Opening Slide (slide 1)
Welcome to the Hypertension Maternal Safety Bundle AIM eLearning Module 3: where we
will review Recognition and Prevention for every patient
Learning Objectives (slide 2)
Upon completion of this activity you will:
1.
have reviewed standardized measurement and assessment strategies for all
pregnant and postpartum women with hypertension
2.
Discuss key principles for educating women and their families during the
prenatal and postpartum period:
a. Recognition of symptoms
b. Seeking care
c. Advocating for themselves
Recognition and Prevention ~ Every Patient (slide 3)
The second domain of the Hypertensive Maternal Safety Bundle is Recognition and
prevention- for every patient and contains 3 key elements.
1.
Establishing a standard protocol for measurement and assessment of BP and
urine protein for all pregnant and postpartum women
2.
Standard response to maternal early warning signs including listening to and
investigating patient symptoms and assessment of key laboratory values
3.
Facility-wide standards for educating prenatal and postpartum
Standard protocol for measurement and assessment (slide 4)
The first recommended practice is the adoption of a standard protocol for the
measurement and assessment of Blood Pressure and for Urine Protein for all pregnant and
postpartum women. The adoption of standard methods for measurement and assessment
of blood pressure and urine protein for pregnancy and postpartum women is crucial to
recognition to ensure subsequent interventions are based on reliable and reproducible
vital signs and laboratory values.
Measurement of blood pressure (slide 5)
In pregnancy many women tend to get a little fluffier and their blood pressure can be
more difficult to obtain. “Blood pressure measurement is one of the most important basic
clinical assessments that we do, yet it is often one of the most inaccurately performed
assessments, leading to delays in diagnosis and treatment” It is important that our teams
understand and demonstrate competency for accurately obtaining and recording of blood
pressures.
Measurement of blood pressure (slide 6)
For accurate blood pressure measurements, it is important to understand the limitations of
the equipment used to perform blood pressure measurements. The method most often
used in the hospital setting for accurate measurement of blood pressure is the oscillatory
method, or automated blood pressure machine. With automated BP machines recent data
has indicated the potential for underestimating both systolic and diastolic readings by as
much as 10mm of mercury. It is recommended that oscillatory blood pressures be validated
with manual readings and calibrated frequently.
Measurement of blood pressure (slide 7)
Obtaining a manual blood pressure using a Mercury Sphygmomanometer is the gold
standard, but these are not easily found in today’s hospital setting. Most facilities use the
manual Aneroid or clock face blood pressure device. Most organizations are not aware
that these devices need to be calibrated routinely for accuracy. It is important to check
manufacturer recommendations for both manual and automated blood pressure devices
for appropriate calibration and maintenance.
Cuff size (slide 8)
Size: When obtaining a BP the cuff size matters. The most common error in blood pressure
measurement is use of inappropriate cuff size. Considerable overestimation can occur if
the cuff is too small and underestimation if the cuff is too large. It is important to ensure
that each unit that cares for maternal patients has a range of sizes to accommodate
individual patients. If in doubt on what sized cuff to use, measuring of the arm should be
completed.
Steps for Obtaining Accurate Blood Pressure Measurements (slide 9)
The position of the pregnant patient can have a sizable impact on blood pressure
measurements and the incorrect positioning of the maternal patient potentially having an
impact by as much as 2 to 15 mm of mercury

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The maternal patient should sit quietly for five minutes before BP is taken and be in
Low Fowler’s or Semi-Fowler’s with the back supported and a slight tilt for uterine
displacement for optimal blood flow.
Repositioning patient’s to left side to obtain a better reading is not recommended
and may underestimate BP by 10 - 20mm of mercury
Blood pressure key points (slide 10)
Implementation of standard blood pressure measurements needs to be built into
institution protocols. Some key points when obtaining a maternal blood pressure:
 DO NOT reposition patient to either side to obtain a lower BP if high
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
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Retake in other arm, use the highest reading
If ≥ 140/90, repeat within 15 minutes
Be Consistent
o Use the same arm (with the highest reading)
o Use the same position
o Use the same cuff size
Evaluate all BP trends vs. isolated values
If using automatic BP monitors, do not “auto-cycle”. Be present to confirm
appropriate BP technique criteria have been met
Steps for Obtaining Accurate Blood Pressure Measurements (slide 11)
Resources for obtaining accurate blood pressure measurements can be accessed on Council
on Patient Safety in Women's Health Care Safety Action Series webinar on Blood Pressure
Basics and within the CMQCC Preeclampsia Toolkit.
Proteinuria (slide 12)
Proteinuria is one of the cardinal features of preeclampsia. However, two important
points should be noted
 First, the severity of proteinuria is only weakly associated with adverse maternal
and neonatal outcomes, and should not be used to guide management.
 Second, proteinuria may be absent: Up to 10 percent of women with clinical and or
histological manifestations of preeclampsia and 20% of women with eclampsia
have no proteinuria at the time of initial presentation.
These observations and recommendations are reflected in the 2013 ACOG Task Force on
Hypertension in Pregnancy recommendations, which no longer require proteinuria for the
diagnosis of preeclampsia if other severe preeclampsia features are present
Measurement of proteinuria (slide 13)
The testing for presence of proteinuria has long been accepted as an essential criterion for
the diagnosis of preeclampsia.
•
•
The gold standard for the definition of proteinuria is the excretion of 300 mgs or
more of protein in a 24-hour urine collection.
A dipstick reading of 1+ or greater also suggests significant proteinuria, but
because of the high number of false/positive and false/negative results, it should be
used only when quantitative methods are not available.
Standard response to maternal early warning signs (slide 14)
The second component of the Recognition Domain is the implementation of a standard
response to maternal early warning signs, including listening to and investigating patient
symptoms and assessment of laboratory values. (e.g. CBC with platelets, AST and ALT).
The Failure to Rescue or the failure to recognize or act on early signs of distress has long
been identified as a critical factor in reducing maternal morbidity and mortality.
Research conducted by the California Pregnancy Associated Mortality Review Project
reviewed the Causes, Characteristics, and Improvement Opportunities of pregnancy
associated deaths in California between 2002 and 2005 identified “Preeclampsia related
death as one of the most preventable with high rates of delayed response to symptoms
and vital signs, ineffective control of hypertension, inadequate staff knowledge around
blood pressure management, misdiagnosis, and lack of continuity of care”.
In many cases outlined in this report, the early warning signs of impending maternal
collapse went unrecognized with a failure to recognize worsening signs of preeclampsia
resulted in delayed diagnosis and subsequent treatment of hypertensive disorders.
Maternal Early Warning System (slide 15)
Given the potential for significant maternal morbidity and mortality that can result from a
hypertensive crisis during pregnancy, it is critical that health care facilities develop and
implement protocols such as the Maternal Early Warning System, that establish standards
for when a patient will receive prompt bedside evaluation by a physician or other clinician
with the ability to initiate emergency therapeutic interventions as needed.
The AIM eLearning Module 1 the Maternal Early Warning System serves as the foundation
which further supports essential criteria in the Core Maternal Safety Bundles and can be
used to identify maternal patients who require urgent bedside evaluation. You may learn
more about the MEWS by clicking the resource link on this slide, at the end of the
eLearning Module or by visiting the AIM resource website
Listening to and investigating patient symptoms and assessment of laboratory values
(slide 16)
Identification of risk factors for severe hypertension and preeclampsia can help to improve
readiness in allowing for increased surveillance and early recognition, increase the use of
preventive measures, and prepare the team to initiate an early response.
Identification of risk during prenatal visits present an opportunity for antenatal planning
and teams should work in advance to have a multidisciplinary plan for patients with
known high risks. An antepartum risk assessment and anticipatory planning should include
consideration, dependent on organizational resources, of transfer of care for women with
the highest risk for severe hypertension and preeclampsia.
A baseline laboratory evaluation with ongoing maternal evaluation should include a CBC,
liver enzyme and serum creatinine level assessment with the frequency modified based on
clinical findings.
Assessment of risk (slide 17)
Risk-assessment tools are available and are useful in planning. The implementation of a
standardized risk assessment tool such as the Preeclampsia Early Recognition Tool or PERT
tool will contribute to the timely recognition and treatment of patients presenting with
severe hypertensive disorders. Such assessment tools should be readily available on
obstetrical units and all other departments caring for pregnant or postpartum patients and
when possible, built into the electronic medical record system
It is recommended that facilities use as a their framework when developing hypertension
in pregnancy protocol the updated diagnostic criteria in the 2013 ACOG Task Force on
Hypertension in Pregnancy Guidelines. This comprehensive guideline provides
recommendations for diagnosing and treating preeclampsia have been established for
obstetric providers at all levels of practice and in all practice settings in the United States.
Facility-wide standards for educating women (slide 18)
The 3rd component of the Recognition domain is the implementation of facility-wide
standards for educating women on signs and symptoms of preeclampsia and hypertension.
The protocol should outline how to inform women of the signs and symptoms of
preeclampsia and when to notify their provider. There are multiple opportunities
throughout the continuum of care including during prenatal visits, when attending
childbirth class on admission to hospital and before discharge. Maternal recognition
improves outcomes. Patient factors such as failure to understand the severity of her illness
or delays in reporting symptoms have been shown to contribute to preventable maternal
deaths from preeclampsia including in the days or even weeks postpartum.
Facility-wide standards for educating women (slide 19)
The foundation for a positive physician-patient interaction is formed by establishing a
partnership and creating a meaningful dialogue. Improving communication with patients,
listening to their concerns, and facilitating active partnerships should be central to any
patient safety strategy.
Providing patient education improves their recognition of symptoms, leading women to
seek care allowing for timely interventions and improved outcomes. We know that patient
education does not prevent preeclampsia, but many of us know the all too common catch
phrase (fly into center) “If only I knew”
Knowledge of symptoms (slide 20)
Unlike most other maternal health crises such as hemorrhage, the symptoms of
preeclampsia are usually considered non-specific and thus may not be recognized by the
woman and her family as special concerns in pregnancy. Although more women today are
familiar with preeclampsia, their knowledge of specific symptoms is lacking, contributing
to their delays in seeking care. Patients may have overt or ambiguous symptoms of:
 headache
 visual disturbances
 abdominal pain
 shortness of breath
 generalized swelling
 complaints of “I just don’t feel right”
Key Strategies for Effective Patient Communication (slide 21)
The use of patient-centered caring communication skills, and shared decision making has
the potential to improve outcomes. Key education strategies for effective patient
communication include:
• Providing information in both oral and written communication and using plain,
non-medical language
• Do not assume your patient’s literacy level or understanding by physical appearance
• Use proven tools that support consistent message such as:
• The "Chunk & Check" strategy. Breaking down the information into
manageable "chunks." After each chunk is delivered then discuss with the
patient their understanding.
• Or the “Teach Back” technique where you ask your patient (or a family
member) to explain—in their own words—what they need to know or do
• It is essential that we include family members in patient teaching. Effective
communication, cultural competence, and patient- and family-centered care are
important components of safe, quality care.
Patient education materials (slide 22)
The Preeclampsia Foundation has developed education that can be given to mothers which
uses clear language, reinforcing simple messages and includes pictorial representations.
These resources are available in English and Spanish and are available at preeclampsia.org.
Summary (slide 23)
In summary, the second domain of the Hypertensive Maternal Safety Bundle is Recognition
and prevention- for every patient and contains 3 key elements
1.
Adopting a standard protocol for measurement and assessment of BP and urine
protein for all pregnant and postpartum women. The adoption of standard
methods for measurement and assessment of blood pressure and urine protein
for pregnancy and postpartum women is crucial to recognition to ensure
subsequent interventions are based on reliable and reproducible vital signs and
laboratory values.
2.
Implementing a standardized response to maternal early warning signs
including listening to and investigating patient symptoms and assessment of
laboratory values.
3.
Facility-wide standards for educating prenatal and postpartum. The protocol
should outline how to inform women of the signs and symptoms of
preeclampsia and when to notify their provider.
Resources and References: AIM Hypertension Maternal Safety Bundle (slide 24)
With every AIM eLearning Module you will be provided with links to resources and
materials that will support the development of your teams journey to impact change.
Please download these resources using the link at the top of this page before leaving the
each of the eLearning modules.
AIM Program Contact (slide 25)
Please contact AIM directly with any questions on the materials provided or how we can
better support your needs.