Posts Tagged ‘pre-eclampsia’

Why the California Toolkit: “Improving Health Care Response to Preeclampsia” Was Created

February 6th, 2014 by avatar

by Christine H. Morton, PhD

Researcher and Lamaze International Board Member Christine H. Morton, Phd shares information about a just released Toolkit on educating professionals about preeclampsia and it’s potentially very serious consequences.  Dr. Morton discusses how you can get a copy, take a webinar introducing the features and help reduce the number of women impacted by this serious pregnancy illness. – Sharon Muza, Community Manager.

Screen Shot 2014-02-05 at 10.25.11 PMWhen my academic partner and I observed childbirth classes several years ago as part of our Lamaze International-funded research (Morton 2009, Morton et al, 2007), we noted that many childbirth educators included a list of signs and symptoms to watch out for during their initial class meeting with expectant couples.  Some of these signs and symptoms were signals of early labor (mucous plug, leaking amniotic sac, contractions) while others might portend a more serious complication such as placental abruption (bright red bleeding), or preeclampsia (blurred vision, extreme swelling, headache), or worse case scenario, fetal demise (reduced to no fetal movement).  At the time, we wondered about the seeming contradiction of classes ostensibly designed to promote confidence in women’s bodies to give birth while from the outset telling women about things to watch out for, or “warning signs.”  Some instructors advised students to post the list on the fridge or on the bathroom mirror.

Now, after five years working at the California Maternal Quality Care Collaborative, and reviewing hundreds of cases of maternal death, I understand the importance of sharing information with pregnant women (and their partners) so they can understand when a symptom or condition goes beyond normal.  I understand why it is so important for women to know their own bodies, including their normal blood pressure, so they (or their partners) can be effective patient advocates if they sense something doesn’t feel right.

It’s an important balance for educators and other birth professionals to discuss the normality of physiological birth alongside the reality that about 8-12% of women will have medically complicated births. (Creanga, 2014), (Fridman, 2013) I remember hearing from partners who wanted to know what to look out for, so they could fulfill their roles as “protectors” as well as “co-creators of sacred space,” as one educator referred to them. Screen Shot 2014-02-05 at 10.25.45 PM

Preeclampsia is the second leading cause of pregnancy-related death in California, accounting for 17% of all deaths. (Druzin et al, 2014.) Preeclampsia is a severe obstetric condition characterized by high blood pressure, which left untreated, can lead to stroke, prematurity and death of women and babies.  As part of the California Pregnancy-Associated Review (CA-PAMR), an expert committee analyzed the medical records of 25 women who died of preeclampsia.  The committee identified contributing factors, and opportunities to improve care. All of the California deaths due to preeclampsia had some chance of preventability, with nearly half having a good-to-strong chance to alter the outcome.  For every woman who dies, at least 40-50 experience severe complications requiring ICU admission and another 400-500 experience moderate-to-severe complications from preeclampsia or other hypertensive disorders.   One important factor in the deaths was delayed recognition and response to signs and symptoms of severe hypertension.

Screen Shot 2014-02-05 at 10.26.04 PMThe lessons we learned from reviewing those cases were used to inform the development of the California Toolkit: Improving Health Care Response to Preeclampsia.  CMQCC and the California Department of Public Health (CDPH), Maternal, Child and Adolescent Health (MCAH) Division collaborated to develop and disseminate this toolkit using Title V MCH funds provided by CDPH-MCAH. The goal of this toolkit is to guide and support obstetrical providers, clinical staff, hospitals and healthcare organizations to develop methods within their facilities for timely recognition and organized, swift response to preeclampsia and to implement successful quality improvement programs for preeclampsia that will decrease short- and long-term preeclampsia-related morbidity in women who give birth in California. (Druzin et al 2014).

Experts from obstetrics, perinatology, midwifery, nursing, anesthesia, emergency medicine and patient advocacy relied on best evidence, expert opinion and the Toolkit includes:

  • Compendium of Best Practices: eighteen articles on multiple topics around hypertensive disorders
  • Appendices: Collection of all Care Guidelines including tables, charts and forms that are highlighted in Article Sample forms for policy and procedure
  • Slide set for Professional Education: slides that summarize the problem of and the best practices for preeclampsia to be used for local education and training

Of particular interest, the toolkit addresses the management of severe preeclampsia < 34 weeks, the importance of recognition and treatment of delayed postpartum preeclampsia/eclampsia in the emergency department and early postpartum follow-up upon discharge for women who were diagnosed with severe hypertension during childbirth.  The Preeclampsia Foundation was a partner on the Task Force, and has created educational material for pregnant women and their families, in English and Spanish.  Hospitals, clinics and childbirth educators can order these materials at no cost (shipping and handling only) from the Foundation.  There is a free webinar available on February 25th introducing the toolkit to professionals.preeclampsia

Thinking back to my childbirth education observations, I am struck that the educators never mentioned preeclampsia or defined it.  Not one suggested women should know their normal blood pressure.  The Preeclampsia Foundation commissioned a report in 2012 which reviewed the top pregnancy and childbirth advice books and found that many either failed to mention the condition or contained misleading or incorrect information about preeclampsia, HELLP or eclampsia.  With hypertensive disorders of pregnancy on the rise (as well as other maternal morbidities) (Fridman et al 2013; Creanga et al 2014) it’s important for childbirth educators and birth professionals to help women understand signs and symptoms and to know what those signs and symptoms might mean.

Even as we know most women are healthy and are highly unlikely to experience a severe complication in pregnancy and childbirth, we must also acknowledge that some women do, and by leaving them out of the classes and books, we silence their reality.  As one woman noted in a research study on experiences of severe pregnancy complications said:

There’s a lot of information out there or bad information that can make you feel like you did this to yourself. But there’s every kind of woman that has gone through some sort of thing. You don’t see red flag kind of behaviors in the population of women who get preeclampsia or a lot of the other kinds of issues that can cause childbirth injury and the bad childbirth experiences. I understand the way the books put it is that they want to reassure you that it’s not going to happen to you, but the kind of flipside of that is to say that when it does happen to you, where are you then? You know? I think they set you up for PTSD, for postpartum depression. They kind of make it seem, like, “Oh hey! You’re fine. Everything’s going to be great. It’s not going to happen to you” so what are you left when it does happen? (Lisa, in Morton et al 2103).

We owe it to pregnant women to give them the information they need to understand the fullness of their pregnancy and childbirth experiences, whether normal or complicated.  The Preeclampsia Toolkit will hopefully help those clinicians who care for childbearing women better manage and reduce the severity of complications when they arise.  Since its release last month, the Toolkit has been downloaded over 1376 times in all 50 states states (plus District of Columbia and Puerto Rico) along with 5 countries; Australia, Canada, Wales, Mexico and Malaysia.  The response to this Toolkit has been incredible and it is clear that there is a need for practical tools that hospitals and clinicians can use to improve their response to hypertensive disorders of pregnancy. 

Do you share information about preeclampsia in your classes and with your clients?  How do you discuss it?  What are your favorite learning tools?  Let us know in the comments. – SM


Creanga, MD, PhD, Andreea A. ; Cynthia J. Berg, MD, MPH, Jean Y. Ko, PhD, Sherry L. Farr, PhD, Van T. Tong, MPH, F. Carol Bruce, RN, MPH, and William M. Callaghan, MD, MPH, Maternal Mortality and Morbidity in the United States: Where Are We Now? JOURNAL OF WOMEN’S HEALTH, Volume 23, Number 1, 2014, DOI: 10.1089/jwh.2013.4617

Druzin, MD Maurice; Laurence E. Shields, MD; Nancy L. Peterson, RNC, PNNP, MSN; Valerie Cape, BSBA. Preeclampsia Toolkit: Improving Health Care Response to Preeclampsia (California Maternal Quality Care Collaborative Toolkit to Transform Maternity Care) Developed under contract #11-10006 with the California Department of Public Health; Maternal, Child and Adolescent Health Division; Published by the California Maternal Quality Care Collaborative, January 2014.

Fridman, PhD, Moshe; Lisa M. Korst, MD, PhD, Jessica Chow, MPH, Elizabeth Lawton, MHS, Connie Mitchell, MD, MPH, and Kimberly D. Gregory, MD, MPH, Trends in Maternal Morbidity Before and During Pregnancy in California, Am J Public Health. Published online ahead of print December 19, 2013: e1–e9. doi:10.2105/AJPH.2013.301583)

Morton, C. H. (2009). A fine line: Ethical issues facing childbirth educators negotiating evidence, beliefs, and experience. The Journal of perinatal education, 18(1), 25.

Morton, C.H., A. Nack, and J. Banker, Traumatic Childbirth Experiences: Narratives of Women, Partners, and Health Care Providers. Unpublished manuscript. 2013.

Morton, C. H., & Hsu, C. (2007). Contemporary dilemmas in American childbirth education: Findings from a comparative ethnographic study. The Journal of perinatal education, 16(4), 25. Chicago


Childbirth Education, Guest Posts, Maternal Mortality, News about Pregnancy, Pre-eclampsia , , , , ,

Pregnancy and Childbirth Advice Books through the Lens of Preeclampsia

July 3rd, 2012 by avatar

Guest post by Science & Sensibility contributer Christine H. Morton, PhD

(Full disclosure:  the organization I work for, CMQCC, has been working with representatives from the Preeclampsia Foundation over the past year on the CMQCC task force developing a Preeclampsia Toolkit, and I am a big fan of their executive director, Eleni Tsigas, and frequent re-tweeter of @preeclampsia).

The Preeclampsia Foundation released a new guide to pregnancy and birth books last month, a comprehensive report distilled from a review of more than 60 such books, on their accuracy, coverage and clarity of information on hypertensive complications in pregnancy.    As readers of S&S are well aware, there are numerous books geared to expectant couples, pregnant women, and male partners; by authors who claim their authority by virtue of their clinical degrees and practice, their teaching and research credentials, as well was their personal and celebrity experience.   This is the first time I’ve seen a guide to pregnancy and birth advice books from the lens of a serious disorder in pregnancy:  preeclampsia.

May was Preeclampsia Awareness Month. Hypertensive disorders of pregnancy, including elevated blood pressure, preeclampsia, eclampsia and HELLP syndrome are estimated to affect 12-22% of pregnant women and their babies each year.1 Preeclampsia is a leading cause of pregnancy-related death in the US and in the state of California, and one of the most preventable. Adverse neonatal outcomes are higher for infants born to women with pregnancies complicated by hypertension. Care guidelines have recently been developed in many countries, including the UK, Canada and Australia, with a revised practice bulletin to be released from ACOG later this year. A key focus in many of these guidelines is accurate measuring of Blood Pressure, and standardized pathways of care, depending on the clinical situation. These guidelines note that one reason for their creation is the clear evidence that the surveillance of women with suspected or confirmed preeclampsia is variable between practitioners.2,3
 Seeking to understand their experience, women turn to books, their childbirth educators and doulas to help them navigate through this new and unexpected turn into complicated pregnancy.   While many women have healthy pregnancies and births, those who are having symptoms, or have been diagnosed with preeclampsia, eclampsia or HELLP syndrome, need accurate and clear information.    Early detection, and treatment, is a proven way to lessen the severity of the disease, and mitigate its impact.  Are some pregnancy and childbirth guidebooks better than others in informing readers about these issues?

To answer this question, researchers Jennifer Carney, MA and Douglas Woelkers, MD reviewed more than 60 pregnancy and childbirth advice books and ranked them using a consistent set of criteria in five categories: Depth of Coverage, Placement of Coverage, Clarity and Accuracy of Information, Description of Symptoms, and Postpartum Concerns.  In their methods section, they note that

“Books were downgraded for out-of-date information, missing or inaccurate information and placement issues, including inaccurate or inadequate indexing.    Of the more than 60 books reviewed, none ranked above “8” in all five categories. In fact, only a handful of books scored above “8” in the category of “Postpartum Concerns,” since many books routinely state that the cure for preeclampsia and related disorders is the birth of the baby.”

Childbirth educators and doulas have strong views on the ‘best’ books to guide women through pregnancy and childbirth and might be surprised to find that even best selling books like Ina May’s Guide to Childbirth (2003) scored only a 2.6, while the much excoriated, yet highest selling advice book: What To Expect When You’re Expecting (2009) ranked last in the Preeclampsia Foundation’s TOP TEN list, with a score of 7.2.  All books reviewed are listed in the Appendix of the report.

One helpful feature of the report is a sampling of questionable claims found in pregnancy guidebooks:

“Preeclampsia never happens before the twentieth week, but your blood pressure may start to rise steadily after this. Delivery of the baby and placenta ends the problem.” From Conception, Pregnancy, and Birth by Miriam Stoppard. In rare instances preeclampsia can occur prior to 20 weeks; it can also occur up to six weeks postpartum.

The report further explains why it’s important for books on childbirth to also mention preeclampsia, eclampsia and HELLP Syndrome, since this disease can develop immediately prior to, during or after delivery.  Among the childbirth books, the reviewers found,

Only Penny Simkin’s book The Birth Partner: A Complete Guide to Childbirth for Dads, Doulas, and All Other Labor Companions (2007) provides adequate information about preeclampsia, eclampsia, and HELLP syndrome. Although this book incorrectly uses the term pregnancy-induced hypertension (PIH) to describe preeclampsia and eclampsia, it provides a useful list of symptoms and the possible treatments, including cesarean delivery. It also presents some of the emotional issues that might arise from a diagnosis of PIH and includes some information on HELLP syndrome. It acknowledges the possibility of postpartum preeclampsia and eclampsia, something that many of the general pregnancy books omit.

The report can help childbirth educators and doulas point women to the best information about hypertensive disorders, but its authors also hope these results will guide authors in future revisions.  At the very least, up to date terminology, accurate information and complete indexing is critical in revisions. Books geared primarily to women with relatively healthy pregnancies always face the challenge of balancing reassurance, the optimality of physiological birth and the diverse range of potential complications in pregnancy.  Yet such books can point readers to resources like the Preeclampsia Foundation for up-to-date and user-friendly information and community pages.

Take-away points for Childbirth Educators and Doulas:

  • Check your website and be sure to link to Preeclampsia Foundation website for unbiased, evidence-based information on this disease.  They are on Facebook too.
  • Tell your students to ask about their blood pressure at all prenatal visits and during labor.  They should know what their ‘normal’ range is, and if their BP is ever above 140 systolic or 90 diastolic, to be alert to signs and symptoms of preeclampsia, and report these changes to their care providers.
  • Many factors can affect BP readings:  BP cuff size should be appropriate, especially among women with a high BMI; the measurement should be taken while sitting, with arm at heart level; automated BP machines may underestimate the BP.
  • Remind pregnant women (and their partners) that although lots of attention will naturally be focused on the baby, they have to be alert to the new mother’s health symptoms postpartum too.  While postpartum is a whole new normal, women need to know that any significant bleeding, fever, headaches, nausea, or visual disturbances, are NOT normal, and they should follow up with their health care provider immediately.

Preeclampsia is a serious, if unlikely, complication of pregnancy.  Women diagnosed or at risk for developing hypertensive disorders of pregnancy can find accurate information for all literacy levels (and some Spanish language resources), as well as a supportive community at the Preeclampsia Foundation, a US-based 501(c)(3) not-for-profit organization whose mission is to reduce maternal and infant illness and death due to preeclampsia and other hypertensive disorders of pregnancy by providing patient support and education, raising public awareness, catalyzing research and improving health care practices.


1. American College of Obsetricians and Gynecologists. Diagnosis and management of preeclampsia and eclampsia; ACOG Practice Bulletin No. 33. Obstetrics & Gynecology. 2002;99:159-167.

2. Repke JT PM, Holzman GB, Schulkin J. Hypertension in Pregnancy and Preeclampsia: Knowledge and Clinical Practice Among Obstetrician-Gynecologists. Journal of Reproductive Medicine. 2002;47(6):472-476.

3. Caetano M OM, von Dadelszen P, Hannah ME, Logan AG, Gruslin A, Willan A, Magee LA. A Survey of Canadian Practitioners Regarding Diagnosis and Evaluation of the Hypertensive Disorders of Pregnancy. Hypertens Pregnancy. 2004;23(2):197-209.

4.  Hogan JL, et al.  Hypertens Pregnancy. Body Mass Index and Blood Pressure Measurement during Pregnancy. 2011;30(4):396-400.  PMID: 20726743

Read more about Christine H. Morton, PHD on our contributor page.





Book Reviews, Childbirth Education, Guest Posts, informed Consent, Maternity Care, Medical Interventions, Patient Advocacy, Practice Guidelines, Pre-eclampsia, Pregnancy Complications, Uncategorized , , , , , , , , , , , , , , , ,

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