Preventing PIH in Rural California

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Cheryl Thomas, NP/CNM, with Adventist Health's Healthy Beginnings Program in Hanford, has treated a number of women with pregnancy-induced hypertension (PIH) over the 30 years she's spent in rural healthcare. "Since there are no preventive measures for PIH, we teach women the signs and symptoms so they will be able to identify problems early on," she said. "Women can contact their providers at any time - there's always someone on-call for our practice - or they can come to our obstetric unit for an assessment."

As a certified nurse midwife, Thomas takes calls for low-risk patients, while an ob/gyn covers calls from high-risk women. "We might hear from a woman with a headache that doesn't go away, or someone who is dizzy along with a headache," she said. "A pregnant woman might tell us she has swelling in her hands or feet. We listen to her complaints and go through the process of elimination to determine what's going on."

Because it's hard to differentiate between normal swelling and the onset of PIH over the phone, Thomas will ask the woman to come in for a blood pressure check and a test for protein in her urine. "Symptoms aren't always clear-cut; they can be very vague and non-specific yet still clinically significant," she noted. "And a woman doesn't have to have all the symptoms of PIH to be diagnosed with the disorder."

Depending on the degree of hypertension and proteinuria, the nurse midwife will take action, which might include a consult with the ob/gyn to develop a proper management plan and determine follow-up. "We can refer the woman to our high-risk obstetric clinic as well," Thomas said.

Kimberly Tillotson, MSN, CNM, CHNP, who manages three outpatient obstetrics clinics at St. Mary Medical Center, Apple Valley, and in nearby Adelanto and Hesperia, instructs pregnant women to call the nurse midwife pager and report their symptoms any time day or night. "I can tell you that anyone with a severe headache that won't go away is asked to come into labor and delivery for an evaluation," she said. "We pay special attention to women of advanced maternal age and to those adolescents who are pregnant."

Those calls are taken very seriously. "One of our nurse midwives carries the on-call pager 24/7, and we tell our women, 'If you page us and don't hear back within 10 minutes, call again because that means we did not receive your page for some unknown reason,'" Tillotson said. "For back up, we give women the phone number for our L&D nurses at the hospital."

Tillotson and her team are dedicated to providing comprehensive care in the rural areas they serve. "These communities were pretty affordable for young families for awhile, but with the economy changing, those families are really struggling," she said. "We provide obstetric services to an underserved population that's primarily young Hispanic families; 99 percent are insured through Medi-Cal."

When women first call in to say they're pregnant, they're triaged by an LVN to see if they're candidates for midwifery services. "If the woman is an insulin-dependent diabetic, has had three or more C-sections, or has a history of PIH treated with magnesium sulfate or HELLP syndrome, she'll be followed by an ob/gyn," Tillotson said.

The LVN explains midwifery services, makes a new patient appointment for the woman and sends her a health history to complete and bring to that appointment. "At that first visit, we'll help her get paperwork done, including a Medi-Cal application if appropriate," Tillotson said. "We order lab work, go over the warning signs and symptoms of pregnancy complications including PIH, complete a nutritional assessment and recommend prenatal vitamins."

Every effort is made to accommodate young mothers who work or have transportation or child care issues. "If the midwife on call isn't delivering another baby when the new patient comes in for her first visit, she'll do a comprehensive assessment; worst case, we'll have her back within a week for that assessment," Tillotson explained.

Tillotson takes a proactive stand against PIH and other complications of pregnancy. "As a Christian-based hospital, we have a good network here at St. Mary to deliver care to the poor and underserved," she said. "We have counselors on our clinic staff to help those women going through social situations that are difficult, and we meet every week to discuss at-risk patients and develop action plans with our ob/gyns."

Within St. Mary's ob/gyn network, education about PIH begins with the initial client orientation, when the provider gives the woman a sheet and booklet explaining what's normal and what's not normal during pregnancy. [See Dangers of Pregnancy-Induced Hypertension] The nurse midwives focus on empowering mothers-to-be through relevant and timely education. "We partner with the women for a healthy pregnancy, and never say, 'I need you to do this or that,'" Tillotson emphasized. "Instead, we'll explain, 'When you take this lab slip over and get your blood drawn, we'll use the information to take good care of you and your baby by doing X and Y.'"

Appropriate information about PIH is shared throughout the continuum of perinatal care at both prenatal centers. "During their initial visit with the nurse midwife, moms are taught about PIH as one of the diseases that can develop because of pregnancy," Thomas said. "We describe the screening that will be done at each visit to detect early signs of the disease - weight, urine test for protein and blood pressure checks. We give them literature to read at home to reinforce that message and encourage them to review it throughout their pregnancy."