Where are the contraceptive options for males? It’s Not Just a ‘Women’s Issue’

By Kate McNair, RN, BSN, SANE

The sexual revolution began in 1960 with the emergence of a novel birth control for women in the form of a pill. Despite the increase in contraceptive options for women over the past 55 years (including many new long acting and reversible options), options for males have remained stagnant and have not progressed beyond the condom.

Although there have been attempts to create hormonal birth control for males, barriers persist. A recent study tested an inject-able male hormonal contraceptive (testosterone and progestin) with 266 male participants across 10 sites (Behre et al., 2016). These injections attempt to interrupt the normal hormonal cycle and decrease sperm count, rendering the male reversibly infertile (Ashbrook, 2016). The efficacy was 96%, a rate higher than OCPs(Oral Contraceptive Pills) for women (Ashbrook, 2016; Behre et al., 2016). Unfortunately, although the results were encouraging, the trial was abruptly halted last November due to reported side effects. Males reported acne, mood swings, and pain at injection site (Behre et al., 2016). Males also reported increased libido (Behre et al., 2016). Rationale for the discontinuation of the study has not been reported by the review board at the World Health Organization.

The reported side effects experienced by the males in the Behre et al. (2016) study mirror contraceptive side effects experienced by females. This further supports persisting patterns of cultural patriarchy in today’s science and reinforces cultural messages to the public that family planning and contraception is fundamentally a responsibility and burden placed solely on the female. While science may never occur without cultural bias, as personal beliefs and viewpoints tend to permeate our work (consciously or not), women’s health nurses can lend their support and voice to promote efforts to eradicate the androcentric bias in today’s contraceptive research.
As I become a nurse scientist, I am emboldened and hopeful, not deterred. I see opportunity for change in science, influenced by leaders in the nursing field. We must make a point to understand underlying biases in science and encourage nurses to have their voices heard. Only then can nurses advocate fully for the women they serve. Contraception is not just a women’s responsibility or burden, and we can change this paradigm starting now.

References
Ashbrook, T. (2016, November 4). Fresh controversy in male birth control. On Point.
Podcast retrieved from http://www.wbur.org/onpoint/2016/11/04/male-birth-control
Behre, H., Zitzmann, M., Anderson, R., Handelsman, D., Lestari, S., McLachlan, R. &
Colvard, D. (2016). Efficacy and safety of an injectable combination hormonal
contraceptive for men. Journal of Clinical Endocrinology and Metabolism.
Retrieved from http://press.endocrine.org/doi/pdf/10.1210/jc.2016-2141

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Kate McNair is a women’s health nurse practitioner & PhD student at Boston College. She also maintains clinical practice as an OB/GYN RN at a community health center in Roxbury, MA. Follow her on Twitter @fem_nurse.

Pediatric Clinical Experience – Incorporating Core Values into Care

By Michael Burke

As nursing students in the pediatric clinical setting, the character and values we display are crucial to not only our own growth, but also to the well-being of our patients. We all understand that the “student” label is often correlated with inexperience, and can lead to feelings of uncertainty and apprehension from patients. In the pediatric setting, hearing “student nurse” can add an extra level of anxiety for parents whose vulnerable, sick children are at risk. While parents may be wary of having students as caregivers for their children, there are several ways to help put them at ease and give confidence to both parties. In the pediatric setting parents are often exponentially more nervous than the patients themselves, but through positive practice values and confidence, the student nurse has the ability to truly make a difference when it comes to providing the best family and patient centered care possible.

According to Ruhl, Golub, Santa-Donato, Cockey, and Bingham (2016), nurses who give care integrate six core values into their practice including compassion, engagement, integrity, courage, humility, and wisdom. During our time as students in the pediatric clinical, I found that of these six core values, integrity served me the best and helped me grow the most when it came to family centered care. Integrity is something that is valued in all facets of life, but is expected in the nursing field. It is something that nurses pride themselves on not only because of the types of people who pursue nursing, but also because it can have a very positive influence on patients and families. Integrity is shown through honesty, respect, and judgment-free care and the nurse with integrity will stand up for the patient and family even while risking criticism and/or distain (Ruhl et al., 2016).

On the final clinical day of our pediatric rotation, I was assigned to a 42-day-old male patient who had presented one day earlier in respiratory distress, which was later determined to be a symptom of positive metapneumovirus. When I first entered the room with my clinical instructor, the introductions revealed that the patient’s mother was also a nurse, but had no experience with pediatrics and was understandably very concerned about her son. As a student in this situation, I could tell that the mother was instantly uncomfortable with my presence, but the clinical instructor did a great job of integrating me into the conversation and into the patient’s care. Weighing only 3.18kg with a respiratory infection, the patient was rather unstable throughout the shift, often fluctuating from low 90’s O2 Sat down to the low 80’s at some points even with supplemental 0.2L/min O2 by nasal cannula. The patient was prescribed PRN nebulizers, corticosteroids, and suctioning for these situations and with busy nurses and a busy clinical instructor; it was my responsibility to be on top of the patient’s status. Over the course of the shift it was often me alone with the patient and the mother, and from her perspective, I can imagine her hesitant feelings about this, especially considering her profession. However, through use of the core values, most notably integrity, I was able to gain her trust over the course of the shift. If there was something that she was more comfortable having the primary nurse do instead of me, I showed understanding and alerted the nurse. If she had a question and I did not know the answer, I would find the primary nurse or my instructor in order to find out. If I did know the answer I would simply and confidently respond. I could tell that her comfort level increased over time and by the end of the shift, she trusted my judgment enough to leave her son in my care while she took a dinner break. As a student, the important thing was not to know everything; the important thing was that I had the judgment and honesty to know my limits and ask for help when needed.

Reference

Ruhl C., Gulab Z., Santa-Donato A., Cockey D. C., Bingham D. (April/May, 2016).  Providing nursing care women and babies deserve. Nursing for Women’s Health Journal, 20(2), 129-133

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Michael Burke was born in Boston and raised in Carlisle, MA by his parents Kate and Jim. He attended Concord-Carlisle High School and went on to earn a BA in Anthropology and a minor in Journalism from The George Washington University in Washington DC, where he also served as captain of the division 1 men’s soccer team. Currently a student nurse in his final semester at MGH Institute of Health Professions, Mike hopes to continue to progress as a student and future nurse by providing the best care possible to his patients.

A Special Thank You to Our Preceptors

Elizabeth Rochin, PhD, RN, NE-BC
Vice President of Nursing, AWHONN

After long days or nights, and years into a career, we as nurses may forget what initially brought us into nursing. If you want to remember, simply ask a student. In fact, I had the opportunity to ask fourteen nursing students just today why they chose nursing as a career path.

Here is a sampling of what they said:

• “I wanted to make a difference in someone’s life.”
• “There is nothing more pure than helping someone in need.”
• “I knew since I was three years old that I wanted to be a nurse. I think I inherited it, my mom and grandmother are nurses.”
• “This is my second degree. I discovered in myself a very strong need to help others, and went back to school. This was the right decision.”
• “I was originally in sales and marketing, and realized that I loved making connections and promoting relationships. This was the perfect way to do both.”
• “The first time a patient said, ‘You’ll make a great nurse,’ I knew I made the right decision.”
• “I can’t imagine doing anything else. This is the perfect way to give back.”
• “To use my hands to help heal a patient, or help to bring a new life into the world, I can’t think of anything better.”

Most of us will remember thinking about one or more of the quotes above, and will bring us back to our own days as a student nurse, and renew the passion in our work.

For the next several weeks, colleges and universities throughout the nation will graduate the newest members of women’s health, obstetric and neonatal nurses. We congratulate and welcome you to your new lives and careers. Nursing offers such diversity in career paths, and the opportunities for expert bedside care, advanced practice and nursing leadership roles have never been greater. There has never been a more exciting time to be a nurse!

But it is also important that we understand and remember that at one time or another, we were all new. None of us came into nursing knowing everything. We all needed a hand to hold us steady, and a guide to offer direction and counsel in how to move from a new graduate to a team member who could safely and effectively care for patients and their families.

Occasionally we forget what it felt like to be new. And we must be willing to remember. The greatest gifts we can bestow upon our newest nurses are understanding, time and expertise. We must commit to assisting our new graduates to grow and develop, and assist them to make the difference they want to and know they can make.

I would like to take this moment to thank all of our outstanding preceptors who strive to give our new graduates (and all new nurses, for that matter!) the best possible experiences and learning opportunities. Preceptors are those nursing team members who work with a new nurse for 12-20 weeks, and sometimes much  longer, to ensure appropriate training and competence. Preceptors are the “life blood” of nursing, and your effort and dedication to your orientees and organizations does not go unnoticed. Thank you for taking on this vital role and for shaping the next generation of women’s, obstetrics, and neonatal nurses.

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Liz  has over 25 years of Women’s and Children’s experience and  has devoted her professional career to the care of women and children with roles as a staff nurse, nursing educator and most recently executive leadership. She has presented nationally on patient experience and mentoring new nursing leaders. In 2008, Liz was named to the Great 100 Nurses of North Carolina, and is a member of Sigma Theta Tau. In addition to her clinical work and expertise, Liz has taught at the baccalaureate and graduate levels at East Carolina University College of Nursing. She is board certified as a Nurse Executive by the American Nurses Credentialing Center.

My Top Five Exercising Tips to Improve Your Mind, Body, and Spirit

Lynn Erdman, MN, RN, FAAN,

For Nurses Week, we are promoting the “year of the healthy nurse.” We are encouraging nurses, like you, to focus on having a healthy mind, body, and spirit, to support your overall wellbeing. For me, I love exercise and have become more committed to it than ever. I find that the simple activity of exercising helps to clear my head and prepares me for my day. If your body and the mind are healthy, the care you can give your patients will be improved.

Exercising has so many benefits for the body: weight management, endorphins that elevate your mood and the energy it delivers to you. Here are my personal five tips for exercising that I believe will help improve your mind, body and spirit.

1. Establish routine. As nurses, our schedules can be pretty hectic and unpredictable, which is why it’s important to establish a regular exercise routine. This is key because when you neglect to establish a routine, it’s easier to make excuses or find reasons not to workout. For me, I go to the gym at 5 AM because that works for me. Take a step back and see what time works best for you. Exercise has to be established as a priority and built into your schedule for a day or for the week.
2. Stand up regularly at work. As nurses, we stand up most of the day which is a wonderful way to stay active during the day. I find that getting up every once in a while is important to do at work because it keeps the blood flowing. It’s as simple as taking a brisk walk around the block, the facility or the grounds that can make all the difference. If you have the opportunity to have a standing desk, use it. I love mine. It makes it easier to walk around the office, and simple tasks that require you to go to a different part of the office are no longer hard to do.
3. Use a medicine ball as your chair. If I am going to sit at work, I always sit on my medicine ball chair. This keeps my body still exercising even when I am sitting because it keeps my leg muscles moving and works out my core.
4. Switch it up. When it comes to exercise, many of us are creatures of habit. We tend to gravitate towards doing the same routine on the elliptical, treadmill, or muscle work out. Regular workout is great but to maximize the time spent at the gym it’s important to include variety in your exercises to keep your muscles challenged. This helps overcome a weight loss plateau, builds new muscles, and prevents boredom from doing the same routine.
5. Meditate for five minutes a day. Spend five minutes a day doing either spiritual meditation or just focus your mind in a direction of positive thinking. As nurses, we have stressful days. Meditation helps relieve some of the stress you face in your day-to-day life.

I have found that when I take care of my body and my mind my overall spirit is better. Nurses have hard days and multiple stress points at work. Whether its meditation, yoga, or exercise, all of these methods help improve the work-life balance we all reach to achieve.

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Lynn Erdman, MN, RN, FAAN,
Chief Executive Officer, AWHONN

Lynn joined AWHONN in 2014 with more than 30 years of experience in the healthcare and nonprofit sectors.  She is a highly skilled national leader in the field of nursing and previously held key national leadership positions with three global health organizations: the American Cancer Society, the American College of Surgeons, and the Susan G. Komen Global Headquarters.  Lynn has also served in top leadership positions with several hospitals and healthcare systems.

Human Trafficking in the US is Real! Here’s How Nurses Can Help

by, Leith Merrow Mullaly, RN, MSN, IBCLC

Sex trafficking is a form of modern slavery that exists in our own backyard. Traffickers resort to violence, threats, lies and other forms of intimidation to force both adults and children to take part in sexual acts against their will. Sex trafficking can occur anywhere, even in your very own community.

In 2016, the National Center for Missing & Exploited Children estimated that 1 in 6 endangered runaways reported to their Center were likely sex trafficking victims.  The Urban Institute estimated that the underground sex economy ranged from $39.9 million in Denver, Colorado, to $290 million in Atlanta, Georgia.  Prostitutes are victims of these crimes.

Yet, sadly, since 2007 the National Human Trafficking Resource Center Hotline has received only 145,764 calls*  (1-888-373-7888).  Why is this? Many of the victims of sex trafficking have no knowledge that such a resource even exists.  To make a phone call to get help is not possible for most victims as communication is strictly controlled and monitored by the pimp who has all the power.  Perhaps, we nurses should have this phone number posted in areas where women in your care can see it.  Nurses should also be aware of the warning signs associated with trafficking, and  when we suspect our patient/client may be such a victim, we should hand them a phone!

Commercially exploited children in our country have almost universally been sexually abused and enter prostitution with a history of complex trauma.  Their families have been absent or dysfunctional.  Several young women with whom I work were identified by teachers as abused (eg, a 7 year old who wouldn’t change gym clothes because of bruises all over her body).  There  were mixed reaction from teachers.  Some did follow up with local child protective services.  Some called parents.  One young woman told me “My teacher was concerned but my mother denied any sexual abuse but then said ‘well, she is so suggestive around my husband’; I was 6 years old!”  Many girls tried to tell an adult but many were afraid.  Some shared “I have told people and nobody believed me”.  Some were placed in foster homes, and believe it or not, they were molested and recruited by their pimps from the foster care system.

What can nurses do?  This may seem so much bigger than what we can do as individuals. But we can develop a more acute awareness about the realities of human sex trafficking right in our own environment.   When you hear or suspect human sex trafficking may be occurring to the patient sitting before you, believe them!  They very frequently display a fearful, distrusting affect because many times they have tried to tell and NOT been believed.  Offer them your belief.   Former President Jimmy Carter wrote an editorial in the Washington Post (May 31, 2016) entitled: “Curb prostitution, punish those who buy sex rather than those who sell it”.  I recommend reading this. Carter describes the “Nordic Model” which is a system that treats purchasing and profiting from sex as major serious crimes.  That might be something for which nurses in small or large groups, such as an AWHONN  Chapter or Section, can advocate for at their own local or state level.  Just imagine the impact it could have if the men in your community who are purchasing sex were prosecuted and exposed in public as the criminals they actually are.  We have heard “but he is a pastor” and “but he is on city council” and “ their reputations would be destroyed”.  Women and children who are sold for sex face more than ruined reputations, they face ruined lives!

As health care providers and patient advocates we must begin to work vigorously with our own elected officials to change the unacceptable and shocking status quo.  Did you know that trafficked children are treated as criminals in many jurisdictions even though under Federal law those under 18 years old are classified as victims?

My state, the Commonwealth of Virginia, was the last state in the country to pass a stand-alone human sex trafficking law (2015).  Now, anyone assisting, or working to traffic, sell or purchase prostitution can be arrested and charged.  This law came about because of the incredible tenacity and diligent work of a very few advocates working with their local legislators.  They provided both Representatives and their constituents with education on this issue.

Health education has always been a strong focus for nurses.  The public looks to us to educate them and the public trusts nurses to provide solid, honest information.  My “own public” sat in disbelief when we first started talking about sex trafficking right here where we live and work.  I heard comments like “No way, this is a lovely community.  Not here!”  As they learned the realities they were initially horrified, but now are very energized to help in any number of ways.  We also can’t  forget to educate parents.  They need to know that when young teens, girls and boys, meet other “youth” on the internet they are often opening themselves to traffickers.  When middle and high school kids sext and post photos they can and do become easy prey to predators.

If your community doubts the very idea of sex trafficking in your town, send them to a website called “Backpage”.  It is a trafficking website that lists ads for prostitution.  In my small size city there are more than 20 ads a day!  “Plenty of Fish” is another site that purports to be a dating site. We have had some of our trafficked victims “hooked up” on this site with “clients” purchasing sex.  If a nearly naked woman is advertising to come to a hotel room to provide a “massage”, read between the lines.  If the face is blurred, it most likely means the girl is a young minor.  If you look…unfortunately you will find human sex trafficking right in your own backyard.

Overwhelmingly the young women with whom I work had dreams of growing up to be moms or lawyers or teachers or doctors or nurses.  One girl had seriously and sincerely wanted to be an astronaut.  No one ever dreamed of growing up to be a prostitute!  They were brought into the “life style” as young minors.    They did not choose the life and do NOT benefit financially (a common misconception).  Once used, these victims are humiliated, shamed, embarrassed and trapped in a system they despise but have no idea how to escape.  Many seem to know of a girl who tried to escape who either “disappeared” or who was re-captured with her photo posted on line with her head shaved and tattooed by  her pimp.

NURSES CAN MAKE A HUGE DIFFERENCE if we just start working together to: 

• Learn the facts about Human Sex Trafficking in our own communities
• Work more closely with local and state law enforcement
• Provide vitally-needed education to our peers, friends, organizations and parent groups
• Advocate with legislators to enforce the law and explore alternatives such as the “Nordic Model” which is now used in Canada, France and Sweden
• Believe a patient who trusts you enough to share their situation
• Post the National Human Trafficking Resource Center Hotline – 1-888-373-7888—in a visible location in your setting
• Be hyper-alert to telltale signs such as :
  • Tattoos or branding
  • Very unclear past history and no stable address
  • STD’s, especially repeated episodes
  • Wearing scanty clothes – often 2 sizes too small
  • Presence of cotton or debris in vagina and/ or rectum
  • Problems with jaw or neck
  • Inability to keep appointments
  • No identification
  • Accompanied by a person who does not allow the patient to speak or does not want to leave them alone during interview and/or care
  • Inconsistent stories (conflicting stories or misinformation)
  • Lack of documentation of age- appropriate immunizations and health care encounters

There are 3 million nurses in our country.  I believe that together we have the power to change hearts and minds so that our local communities and our nation understand the realities of human sex trafficking.  I serve on the Foundation Board of a home for victims. Our motto is: “Changing one life at a time and changing the world for future generations”.  I have seen the first goal come true with individual young women.  Won’t you join me in meeting both goals?

AWHONN believes Nurses are ideally positioned to screen, identify, care for, provide referral services for, and support victims of human trafficking. Therefore, the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) supports improved education and awareness for nurses regarding human trafficking. Learn more about AWHONN’s position on this critical topic.

Resources:

• AWHONN’s Position Statement on Human Trafficking
• Polaris Project 

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References

*Number of calls reported to the Human Trafficking Hotline as of December 2016 for more information visit https://humantraffickinghotline.org/

Estimating the Size and Structure of the Underground Commercial Sex Economy in Eight Major US Cities

National Center for Missing & Exploited Children

Urban Institute

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Leith Merrow Mullaly, RN, MSN, IBCLC
Leith Mullaly is a past president of AWHONN and has served at all levels of the organization. Leith has a passion for both nursing and the specialty of Women’s Health and Newborn care. Her focus within AWHONN has always been to mentor future leaders and encourage nurses’ participation in their professional association. She has experience as a Staff Nurse, Staff Educator, MCH Director, Clinical Faculty Member, Certified Lactation Consultant and Author. She is a nationally ranked speaker on topics such as Postpartum Depression, Breastfeeding, the Image of Nursing, Service Excellence, Perinatal Loss and Bereavement, Mature Primiparas. Her interest in care for Victims of Human Sex Trafficking has been a major focus for the past several years.

Lessening the Risk of Birth Trauma

By Karin Beschen, LMHC

 “I was at a routine dental office visit a few weeks after my daughter was born. I remember being reclined in the chair, the bright overhead light and the scent of latex.  Images of surgical masks whipped through my mind.  Fear rushed through my body and I shook uncontrollably.  My body felt hollow and numb but also heavy and out of control.  In that moment I truly believed I was having another emergency c-section.”

This quote is from a woman who experienced a traumatic birth.  She is the mother of a beautiful baby and has had many moments of joy and connection, but also times of panic and fear.  “Mini movies” of her daughter’s birth play in her mind throughout the day.  She deleted the photos of her daughter in the NICU and she wants to disappear when her friends talk about pregnancy.  The birth didn’t end when her baby was born; it followed her from the hospital and it has interfered with many aspects of her life.

Research reveals that between 33-45% of women perceive their births to be traumatic. (Beck, 2013).  Birth trauma is defined as “an event occurring during the labor and delivery process that involves actual or threatened serious injury or death to the mother or her infant.  The birthing woman experiences intense fear, helplessness, loss of control and horror.”  (Beck, 2004a, p. 28).

Approximately 9% of women experience postpartum post-traumatic stress disorder (PTSD) following childbirth. Most often, this illness is caused by a real or perceived trauma during delivery or postpartum. These traumas could include:

• Prolapsed cord
• Unplanned cesarean
• Use of vacuum extractor or forceps to deliver the baby
• Baby going to NICU
• Feelings of powerlessness, poor communication and/or lack of support and reassurance during the delivery
• Women who have experienced previous trauma, such as rape or sexual abuse
• Women who have experienced a severe complication or injury related to pregnancy or childbirth, such as severe postpartum hemorrhage, unexpected hysterectomy, severe preeclampsia/eclampsia, perineal trauma (3^rd or 4^th degree tear), or cardiac disease

My therapy work with mothers is typically after a traumatic birth.  The more I learn about the mother’s labor and birth experience, the more I can understand what care and education could have better supported her during  birth.

The “3 E’s” – explain, encourage and empathize – can be a useful framework for obstetrical staff in lessening the risk of a traumatic birth.  

Explain  

When explaining a process, options or a procedure, always include the woman in the discussion of her own care.  There is a distinct difference in hearing a discussion and being a part of one.  If plans change, explain what is happening and what is needed to correct the situation.

Encourage

The connection a mother has with those caring for her during childbirth is deep — you are present during one of the most emotional, unpredictable times in her life.  Encouragement is empowering and can offer the mother a sense of control.  Encourage questions.   If plans change, discuss possible alternatives.   Using “we” in conversations shows alignment and rallying together.

Empathize 

Women in labor yearn for companionship, support and empathy.

Phrases such as “I know,”  “I’m here,” and “Yes” are phrases that connect staff with a woman’s experience when she feels pain, fear, disappointment or frustration.

I’ve heard many birth stories over the years; devastating stories of physical compromise, intense fear and loss of the baby’s life.  How the mother is cared for, is what she remembers.  The tone of your voice.  The gentleness.  The validation of feelings.  One of my clients was unaware she was being rushed for an emergency cesarean.  She said in all of the chaos and in a knee-chest position, she extended her arm and a nurse held her hand.  Beauty within terror.   It was a simple gesture and it has been the most powerful, healing memory for her.   Even in the midst of an emergency, someone saw her need.  Someone saw her.

Obstetric staff has great influence on how a mother remembers her birth experience.  Expressing empathy and explaining and encouraging a laboring and postpartum mom can influence her health and well-being.  New mothers who receive the “3 Es” can better transition to home, experience less anxiety, have more positive feelings about themselves and improved bonding with their babies.

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Karin Beschen is a Licensed Mental Health Counselor specializing in reproductive and maternal mental health.  She also serves as a volunteer co-coordinator for Iowa for Postpartum Support International.

 

 

Additional Resources

Postpartum Support International 

PaTTCh (Prevention and Treatment of Traumatic Birth)

Improving Birth

References

Beck, C. T. (2004a). Birth trauma: In the eye of the beholder. Nursing Research 53(1), 28-35.

Beck, C. T., Driscoll, J.W., & Watson, S. (2013). Traumatic Childbirth New York, NY: Routledge.

 

 

 

Navigating a Labor Experience: As A Student

By: Amy Smith, Student Nurse at MGH Institute of Health Professions, Boston

I could feel the excitement in the room as I entered. The couple was receptive to my questions and suggestions; and the woman was more than happy to involve me in her care.  I tried to build rapport even though I was nervous in my role as a nursing student. This was the first time I had assisted a woman in labor and, after her membranes were artificially ruptured, her contractions started to come about two minutes apart.  At one point, I had my hand on her back and her husband smiled at me across the room and signaled for to me to remove my hand!  It was a great moment in which the support person and I connected!  I remained quiet during her contractions and I asked her if she wanted me to breathe with her but she said she had it under control. I kept thinking back to my own labors and what I felt I wanted from support people so I asked her if she would like lower back counter pressure but she refused.  The family had not done a childbirth preparation course so I assumed that their interest or skills with working through labor was limited.  I thought that they would need my help more yet her prenatal yoga practice seemed to have given her the tools she needed to get through her labor. The tools I offered her personally were meditative.  I told her to focus on her favorite place, to discuss her needs and frustrations with us in between contractions and reassured her that I was there for her to breathe with her and regulate her breathing as needed.

Reflecting on the Nursing Care Women and Babies Deserve virtues I used during this experience, I believe they were humility and engagement. Humility in that I had to understand I did not know what was best for this family. I assumed they would want and need what I needed during childbirth or skills I learned from the comfort measures video I used to prepare for this clinical experience. The woman decided what she needed and I was there to support her. In respecting their wishes I could engage with the family. Before I left them for the day they commented, “We felt like we had our own doula”.  It was easy and a pleasure to engage with this couple and follow their commands and offer suggestions. I told them I had never wanted to stay at clinical so much as I did with them. I will always remember this family.

 

Additional Resources

AWHONN’s Nursing Care and Women Babies Deserve Poster –  AWHONN’s statement on ethical nursing practice, Nursing Care Women and Babies Deserve, is rooted in the American Nurses Association’s Code of Ethics for Nurses, and provides nurses with core elements of ethical nursing practice for our specialty and corresponding examples of the virtues of ethical practice in action.

Read a commentary about Nursing Care Women and Babies Deserve in AWHONN’s journal Nursing for Women’s Health. Consider submitting your own story of how you or your colleagues practice nursing care that women and babies deserve at https://www.awhonn.org/?NursingCare

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Amy is an ABSN student at MGH Institute of Health Professions, Boston.  She was a stay at home mother for 12 years,  a community coordinator for a non profit kids running program and a volunteer at Dana Farber Cancer Institute in Boston before deciding to enter the nursing field.  With extensive volunteer experience from a camp for blind & visually impaired adults and children, to co-president of an elementary school PTO, she enjoys working with diverse groups of all ages.  Amy aims to work in labor and delivery after graduation in August 2017 but is also interested in global health and epidemiology.  She has intentions to keep making a difference in the lives of those she may never meet again.

Childbirth While Recovering From Addiction

By Tasha Poslaniec , Perinatal Quality Review Nurse

The first time that I cared for a patient who was both recovering from drug addiction while experiencing acute pain, was in Labor and Delivery in 2014. Neither of us was prepared for this. We both exchanged the same shell-shocked, “What do we do now?” look several times that shift. I had a profound realization that day; I needed to come up with a better plan.

My initial idea was a literature search in Pubmed, a free national database of indexed citations and abstracts from thousands of science and healthcare journals. I also hit up Cochrane, a database that provides systematic reviews of evidence based medicine.

While it is difficult to get a good estimate on the prevalence of drug addiction in pregnancy, the National Institute on Drug Abuse published data in 2015 showing that 21,732 infants were born with Neonatal Abstinence Syndrome (NAS) in 2012. That’s equal to one baby being born every 25 minutes with this syndrome. That is a lot of potentially challenging labors to manage.

Ultimately, the most important take away from my research was “treat the pain, not the addiction”. While it’s never ideal to administer narcotics to a recovering addict without a bigger plan, it’s still superior than allowing a patient to suffer.

In an ideal world, the best plan is to have a pre-labor consultation with the patient and anesthesiologist. This can be tricky to make happen as pain control is rarely addressed (especially the kind that recovering addicts need) during the prenatal course. The opportunity for this most often occurs when women are induced, or come in for antepartum testing. I was fortunate enough that my recovering patient was having both of those.  I was able to broach the topic during an NST, and I then requested her when she came in for induction. We were both thankful that the anesthesiologist on that day was open to discussing a plan that she was comfortable with. Just talking together as a team helped her relax.

My patient at that time was taking methadone, which I learned while doing my nursing assessment. Since she had not taken a childbirth class, I gave her homework to research how methadone can both increase the body’s sensitivity to pain (hyperalgesia) as well as limit the options for other pain medications like Stadol, due to the opioid agonist therapy (OAT) she was in. By front loading her understanding of how her pain control was about more than just preventing a relapse, her expectations were set to be more informed as well as more realistic.

The plan that we all agreed upon involved several key areas:

• Set the expectation. While this falls under “patient education” it’s such a powerful tool that it bears having its own bullet point. Having a realistic and frank discussion about the realities of labor is important for any patient, and it should begin with prenatal care. As any L&D nurse can tell you, there is nothing more disheartening than a woman in labor demanding “the shot that takes all of the pain away”.
• Utilize non-pharmacological modalities as much as possible. I created a folder with childbirth information for her in which Penny Simkin figured prominently. Her free guide with illustrations of positions and easy to read mantras were the perfect shorthand for the situation. While we started her induction, we discussed the handouts together.
• Consult with anesthesia ASAP. Again, this can be difficult since you really need a doctor who is on board and .The plan that we came up with was for a labor epidural as soon as she wanted one. Thankfully, ACOG supports labor epidurals at any dilatation, and the evidence supports that receiving one “early” does not adversely affect labor outcomes. The other nuance was to administer the epidural without any opioids. No fentanyl mixed in, just Lidocaine and Bupivacaine. While the likelihood of the opioids placed in the epidural space crossing over into her circulation were pretty minimal, it was a very real concern for her, and we needed to respect that.
• Have a plan B. Should things not go according to plan go sideways, we needed to have a course of action nailed down. This included contacting the obstetrician and enlisting their support while also reminding them that a patient in OAT can require as much as 70% more opiates to manage pain (which she was willing to take should she need surgery) post-operatively. We also discussed a social services referral in this event to help provide services to prevent relapse.
• Provide continuous support. I have to say, this simple intervention was the most effective thing that I did. It helped that our census was low, and I had an understanding charge nurse.

In the end, a lot of stars aligned that day, as my patient was able to cope with the pain, receive an epidural, and ultimately give birth to a healthy baby girl.

Educating the patient, creating a team, and formulating a plan with the patient’s input, as well as providing continuous support, has guided me with the increasing number of patients that arrive in similar situations. This experience has also led me into many different discussions with other nurses and doctors.

The consensus has been that this growing population of patients is compelling enough to establish a pathway for care during labor.  Something we are working on and will hopefully provide a road paved with evidence based best practices in the near future. And while these patients are by no means representative of every person struggling with addiction (recovering or not) they allowed me to recognize a growing need, as well as to learn new ways of helping patients to cope with the dignity and compassion we all strive to provide for the patients we are caring for.

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Search for these resources available in the AWHONN Online Learning Center 

• Opioid Use in Pregnancy: Detection and Support Webinar
• Breastfeeding Implications for Women Receiving Medication Assisted Treatment for Opioid Use Disorders Webinar

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Tasha Poslaniec has been a registered nurse for 17 years. She has been working in obstetrics for over a decade and is currently a Perinatal Quality Review Nurse and Childbirth Educator.

She also writes about nursing and childbirth and has been published in the Huffington Post and the American Journal of Nursing. Pain control in childbirth has long been a topic of study and research for her.

Stress The Modern Day Predator

Holly A. Lammer, RNC-OB C-EFM

“The history of man for the nine months preceding his birth would probably be far more interesting and contain events of greater moment than for all the three score and ten years that follow it.”

~Samuel Taylor Coleridge

Decreasing the amount of stress that we encounter daily is beneficial to our health.   Stress initiates the body’s ‘emergency response system’ which activates the adrenal glands to secrete cortisol and adrenaline.  Cortisol is important for energy (glucose metabolism), blood pressure regulation, immune function and inflammatory response, but is secreted in higher levels during increased stress.  Heart disease, diabetes, autoimmune disorders, chronic inflammatory disorders, mental health issues, obesity can all in some way be linked to how the chemicals of stress wreak havoc on our bodies.   Statistics paint a grim picture:

• Preterm birth in the U.S. is higher than in other developed countries (Kaiser Family Foundation, 2015).
• Stress is associated with an increased chance of preterm birth (PLos One, 2012)
• High rates of anxiety and depression, according to WHO, the U.S. has one of the highest rate of mental disorders of any other developed country. (U.S. News, 2016)
• High rates of obesity – females affected more than males (World Obesity, 2017)
• Immune and allergy disorders, chronic diseases have increased drastically in the last few decades (overwhelming majority affecting women)(Molecular Metabolism, 2016)

One concern is how these chemicals affect a woman and her growing fetus during pregnancy.  Many pregnant women  are exposed to chronic stress;  examples are the stress of jobs, finances, family responsibilities, the expectation and drive for success, high fat and low nutrient diets, lack of time for physical activity,  lack  of community and family support, intimate partner violence, effects of racism and social marginalization.  Stress chemicals can pass to the developing baby through the placenta.

Watering the Seeds of Peace:

But pregnant women can seek to balance and reduce their stress in order to pass on positive neurological chemicals to their babies.  In particular, mindfulness practices such as yoga and meditation have profound impacts on the human brain and, when practiced in the prenatal period, can also influence the growing brain of the fetus. (PLos One, 2012)These types of practices produce changes in the neural pathways and hormonal centers that support parasympathetic response and as these neural connections are strengthened, sympathetic hypersensitivity is decreased. Mindfulness has the potential to reduce the effect of stress chemicals in the body (Journal of Obstetric, Gynecologic and Neonatal Nursing, 2009) since these chemicals are being sent directly to the fetus, through the placenta.

Mindfulness may also reduce the effects of stress chemicals in the baby.  Research shows increases in gray matter concentration in the left hippocampus, which affects learning, memory, and emotional control.  Infants  born of mothers who practice meditation have been shown to have better self-regulation and more emotional control. (Infant Behavior and Development, 2014)

Practicing mindfulness on a regular basis can also “create change in the brain that support feelings of peace, contentment, self-confidence and joy.  As these connections in the brain are strengthened, states of anxiety, worry and anger are decreased. Consequently, incidence and severity of stress related conditions are decreased and may, at the very least, become easier to manage.  Mindfulness practice has been shown to decrease anxiety, depression, insomnia, hyperactivity, substance abuse and chemical dependency.  It can also increase bonding and connection to others.

Preparation for Birth

In addition to all the above mentioned benefits, mindfulness has the added benefit of decreasing sensation of chronic and acute pain and possible subsequent psychological distress caused by pain.  This effect has been correlated to altered function and structure in somatosensory areas and an increased ability to disengage regions in the brain associated with the cognitive appraisal of pain, basically ‘reframing’ the sensation.  Most childbirth methods are based on meditative techniques (Lamaze and Bradley breathing, Hypnobirthing, etc.)  Mindfulness practices also enhance immune function – extremely important in pregnancy where it is already suppressed.  If there is a complication that is present (obesity, immune disorder, mental illness) or one that is diagnosed during the pregnancy (gestational diabetes, hypertension, multiples) or that happens during birth (prolonged labor, surgical intervention), regular meditative practices can help prime the immune system so that the effects of these events may be milder.

It’s as simple as ‘ABC’

One of the great things about mindfulness is that it can be practiced literally anytime, anywhere.

A is for Awareness:  Simply pause or stop and become AWARE of the present moment. An easy way to do this is just notice the body in space… the arrangement of the legs or arms, the overall tone in the body… the sensations in the body. Use the senses to drive your awareness:  the feel of the coffee cup in your hand, the sound of a bird chirping or the rain on the roof, the warmth of the sun on your skin.

B is for Breathing:  Bring your awareness to your breath.  The breath is always present.  Notice the inhalation and the exhalation.  Just by noticing the breath without changing it in any way, nervous system shifts to parasympathetic activity. You can enhance this shift by guiding the breath to be longer and deeper. Regulating the breath in this way also decreases blood pressure and heart rate.  Imagine your breath bringing oxygen to your growing baby. Imagine your baby listening to your deep rhythmic breaths and the slowing of your heart beat.  Calm, serene.

C is for Consciousness:   Or ‘thinking’. Now you have the space in the nervous system to examine your thoughts. Notice that they come and go like clouds on a windy day.  If there is a particular thought or sensation that is troubling you or seems uncomfortable, you have the ability to CHOOSE your reaction instead of unconsciously reacting with habitual patterns of response.

When we practice in this way, even for a few minutes a day, our nervous system slowly begins to rewire and connections of peace and joy are strengthened.  In the pregnant mom, this benefit is wiring the baby’s brain from the very beginning of development.

Helpful Resources and Links

• Antenatal mindfulness intervention to reduce depression, anxiety and stress
• Fit Pregnancy: 5 Prenatal Meditation Techniques
• Impact of stress and stress physiology during pregnancy on child metabolic function and obesity risk
• Incidence and prevalence of chronic disease
• Mindful Birthing
• Prenatal meditation influences infant behaviors
• Relaxation Response and Resiliency Training and Its Effect on Healthcare Resource Utilization
• The Association for Prenatal and Perinatal Psychology and Health
• The effects of mindfulness-based yoga during pregnancy on maternal psychological and physical distress.
  

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  Holly Lammer is an Obstetric Nurse, Clinical Educator and Childbirth Instructor for St. Luke’s Health System based in Boise, ID.  In addition to teaching credentialed courses through AWHONN and AHA,  she develops and teaches curriculum for prenatal and perinatal specialty courses offered in the St. Luke’s system.  Holly is also registered with the Yoga Alliance as a 500-hr Yoga Instructor and on faculty as a Prenatal Yoga Teacher Training Instructor. She is certified in Inpatient Obstetrics and Electronic Fetal Monitoring through NCC and is in process of obtaining her Pre and Perinatal Psychology Educator through the Association for Pre and Perinatal Psychology and Health.

  Holly has blended her experience in high volume high risk inpatient setting with her training and research in mind-body therapies to form unique educational programs for pregnant women and the providers that care for them, including Intuitive Birth – the area’s only Mindfulness-Based Childbirth Education series. A driving force for patient centered, evidence-based practice, her passion is apparent in her program content and her ability to drive changes at the policy level to improve outcomes for women and babies.

  Holly has spoken regularly at multidisciplinary local and regional conferences on the subjects of physiologic birth, prenatal psychology and health, and mindfulness-based strategies to improve health.  In addition, she provides regular educational opportunities for the public and for inpatients and care providers in her community.

We May Have Different Religions

By Evgeniya Larionova

“We may have different religions, different languages, different colored skin, but we all belong to one human race”. –Kofi Annan (Ghanian Diplomat, 7th UN Secretary-General, 2001 Nobel Peace Prize winner)

What is exactly childbirth? Some people compare it to a miracle, a heroic act, or a surge of love accompanied by strenuous and intense hours of labor. It’s absolutely one the most unique experiences that can happen to a woman’s body. The time when she is particularly vulnerable and in need of much support and care.

For me, a nurse practitioner student on labor and delivery floor at Massachusetts General Hospital, witnessing childbirth was something that I would never forget. Thrown into the action on a first clinical day, I had mixed feelings of joy, excitement and a slight nervousness. I felt extremely privileged and grateful to witness a natural delivery and I was hoping to help a future-to-be mom during the process.

From the morning report I found out that the woman I was assigned to follow was a recent immigrant from Guatemala who belongs to the indigenous Mayan population. Mayan was the patient’s native language but she was also able to understand Spanish. Her husband had been residing in the United States for 5 years. She moved here a year ago and the family has finally reunited.

My patient was accompanied by a traditional nurse midwife known as comadrona. Comadronas are trusted women leaders in their communities who accepted a spiritual calling. They usually don’t receive any formal training but have years of experience delivering babies. Comadronas regard birth as a natural process and rely heavily on God and prayers. The nurses established a plan of care recognizing my patient’s spirituality and personal support system. The Mayan midwife was present during labor and helped with comfort measures. The nurses also invited a qualified interpreter.

When I entered the room, a nurse and a midwife, along with the comadrona, surrounded the tiny woman. One of the nurses was checking her vital signs and the nurse-midwife was encouraging the woman to take slow deep breaths and relax. The comadrona, wearing a traditional colorful embroidered dress, was gently massaging her back. The room was dimly lit and the scent of fresh lavender floated in the air. My patient’s contractions were increasing steadily and were becoming more regular. This was active labor –she was ready to give birth.

The whole atmosphere struck me. There was no other language present in the room but the language of trust, respect and compassion between these women. I immediately wanted to become connected with what was happening- just by holding this woman’s hand and talking to her.

Reflecting back on this experience, I understood that nurses not only created the environment that made this woman feel comfortable and that was respectful of her spirituality but that the environment also had a significant impact on the labor and birth process. Although childbirth is unique and at the same time a unifying biological event for any woman; providing therapeutic communication, physical, emotional, spiritual care and comfort during the labor process is crucial.

The comadrona shared her knowledge and experience with the American nurses. It was important for my patient to have a traditional midwife near the bedside who comforted and prayed with her. There was interplay between modern and traditional medicine that contributed to the positive outcome. Nurses in this particular case were not only culturally sensitive and able to understand cultural values, beliefs and attitudes of clinicians and patients, but also culturally competent and had knowledge, capacity and skills to provide high-quality care (Jernigan et al, 2016).

It’s essential for any nurse in such a unique, heterogeneous country like the United States to be cognizant and open-minded of cultural diversity and the patient’s cultural perspectives. I will take this amazing experience to my future nursing practice and strive to always treat my patients with dignity, respect and compassion. I also hope to continue to integrate a holistic model and culturally sensitive care into our modern childbirth practices.

This woman gave birth to a beautiful baby daughter whom she named after a nurse taking care of her during her labor and birth.

Additional Resources & References
http://prontointernational.org/
https://he-he.org/en/
http://www.mayamidwifery.org/
http://midwivesformidwives.org/guatemala/
http://www.birth-institute.com/study-abroad-guatemala/
http://www.acog.org/
Jernigan, V. B. B., Hearod, J. B., Tran, K., Norris, K. C., & Buchwald, D. (2016). An Examination of Cultural Competence Training in US Medical Education Guided by the Tool for Assessing Cultural Competence Training.Journal of Health Disparities Research and Practice, 9(3), 150–167.

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Evgeniya Larionova received her Bachelors of Science in Nursing from MGH Institute of Health Professions. She is a founder and an Artistic Director of AMGITS Drama&Poetry Club at the Boston Living Center. She is a member of the student Leadership Committee of the Harvard Medical School Center for Primary Care. Evgeniya is passionate about infectious diseases, community health and integrating holistic care in modern practices.  In her spare time she plays in the Russian theater, enjoy reading, playing the guitar and hiking.