control. (2019). Pregnancy-related: Saving women’s lives before, during and after delivery. Retrieved September 15, 2019, from https://www.cdc.gov/vitalsigns/maternal-deaths/index.html
Say, L., Chou, D., Gemmill, A., Tunçalp, Ö, Moller, A., Daniels, J., . . . Alkema, L. (2014). Global causes of maternal death: A WHO systematic analysis. The Lancet Global Health,2(6). doi:10.1016/s2214-109x (14)70227-x
Eshun, Josephine Adomaah, "Creating a Tool for Pediatric Nurse Practitioners to Screen and Refer Postpartum Mothers with Complications During Well-Child Visits" (2020). Doctor of Nursing Practice (DNP) Scholarly Projects. 11.