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.

 

 

 

What You Need to Know About Light Bladder Leakage

By Susan A Peck, RNC, MSN-APN

What do a 30 year old pregnant woman, a 67 year old who has 3 children – all delivered vaginally- and a 45 year who has never been pregnant have in common?  They are all experiencing light bladder leakage and each of them feels embarrassed to discuss it.  Bladder leakage is very common and can occur in any woman, of any age, and of any pregnancy status!

Light bladder leakage also known as urinary incontinence, is an involuntary loss of urine.  It is estimated to occur in up to 1 in 4 women.  The two most common types of incontinence include stress incontinence and urge incontinence, but some women can have a combination of both types.

• Stress incontinence is the loss of urine (small or large amounts) from activities that cause pressure on your bladder such as coughing, running, jumping, or sneezing. It happens when the pelvic floor muscles- that support the bladder- weaken.  The weakened muscles can be caused by pregnancy, previous vaginal births, obesity or being overweight or chronic urinary tract infections.  Sometimes, incontinence may occur without any of these risk factors.
• Urge incontinence is the frequent sudden need to urinate that often causes bladder contractions and the loss of small or moderate amounts of urine. It happens from bladder irritants such as caffeine or alcohol, excessive hydration, use of certain medications such as diuretics (water pills), or neurological conditions.  In some women, this may be called an overactive bladder.

As a Women’s Health Nurse Practitioner, I ask my patients about bladder leakage and incontinence- because most of the time they will not mention it to me first. Here are two stories which are very similar to real life cases I see every day.    The first was a 55 year old fitness instructor who has 3 children, all delivered vaginally.  She sees me once a year for her annual well woman exam and this year when I asked her if she had any bladder leakage, she said yes, that it just started about 6 months prior.  She was quite surprised by this because she teaches Pilates as well as Zumba and thought she had a pretty “strong core”.  But lately, in Zumba class she would feel dribbles of urine coming out.  She was embarrassed someone would see it on her pants, so she’s started to wear a pad to class, but hated exercising while wearing one. Patient B is 30 years old, a mother to a 2 year old son born via cesarean section and working full time.  When I asked her about incontinence, she told me that since her son was born, she leaks urine each time she coughs or sneezes and notices that it happens more when she drinks coffee – the caffeine she needs because of her busy life!  She was also quite surprised that the leakage is happening because “she is young and did not have a vaginal birth”.

Both of these women were surprised to know how common bladder leakage is, but very happy to know they are not alone.  During their pelvic examinations, I asked them to each perform a Kegel exercise- by contracting the pelvic floor- so that I could assess their pelvic floor tone.  The Patient A did the Kegel correctly, but had poor tone.  Patient B did not perform the Kegel correctly – instead she was bearing down/pushing out.  I routinely test my patients for their pelvic floor tone and at least 50% of the time, tone is poor, or the exercise is not performed correctly.

Below are some tips to help maintain good pelvic floor muscle tone, which is is critical to prevent or improve bladder leakage.

• Kegel exercises are the easiest way to strengthen these muscles, as well as pilates exercises which focus on strengthening the core. Here is a link from the Mayo Clinic to assure you’re practicing them correctly.

• Weight loss is very important in the management of bladder leakage. Even just a 5-10 lb loss can relieve some abdominal pressure against the bladder.
• Try to reduce exposure to bladder irritants such as caffeine and alcohol and to not let your bladder get too full – even during busy days!
• For some women, referral to a physical therapist that specializes in pelvic floor physical therapy can also be very helpful. Yes, there are physical therapists that specialize in this important muscle group!  In situations where these conservative measures do not help sufficiently, there are urogynecologist physicians – who are gynecologists who have a sub-specialty in pelvic floor medicine- who may offer other treatments including surgery.

Light bladder leakage is a common complaint among women of all ages.  If you are experiencing this, please mention it to your nurse or health care provider, if they don’t ask about it first.  Many women believe it is a normal part of ageing or a normal consequence of pregnancies or childbirth – but there are ways to help, so do not feel embarrassed or uncomfortable bringing up the subject and asking for help.

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Susan A. Peck, RNC, MSN, APN is a practicing Women’s Health Nurse Practitioner. For 20 years, Ms. Peck’s career has focused on women’s health care, first as a labor and delivery staff nurse and for the last 16 years as an Advanced Practice Nurse. She currently works in the Department of Obstetrics & Gynecology within Summit Medical Group, a large multi-specialty practice group in Northern New Jersey.

Ms. Peck’s areas of expertise include contraception, osteoporosis, general gynecology and prenatal care. She has spoken at several national and state conferences including the AWHONN National Convention.

The Cornucopia of Contraception

by, Susan A Peck, RNC, MSN-APN

In 2000, as a new Women’s Health Nurse Practitioner, the provision of contraception to my patients was actually pretty simple.  Most every woman who wanted hormonal contraception used the pill, and there were only a handful of brand name oral contraceptives that we all knew and regularly used.

Shortly thereafter, in 2001, the contraceptive patch and the contraceptive vaginal ring were approved by the FDA.  These other two options quickly became competitors to the oral contraceptive market and gave patients and clinicians more choice, and ways to avoid the sometimes daunting responsibility of daily pill intake.

In the background was the IUD – only ParaGard and Mirena were available at that time.  Still holding on to the worries of the unsafe IUDs of the 1970s and 1980s, most women and clinicians were not supportive of these devices at that time – fortunately that has dramatically changed!  In 2013, the Skyla IUD became available and the Liletta IUD followed in 2015.  And let’s not forget about the contraceptive implant, Implanon (now Nexplanon) that was approved in 2006.

Barrier methods have also always been accessible to women, such as condoms (male and female) and various spermicidal formulations, as well as the diaphragm – did you know the “old” diaphragm is no longer available, but that there is a new one, Caya?

So, when we consider all of these options, and factor in the complexity of some women’s medical conditions or social practices, how can women’s health clinicians consider not only which method might be most acceptable to a woman, but also which method is the safest??  There certainly is a lot to keep track of with all of today’s contraceptive choices.  And if a woman does not use her method correctly, what can a clinician advise?

Fortunately, the CDC has recently published two documents, the 2016 US Medical Eligibility Criteria for Contraceptive Use (MEC) and the 2016 Selected Practice Recommendations for Contraceptive Use (SPR).  The references are invaluable for any clinician who is providing contraception to women.  I have a copy of both at my desk in my office and even after 16 years of practice, I regularly rely on their guidance to make the best, safest recommendations about contraceptive choices for my patients.

I’d like to tell you about two recent patients, for which both references helped guide my decision making. 

First, Jennifer, a 32 year old woman living with multiple sclerosis, has used oral contraceptives successfully for five years.  She enjoys the regular, very light periods she has with the pill, and is a very responsible pill taker – never misses one!  But, this year, when I see her for her annual exam, I learn that her MS has unfortunately taken a turn for the worse.  She is currently in a wheelchair more the 50% of the time and her mobility is greatly limited.  She is very hopeful that this period of immobility will be short lived – there is a new MS drug she is starting next month.  So, I begin to wonder whether an oral contraceptive is the best, safest method for Jennifer.  I use my 2016 MEC App on my phone and determine that due to her immobility related to MS (increased chance of hypercoagulable state) it may be time to change methods.  She and I discuss all options and she decides on the Mirena IUD.  Not only is she pleased with a long term method, she feels more comfortable knowing she is safe – it is one less thing she has to worry about.

My next patient is Mary, a 20 year old healthy college student who tells me that she wants to use the contraceptive implant, Nexplanon.  She is going back to school out of state in two days, and would really like to have the implant inserted today.  In the past, some clinicians have traditionally preferred to insert LARC methods during a woman’s menstrual period to “make sure she is not pregnant”.  However, this is often cumbersome for scheduling and delays an opportunity to provide effective contraception.  So, I use my 2016 SPR and review the section ‘how to be reasonably certain a woman is not pregnant’.  I determine that since Mary has consistently and correctly used condoms since her last period, it is safe to assume she is not pregnant. After receiving her informed consent, I safely place the Nexplanon and she is able to return to college with a highly effective long term method of contraception.

It is important to remember that in nearly all situations the use of a birth control method is safer than an unintended pregnancy. These CDC resources are invaluable guides for clinicians so we can be confident our contraceptive recommendations are based on the latest evidence.  Both the MEC and the SPR are available free – of- charge with the option of downloading an APP for your device.

Tell your colleagues and have these references close at hand!

Susan A. Peck, RNC, MSN, APN is a practicing Women’s Health Nurse Practitioner. For 20 years, Ms. Peck’s career has focused on women’s health care, first as a labor and delivery staff nurse and for the last 16 years as an Advanced Practice Nurse. She currently works in the Department of Obstetrics & Gynecology within Summit Medical Group, a large multi-specialty practice group in Northern New Jersey.

Ms. Peck’s areas of expertise include contraception, osteoporosis, general gynecology and prenatal care. She has spoken at several national and state conferences including the AWHONN National Convention.

 

 

 

Informal Milk Sharing in the United States

by, Diane L. Spatz, PhD, RN-BC, FAAN

Susan is a nurse in a Neonatal Intensive Care Unit (NICU) with a strong human milk culture.  Every day she provides evidence-based lactation care and support to mothers who have critically ill infants. She understands fully that human milk can be a lifesaving medical intervention and received two days of on the job education regarding the critical importance of human milk and breastfeeding.  Seeped in this culture, Susan also believes that nurses and health professionals have an obligation to help families make an informed decision and while it would be ideal if all infants were exclusively breastfed by their own mothers, this is not always feasible or possible.

Susan is also challenged personally Having experienced infertility for 10 years, she has decided to adopt a newborn. She has read the literature and met with a lactation expert .  Susan is aware that even with great effort and time investment, she may never achieve a full milk supply.  She is very concerned about giving her infant formula and asked the lactation expert about accessing Pasteurized Donor Human Milk (PDHM).

The Human Milk Banking Association of North America (HMBANA) is the organization that oversees non-profit milk banks in the United States.  Even though the number of HMBANA milk banks is increasing in the United States and the amount of PDHM has also increased substantially in recent years, PDHM is still prioritized to preterm or vulnerable infants in the hospital setting.  HMBANA milk banks do sometimes dispense PDHM to the community setting.  However, in these instances, it is for infants with special medical needs and usually requires a prescription from a health care provider.

So for Susan who is planning to adopt a healthy full-term infant, she will likely be unable to access PDHM.  Susan is considering informal milk sharing in order to supplement what milk she is able to produce through inducing lactation.  It is important for nurses and other health professionals to be aware that informal milk sharing does exist and also to help families make an informed decision.

There are many reasons why women or families choose to pursue informal milk sharing in addition to the reasons in Susan’s story, including:

• Women who have glandular hypoplasia or breast surgery and are unable to develop a full milk supply
• Men and women who adopt children and may be unable to induce lactation
• Women who have had bilateral mastectomy prior to childbearing
• When a woman dies in childbirth and her family members wish to honor her plans to breastfeed
• A short term need for supplemental human milk due to early breastfeeding challenges or a delay in Lactogenesis II

Although very beneficial in all of the above cases, informal milk sharing is not without any risk because just as antibodies, white blood cells, and other immune components are transferred in human milk, viruses can also be transferred.  In addition, some medications transfer into human milk (most in very small amounts, but some in larger).

Mothers who are considering informal milk sharing should consider the following steps:

1. Get a complete health history from the donor mother. It is essential to understand  the donor mother’s past and current medical history as well as lifestyle choices is essential.  It is also acceptable for the mother to ask the donor mother for a copy of her serologic testing from pregnancy.
2. Find out how the milk will be expressed, labeled, stored, and transported. The donor mother, first and foremost, should have an excess supply of milk that she does not need for her infant. When mothers express milk, care should be taken to ensure the safety of the milk.  At our institution, we have mothers wash their pump equipment with hot, soapy water and rinse well after every use and have them sterilize the equipment daily.
3. What types of containers will be used for storage (the recipient mother could supply these to the donor mother) and how will the milk be stored (fresh or frozen) and transported from the donor mother to the recipient. Conversations between recipient mother and donor mother should be on-going to ensure safety of the milk. In this area the research literature has also evaluated  the use of home heat treatment to “pasteurize” the milk. Research has shown that heat treatment of the milk on a stovetop is not the same as Holder pasteurization, this technique has the ability to destroy viruses.  It is important to note that heat treatment also destroys some of the beneficial components of human milk.

Recently, the American Academy of Nursing published a position statement regarding the use of informally shared milk. This, along with resources shared below can be a starting point to have these conversations with families who are interested in the topic.

As health professionals, is also important to understand that there is a difference between milk sharing –  mothers may share  altruistically and be commerce free or there may be  an exchange of money or mothers who are paid for the milk.  When financial exchange enters the equation, mothers seeking to get paid for their milk may be motivated to dilute or alter their milk.  We should advise parents to be alert and aware of this.

Until PDHM becomes universally available, if a family does not wish to feed their infant formula, the only other option available is informally shared milk.  Having transparent and honest conversations with families to help the understand this practice is essential.

Resources for Informal Milk Sharing

The American Academy of Nursing (2016). Position statement regarding use of informally shared human milk.  Nursing Outlook, 64, 98-102.

Martino, K., & Spatz, D. L. (2014). Informal milk sharing: What nurses need to know. The American Journal of Maternal/ Child Nursing, 39(6), 369-374. doi:10.1097/NMC.0000000000000077

Spatz,  D.L. (2016.) Informal Milk Sharing. American Journal of Maternal Child Nursing;41(2):125. doi: 10.1097/NMC.0000000000000225. PubMed PMID: 26909729.

Wolfe-Roubatis, E. & Spatz, D. L. (2015). Transgender Men & Lactation: What nurses need to know. The American Journal of Maternal Child Nursing,40(1): 32-38. doi: 10.1097/NMC.0000000000000097.

Israel-Ballard, K., Donovan, R., Chantry, C., Coutsoudis, A., Sheppard, H., Sibeko, L., & Abrams, B. (2007). Flash-heat inactivation of HIV-1 in human milk: a potential method to reduce postnatal transmission in developing countries. Journal of Acquired Immune Deficiency Syndromes, 45(3), 318-323.

Diane L. Spatz, PhD, RN-BC, FAAN is a Professor of Perinatal Nursing & the Helen M. Shearer Professor of Nutrition at the University of Pennsylvania School of Nursing sharing a joint appointment as a nurse researcher and director of the lactation program at the Children’s Hospital of Philadelphia (CHOP). Dr. Spatz is also the director of CHOP’s Mothers’ Milk Bank.  Dr. Spatz is an active researcher, clinician, and educator who is internationally recognized for her work surrounding the use of human milk and breastfeeding particularly in vulnerable populations. Dr. Spatz has been PI or co-investigator on over 30 research grants, included several from the NIH.  She has authored and co-authored over 80 peer reviewed publications.  Dr. Spatz has authored or co-authored position statements for the International Lactation Consultant Association, the Association of Women’s Health Obstetric & Neonatal Nursing and the National Association of Neonatal Nurses.

In 2004, Dr. Spatz develop her 10 step model for human milk and breastfeeding in vulnerable infants.  This model has been implemented in NICUs throughout the United States and other countries worldwide. Dr. Spatz has been named a prestigious “Edge Runner” for the American Academy of Nursing related to the development and outcomes of her model.  Her nurse driven models of care are critical in improving human milk & breastfeeding outcomes and thus the health of women and children globally.

Dr. Spatz is also the recipient of numerous awards including: Research Utilization Award from Sigma Theta Tau International and from the University of Pennsylvania:  the Dean’s Award for Exemplary Professional Practice, the Expert Alumni Award and the Family and Community Department’s Academic Practice Award   She is also the recipient of the Lindback Award for Distinguished Teaching. Dr. Spatz received the Distinguished Lang Award for her impact on scholarship, policy & practice.

In the university portion of her job, she teaches an entire semester course on breastfeeding and human lactation to undergraduate nursing students and in the hospital portion of her job, she developed the Breastfeeding Resource Nurse program.  Dr. Spatz is also Chair of the American Academy of Nursing’s Expert Panel on Breastfeeding and their representative to the United States Breastfeeding Committee.  Dr. Spatz is also a member of the International Society for Researchers in Human Milk & Lactation

 

Babies Have Back-to-School Needs, Too

by, Summer Hunt

This time of year from late July into August, many moms are preoccupied with back-to-school shopping for all the basics: pencils, paper, glue and the like, as well as products like paper towels, hand soap and facial tissue. Just as these items are important for school-age kids, babies and toddlers have “back-to-childcare (and preschool)” needs, too—and diapers top that list.

Did you know that babies and toddlers can’t attend childcare without an adequate supply of extra diapers? It may not seem like much, but for the 1 in 3 families who don’t have enough diapers to keep their babies clean, dry and healthy, buying extras typically breaks the bank. Without enough diapers, parents are forced to choose between work—and a paycheck—and taking care of baby.

The Harsh Realities of Poverty
Diapers cost $70-$80 per month, per baby, and parents can’t use food stamps for diapers—in fact, there is zero direct government assistance for diapers. Low-income families can’t afford to buy diapers in bulk, and many do not have access to big-box discount stores or online shopping. This means families hurting the most financially are hit hardest when it comes to buying essential care items like diapers. In fact, the poorest 20% of Americans spend nearly 14% of their income (after taxes) on diapers, according to the National Diaper Bank Network (citing 2014 government data)—that’s $1 out of every $7 of their average $11,253 income spent on diapers, or $1,575 a year on average.

Parents just want to do right by their children. We spoke with four moms last year who talked about their experiences with diaper need. These families are doing their best to keep their babies happy and healthy, even if that means going without or making tough decisions about paying other bills. And with 5.3 million babies in America living in low-income families, these moms are not alone in their struggles.

Nurses on the Front Lines
AWHONN is proud of all the work our nurses to do to take care of moms and babies, especially those in the most vulnerable populations. Our Healthy Mom&Baby Diaper Drive gives nurses the recognition they deserve when they go beyond patient care and collect items like diapers, wipes, clothes, car seats for their tiniest patients.

Across the country, at section and chapter meetings, through community baby showers and diaper drives, when donating diapers to diaper banks and women’s shelters, and in their own hospitals and clinics, nurses are on the front lines every day combatting diaper need for their patients.

Let Us Share Your Efforts!
What are YOU doing in your area to make sure that babies are clean, dry and healthy? Are you:

• Giving out diapers at community and education events?
• Participating in a diaper drive event with your local faith community or civic group?
• Sharing diapers with families in need in any other way?

Tell us your stories at AWHONN.org/diaperdrive, or contact our Diaper Drive consultants Jade Miles and Heather Quaile. Our consultants can also help you increase your efforts or start something new and make sure that your current successes are counted in our final totals. You can also visit DiaperDrive.org to make a dollar donation that will be used to purchase diapers at wholesale for diaper banks across the country. Are you an advocate for cloth diapering? There are several diaper banks that accept cloth diapers, and you could even initiate a cloth diaper drive in your community!

As families everywhere get ready to head back to school, why not toss an extra pack of diapers into your cart to donate to your local bank? Or, head over to DiaperDrive.org while surfing the Internet for prime deals on books and binders and donate $20 dollars to diaper a baby for two weeks. You’ll ensure a brighter future and a better bottom line for babies everywhere—and that’s a guaranteed A-plus in our books.

Summer Hunt
Summer Hunt is the editorial coordinator for publications at AWHONN

Five Easy Steps to Save Lives and Promote Healthy Families

by, Donna Weeks

It’s staggering to think that 54 to 93 percent of maternal deaths related to postpartum hemorrhage (PPH) could be avoided.

So what can we do on our units to reduce the number of women with complications, or even death, from an obstetrical hemorrhage?

I have taken part in many discussions about high tech simulation and drills, and we are always asking ourselves:

• How can we have effective drills without a simulation lab and simulation models?
• Can low tech simulation play a beneficial role in decreasing obstetrical hemorrhage?

I recently took part in a pilot program that the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN)  trialed on postpartum hemorrhage risk assessments, evidence-based oxytocin orders, and hemorrhage drills and debriefing based upon a variety of settings.

Here are a few ideas that I have implemented without utilizing a simulation lab. These easy suggestions may help every obstetrical unit  raise awareness of obstetrical hemorrhage and contribute to decreased maternal morbidity and mortality.

First, have a mock code on your unit using your own crash cart.  You may be surprised to find out how many nurses are uncomfortable with finding key items in your crash cart.  Use a pillow to simulate a gravid uterus and have one nurse demonstrate left uterine displacement while other nurses deliver compressions and ventilations.  Additional nurses may find supplies, IVs, and medications in the code cart.

Second, devise a scavenger hunt and ask your staff to find the closest location of items needed during an obstetrical hemorrhage.  In many units the OB techs check the hemorrhage cart and the nurses may be less familiar with the items on the cart.  They may be leaving the room to get supplies and medications that are already on the cart.  In a true emergency this will use up valuable time.

Third, consider efficiencies. Do you have your medications locked in a Pyxis or Omnicell?  Do nurses have to remove the uterotonics one at a time? Due to the awareness raised by our hospital’s participation in AWHONNs postpartum hemorrhage project,  the day after our medication administration system was installed our pharmacy was notified that we needed a postpartum hemorrhage kit.  Now with one selection we retrieve ergonovine maleate (methergine), misoprostol (cytotec), carboprost (hemabate) and oxytocin (pitocin).

Fourth, how do you drill? What about drills in an empty patient room?  Have a drill in a patient room with nothing more than a mannequin.  Change the scenarios and include the less common situations.  With a type and screen being completed on most admitted labor and delivery patients it is not common to be ordering uncrossedmatched blood.  I use a scenario that includes a woman presenting to L&D with an obvious hemorrhage. This scenario presents the opportunity to review how and when to retrieve uncrossmatched blood.  What is your procedure?  Is there special paperwork or forms?  During one drill we strongly stressed the time element including how quickly we could generate a medical record number and how much time would be lost if an OB tech was sent for the blood. In our institution uncrossmatched blood may only be released to a physician or nurse.  Take the scenario further and include your massive transfusion protocol.  Review when and how to initiate the protocol.

Lastly, practice quantification of blood loss until it becomes routine.  Use scales, work sheets, and a variety of scenarios to keep staff informed and interested.  These can be presented by a charge nurse on any shift without preplanning.  It is just one more way to keep obstetrical hemorrhage on the forefront of everyone’s mind.  The more awareness we raise the better chance we have of early recognition and intervention. The goal is to have a healthy mother and healthy family.

Donna is a Perinatal Clinical Specialist at JFK Medical Center in NJ.  She has always loved OB nursing and also enjoys teaching.  She is currently an adjunct instructor at Kaplan University and Walden University.  She was the Hospital Lead for AWHONN’s PPH Project.

 

 

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Citations

Berg, C. J., Harper, M. A., Atkinson, S. M., Bell, E. A., Brown, H. L., Hage, M. L., . . . Callaghan, W. M. (2005). Preventability of pregnancy-related deaths: Results of a statewide review. Obstetrics & Gynecology, 106, 1228–1234.doi:10.1097/01.AOG.0000187894.71913.e8

California Department of Public Health. (2011). The California pregnancy-associated mortality review. Report from 2002 and 2003 maternal death reviews. Sacramento, CA: Author. Retrieved from http://www.cdph.ca.gov/data/statistics/Documents/MO-CA-PAMR-MaternalDeathReview-2002-03.pdf

Della Torre, M., Kilpatrick, S. J., Hibbard, J. U., Simonson, L., Scott, S., Koch, A., . . . Geller, S. E. (2011). Assessing preventability for obstetric hemorrhage. American Journal of Perinatology, 28(10), 753-760.doi:10.1055/s-0031-1280856

Resources

Get free postpartum hemorrhage resources from AWHONN.

Learn more about AWHONN’s Postpartum Hemorrhage Project

For more in-depth info and to learn more about how to reduce clinician errors associated with obstetric hemorrhage mortality and morbidity, join AWHONN’s newest implementation community on Postpartum Hemorrhage.

Cora’s Law

by, Elizabeth McIntire

In northern Indiana in November of 2009, Cora McCormick was born–a full term apparently normal newborn. Her parents were thrilled at the birth of their first child. Her mother had experienced a perfectly normal pregnancy, labor and delivery. Cora took well to nursing and the new family went home from the hospital 48 hours after Cora’s birth.  Cora, her dad and mom Kristine spent three wonderful days together– until tragedy struck.

Kristine was nursing Cora when suddenly her baby girl turned blue/gray in her arms and stopped breathing. They rushed their newborn daughter to the hospital but nothing could be done. Cora died at five days of life. Cora’s cause of death was congenital heart disease.

Shortly after Cora died, her mother took up a crusade to make congenital heart defect screening in Indiana required as an addition to current newborn screening.

Due to Kristine’s efforts, in January 2012 “Cora’s Law” was passed by the Indiana legislature and required hospitals to screen newborns for critical congenital heart defects.

This is where I got involved. Prior to the law going into effect, perinatal providers throughout the state needed to become aware of the law and how it impacted newborn screening. I was responsible for developing an education program for these providers. As we were gearing up for implementing this law, I had the good fortune to meet Kristine McCormick, witness her advocacy for this screening and witness a mom who’s own heart was broken turn her grief into something truly amazing. I knew that if we could use Cora’s newborn picture—that of a completely healthy looking cubby cheeked baby girl, it would make an impact as we talked to physicians and nurses about the importance of the screening and new law.

Baby Cora

Kristine gave me permission to use Cora’s picture in our educational presentations and in a postcard I helped develop with the screening algorithm on it. Fast forward to February 1st, 2012, one month to the day after Cora’s law went into effect. On that day a baby boy, Gabriel, was born in southern Indiana. He too looked perfectly normal—like Cora. However, before he went home he underwent the screening that Cora’s mom advocated for. The screen was abnormal. The staff at the hospital repeated the screening and again, he failed. With the screening algorithm at hand, they knew what to do and he was transferred to a quaternary center for management. He was diagnose with a critical heart defect and underwent emergency surgery to correct the issue. He did well postoperatively and was able to return home with his family.

Several months after surgery, Gabriel came back to Indianapolis for a routine postop checkup. It occurred to me that Kristine needed to meet Gabriel’s mom and Gabriel’s mom needed to meet Kristine. I wanted these two women to come together—both bound by motherhood, tragedy and victory. They needed to meet, to heal, hug each other, and share Cora’s baby picture, laugh and cry.

Mother to mother—each of them understanding that Cora Mae McCormick was the reason they were there, the reason Gabriel was wiggling in a blanket in Kristine’s arms. I watched as the local news channel filmed the event and next to me was one of the neonatologists who helped with the statewide teaching efforts. I leaned over and told him—“this is what it’s all about. This is why we do what we do”. It was and still is one of the most profound moments in my nursing career.

Click here for additional information on Cora’s Law. You can also find information on the Cora’s Story Facebook page.

To find out more about pulse oximetry screening, visit: http://www.childrensnational.org/PulseOx/ 

 

Elizabeth McIntire, WHNP,WHNP-C, EFM-C
Elizabeth is the Director Maternity & Newborn Health at 
IU Health Riley. Elizabeth started her career in obstetrical nursing and has never looked back. Besides her family, her passions are high risk obstetrics, perinatal safety, and high reliability, challenging the process and modeling the way.

What Children with FASD Want You to Know

by, Marilyn Pierce-Bulger, ANP

Jason is a 13 year old boy who knows he is different but he does not understand why.  He blames himself for the difficulty he has had in school and with social relationships over the years. He thinks he is not trying hard enough or is not smart enough.  His teachers and parents view him as willful, rather, than ‘unable’ due to his hidden disability.

Standardizing Postpartum Oxytocin Administration

by, Jennifer Doyle, MSN, WHNP-BC
Director, AWHONN Executive Board
APN, Women’s Service Line
Summa Health
Akron City Hospital
Akron, OH

Photo: Jennifer Doyle assessing and caring for fellow colleague Amy Burkett, MD, FACOG.

Somewhere in a Labor and Delivery unit, a woman gives birth.  A family is born. A nurse remains at the bedside.  A sentinel, who assesses, plans, and intervenes.  The nurse is equipped with knowledge and skills to holistically care for mom and baby.  The nurse’s primary focus is to promote bonding and breastfeeding. However, despite a safe birth, risk remains.  Postpartum hemorrhage (PPH) is a leading cause of maternal morbidity and mortality.  It is often preventable.

As a labor and delivery staff nurse, there were countless occasions when I held vigil at the side of my patients after they gave birth.  I was prepared with an array of resources to treat PPH. In part, this included uterine massage, oxytocin, methylergometrine, carboprost, and misoprostol.   As a nurse caring for a woman in the immediate postpartum period, my goal was to assess maternal bleeding and avoid PPH, or treat early if it occurred.  I would often stand at the bedside, pondering how much oxytocin I should administer to this new mother, and for how long.

Top 10 Posts of 2015

When we launched AWHONN Connections in May of this year, we could not have imagined the response that we would have received from our members, nurses, parents and members of the media.

In less than a year our blog has received over 232,000 visits, from 167 countries and had 4 blogs republished on the Huffington Post! As the year comes to a close we want to say a HUGE Thank You to our readers and our bloggers.

Here’s Our 2015 Top Ten Round Up!