Author: The Association of Women’s Health, Obstetrics & Neonatal Nurses (AWHONN)

What You Didn’t Know About Donor Milk

2 Comments

by, Diane L. Spatz, PhD, RN-BC, FAAN & Rebecca Law, MA, RN, IBCLC, ANLC ,LCCE, FACCE

Barbara’s Story

Barbara (name changed) recently became a donor due to her prenatal diagnosis with an infant whose diagnosis was fatal.  As part of prenatal care at her institution, all mothers receive a personalized, one to one, prenatal lactation consultation.

For palliative care cases, milk donation is discussed with the mother antenatally so she is aware of the possibility.  In Barbara’s case she had an older child who she breastfed for over two years.  She reported a fantastic breastfeeding experience and spoke enthusiastically about how important breastfeeding was to her as part of motherhood.  With an infant with a known fatal anomaly, Barbara wanted to have the opportunity to breastfeed and experience motherhood.  During the antenatal period, a birth plan was established so that she could hold her infant skin to skin immediately post-delivery and attempt breastfeeding.  Barbara also began the screening process to become a Human Milk Banking Association of North America (HMBANA) donor and was determined that she would pump milk and donate for the duration of her maternity leave.

At the time of delivery, Barbara was able to hold her child and the infant attempted a few suckles at the breast.  Even though the baby did not live for more than a few hours, the she was able to have her breastfeeding experience.  Following delivery, Barbara finished the HMBANA screening process and her serological testing completed.  She was approved as an HMBANA donor and expressed milk for about three months following delivery.  For Barbara donating her milk was a huge part of her grieving experience.  By being able to speak to the milk bank staff weekly, she had the opportunity to have a “mothering” and “breastfeeding experience”.  She reported that it was so meaningful to her to know that her milk was going to help other sick infants right in her own community.  She was thankful she had the little time with her daughter that she did, and felt her daughter’s short life had purpose in helping countless other children.

 

Why would mothers with extra milk donate to a human milk bank?

  1. Optimistic and altruistic behaviors are the primary reasons mothers donate their extra milk to an HMBANA milk bank. Mothers may find themselves with too much milk which they do not want to discard, and by donating their milk they are giving a tangible gift that they know will benefit other infants, because they have seen the benefits of their milk to their own child.Donors report positive emotions and say they would donate again if given the opportunity.
  2. Mothers who are familiar with the needs HMBANA milk banks and the infants they serve are motivated to donate their extra milk. Health care providers can influence a mother by recommending donation of her extra milk to a HMBANA milk bank.
  3. Bereaved mothers, such as Barbara, also choose to become donors to HMBANA milk banks. Some mothers know in pregnancy that their infant’s diagnosis is fatal and other mothers may have an infant who dies after a long hospitalization.  Bereaved mothers report that by donating their milk they give meaning to their child’s life.  They report that by donating their milk it helps in the grieving and healing process and may help with feeling a sense of closure.


Information About Milk Banking in the United States

Pasteurized donor milk is available from both non-profit and for-profit organizations in the United States.  Non-profit milk banks are part of the Human Milk Banking Association of North America (HMBANA) and have a shared set of standardized milk banking practices.  HMBANA has an interdisciplinary board with representatives from HMBANA milk banks as well as external board members from a variety of professions.

In order to donate milk, a mother must go through a vigorous screening process.  The first step is a verbal health screening.  The mother then completes an extensive health history and lifestyle questionnaire related to her health, her infant’s health, her lifestyle and dietary practices and must have a form filled out by her health care provider reporting her health status and laboratory testing from pregnancy.  Additionally, the infant’s health care provider must complete a form stating the infant is in good health (unless in the case of fetal or infant demise). The milk bank coordinator reviews all materials and verbally reviews and confirms information with the mother.  The mother then signs consent to be a donor and at this point the mother must undergo serological testing.  The cost of the laboratory testing is $200-$300 and paid for by the milk bank.

Once a mother has passed all screening and her labs come back negative, she is approved to be a donor.  Mothers can make a one-time donation or be repeat donors.  However, if a mother continues to be a regular donor, the milk bank staff will follow-up regularly to ensure the mother has had no changes in her lifestyle or health.

Raw milk is stored frozen until ready to be prepared for pasteurization.  Raw milk is thawed, pooled, poured and then pasteurized using the Holder pasteurization method.  Each batch of milk that is pasteurized is also cultured post-pasteurization to ensure there is no bacteriological growth. Post-pasteurization, the milk is stored frozen.  Once milk culture comes back negative, milk can be dispensed to donor recipients.

In the United States, most HMBANA milk is donated to hospitals with neonatal intensive care units (NICUs).  Pasteurized donor milk is mostly used for preterm infants or other vulnerable infants.  However, there is some published literature supporting the use of donor milk for term infants or late preterm infants, if supplementation is required during the hospital stay. In the community setting, a prescription from a health professional is required for the milk bank to dispense pasteurized donor milk to a home.

Pasteurized donor milk from HMBANA is provided on a cost-recovery basis causing the milk banks to charge a processing fee of $3.00 to $5.00 per ounce.  Insurance reimbursement varies from state to state resulting in a cost to the hospitals or consumers.

Diane SpatzDiane 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.

 

RebeccaRebecca Law, MA, RN, IBCLC,ANLC,LCCE,FACCE is the manager of a the Lactation and Childbirth Education Departments at Texas Health Harris Methodist Hospital Fort Worth and has over 25 years experience in womens health.  She has received a Masters degree in Health and Wellness with the focus on Human Lactation and is certified as an IBCLC and Advanced Nurse Lactation Consultant. In addition she is certified as a Lamaze Childbirth Educator and has been educating patients and staff for many years.  She is part of the Baby Friendly Hospital Initiative team assisting the hospital with the designation in 2010 and is the current chair of the hospital system BFHI group. She has experience as a podium and poster presenter at several state, national and international conferences including Lamaze International, ILCA, State Breastfeeding Coalitions, and NICHQ.

Top 10 Tips for Dads!

1 Comment

Excited, nervous, anxious, scared, overwhelmed, overjoyed — these are just some of the wide range of emotions you’ll feel when you experience the life-changing event that is becoming a parent for the first time.

This Father’s Day, we wanted to provide some tips and advice from our nurses to help ease those first-time parent jitters.

  1. Congrats on this amazing journey. If you and your partner have made the decision to breastfeed your baby, congratulations! Partner support is one of the biggest long-term indicators of breastfeeding success, so it is important that you support your partner as much as possible. Sign up for breastfeeding class and attend with her and learn as much as you can about how breastfeeding works. After the baby is born, many dads can feel left out because of the amount of time a breastfeeding mom spends with her newborn in the beginning, while the breastfeeding relationship is being established. Support mom and get your own bonding time in by doing the diaper changes, burping the baby, and bathing the baby. Encourage and support mom when she is lacking confidence, and help her find resources if things aren’t going well. Although you can’t breastfeed the baby, there are many ways that you can be close to the baby and take part in the care of baby and mother.
  2. Spend time with your baby and create a ritual or activity that is yours alone. Bonding and special time are important for you and your baby too.
  3. Participate in skin-to-skin. Bring a sweatshirt with a zipper to the hospital. During skin to skin with their baby they can take off their shirt wear their sweatshirt and zip the zipper up with their baby on their chest. Also when newborns are very fussy or crying, it is almost magical to see how quickly baby calms if dad takes off his shirt and places baby skin to skin on his bare chest.
  4. Your involvement is uniquely influential in the health status of your child. Each moment spent holding, bathing, feeding or reading to your baby, facilitates their growth and development. You are irreplaceable in the context of the coaching, modeling, teaching and encouragement that you instill. If you have an insecurity regarding your ability to balance work and families responsibilities or perhaps your own fathers involvement, remember that you are not alone. Forgive yourself when you make mistakes. Your contribution, point of view and playful attitude are necessary pieces of the puzzle which will guide and shape your child’s life – which cannot be replaced. A father’s love is unrivaled!
  5. Ask questions. If you are unsure of something, please don’t hesitate to ask your nurse or doctor.
  6. Take notes during discharge. You and your partner just welcomed your brand-new baby in the world, and now it’s time to bring the little one home. Mom is often exhausted and overwhelmed, be sure to take note of key points when the nurse is providing discharge information that you can share with your partner when you get home after she’s had time to decompress.
  7. Know when to say no. It’s okay to stand your ground and turn away visitors if you and your partner aren’t up for it.
  8. Mothers aren’t the only ones who suffer from postpartum depression/anxiety (PPD/A). Fathers experience depression and anxiety too.  Symptoms include depressed mood; significant weight gain or loss; restlessness; fatigue; insomnia or sleeping too much; feelings of worthlessness; difficulty with decision-making; and thoughts of suicide or death. It is important to watch for changes in mood or behavior, especially since you and your partner have just had or adopted a baby. If you suspect that you or a loved one is suffering, get help and contact your doctor. You can also check out these online resources.
  9. Savor this time. It seems like the older children get, the faster the time flies. Slow down and treasure these moments while they are still small.
  10. You are your child’s biggest hero. In their eyes, you are everything they aspire to be.  Be their best role model and biggest cheerleader.  This means more to them than anything.

 

My First AWHONN Convention So Far!

IMG_3629by, Melissa Strunc, RN

This was my first AWHONN Convention!

The first class I attended was on dealing with neonatal abstinence.  My hospital has a center for addiction and pregnancy and I deal with these babies almost on a daily basis, so when I saw that AWHONN offered a pre-convention seminar on shortening the length of stay for these newborns, I knew I just had to go!

The presentation by Maureen Shogan, MN, RNC, dealt with the newest changes in caring for these infants, and the latest research concerning shortening their length of stay. The first thing that stood out to me was when the Maureen said “Babies are not born addicted!” She proceeded to explain the definition of addiction, which included a pattern of compulsive behavior, impairment and behavioral control, and problems with interpersonal relationships. This certainly doesn’t sound like a newborn!

She clarified that these babies are dependent on the drugs their mothers are taking while pregnant, but are not “addicted”. The word addiction puts a negative stigma on these babies so early in their lives. The second thing that stood out to me was that these mothers, these patients who are doing this to their babies, are someone’s mother, sister, daughter, cousin. Their dysfunction is how they kept alive.

Maureen also presented information on cigarette addiction among these women who are taking other drugs and how this affects the babies’ withdrawal symptoms. She shared the latest research concerning this out of Dartmouth, where they were able to shorten the entire length of stay for these newborns when they factored in the nicotine dependence of these newborns among other slight changes to their approach.

She went on to discuss in depth the scoring system, and how to train nurses to become reliable, instruct parents prenatally and postpartum on what to expect from their babies during the hospital stay. She highlighted the importance of team training for staff in conjunction with psychiatry and finally the importance of the timing of scoring these babies so that we are not giving them unnecessary high scores when they may just be hungry.

Coming into this, I felt that my department was very good at scoring NAS babies, although I do see disparities myself from nurse to nurse. However, in this class I picked up on one specific category that we were scoring these babies higher than we should have, when one point should not have even been included in the scoring system.

I am so glad that I came to this pre-convention workshop, and I will be sharing everything that I learned with my colleagues when I return.

The second workshop I attended involved the rapidly deteriorating OB patient and how to pick up on warning signs, and follow through with the appropriate treatments, all the way through CPR (if necessary), and emergent delivery of the baby. One key point that stood out to me is to never ignore changing vital signs as these will be the earliest indicator that something is going wrong (as well as the fetal heart tracing).

I also had never heard about the importance of displacing the gravid uterus to the left during CPR! This seems so obvious after hearing it, but we do regular simulations on my unit (including the doctors), and I have never heard anyone bring this up!

My take-away quote from this workshop was “I can only control what I do”. I can’t control the doctors and other nurses, but I can take responsibility for my actions and reactions; and this will improve my patients’ safety.

IMG_3685The first general session had so many “ah-ha” moments for me, I don’t even know where to start. Not only was the presenter knowledgeable, but her words touched my heart and soul. It was uplifting and encouraging, at the same time challenging and convicting. As I sat there, I found myself wishing she could do the entire conference – and she’s not even an OB nurse! I left with tears in my eyes, and her presentation wasn’t even sad!! THANK YOU, Captain Beeson! I will definitely be hunting down these slides and sharing her words with my colleagues and managers concerning resilience!

One of the many quotes that stood out to me was, “Getting upset & complaining over silly, stupid things saps your energy from things that are important.” This can be translated into work, personal life, family, etc.

My favorite story she told was concerning crisis, and how there is so little complaining and negative attitudes in time of crisis. She shared a story about the time period after 9/11 when her military hospital sent a large number of their nurses to man a hospital ship off the coast of New York. She immediately started receiving calls, and was able to fill those spots in her hospital with nurses all over the area. It was such a touching story, and it really hit a chord when she said that this is the kind of nursing we need – crisis nursing without the crisis.

I know that I will start being more diligent in staying positive, speaking encouragement and positivity rather than feeding into the negativity. And, again, take responsibility for my actions in my area as well as never taking the “not my problem” attitude after attending this session.

I have already learned so much from this convention, and can’t wait to see what the next few days hold!

 

 

Confidence Building for Nurses

by, Lori Boggan, RN

I would like to call myself a bit of an expert on the subject of confidence.  Working as a travel nurse for many years, mine has been tested over and over again.  The one thing I have learned is that confidence comes and goes and that is perfectly ok.  Some days are better than others.  Travel nursing has forced me to learn new routines, try every new kind of IV catheter, learn each new unit’s policies, and adapt.  In the last five years, I have managed to find myself in another country and added the super challenging task of learning a new language to the list.  It has tested my confidence and given me the opportunity to reflect.  Here are just a few tips.

Develop Routines

There are certain tasks we as nurses do repetitively in our day to day work.  We take reports, check our monitors, calculate our drips, triple check our medications.  No matter how much time it takes initially, make these a part of your day to day routine.  It will be as subconscious as breathing eventually and once mastered, it leaves space for the most important task of critical thinking.  Why is my patient’s urine output low?  Why has my patient suddenly had multiple episodes of desaturation and apnea?

If At First You Don’t Succeed, Try, Try Again

So you didn’t get that IV or blood draw on the first stick?  Ask any honest nurse and they will tell you that it has happened to the best of them.  Having a bad access day does NOT mean you are a bad, incompetent, less worthy nurse.  It means today is not your day and that is ok.  Tomorrow is another day.

Ask

Asking a question is a sign of strength, not weakness.  No matter how small the question or how many times you ask, keep asking until you understand.  When starting in a new unit, whether you are a brand new nurse or a seasoned one, it is your duty to ask questions.  The ones to worry about are the ones that do not ask questions.

Never Stop Learning

That is why there is such an emphasis on continuing education hours when renewing your license.  Continuing education is critical.  There is always something new to learn or some change in research that may change your practice.  Be open to change.

Speak Up

If something does not seem right, follow your instincts and say something.  Chances are you are right.  Always err on the side of caution.  You will learn to trust your own intuition.  Perhaps speaking up can create a change in policy on your unit.

Leave the Bad Days Behind

So you were not super nurse today?  Today was not your day?  That’s ok.  You are only human.  There is no super nurse.  Anyone who pretends otherwise is kidding themselves. We all have had that day where you wake up late, spill your tea in the car on the way to work, walk into a frantic situation in the unit, and then are assigned said frantic situation.  You just want to turn right around and go back to bed.  Take a deep breath.  You will get through it.

While the list can go on and on, I think the most important thing of all is to remember that confidence comes with time and practice.  Each new environment and new job will test your confidence.  And remember, try not to compare yourself to anyone else.  Be the best nurse you can be.

LoriProfileLori Boggan, RN
Lori is a NICU Staff Nurse at Sahlgrenska University Hospital in Gothenburg, Sweden. After becoming a nurse, Lori traveled across the country to work a three-month travel contract in San Francisco, California. Nearly five years later her journey continued to Gothenburg, Sweden, where she now lives and works. She also write her own blog Neonurse at https://neonursetravels.com/

Thank You Nurses

ADVERTISEMENT

by, Pampers Swaddlers
Anne Gallagher-PhotoThe story of Anne Gallagher, staff nurse at the University of Illinois Hospital & Health Sciences, is one of the many stories that inspire and remind us of the dedication and care that goes into the nursing profession.

Anne has been a nurse for 38 years, and nursing runs in her family. Five women in her family were nurses, including her mother, who inspired her to eventually enter into the profession herself. Anne truly believes that nursing is more than a job, it’s a vocation that gives her life meaning. She continues to acquire new knowledge and experience to apply to her work with new parents. Recently, she completed a Master’s Degree from Write Graduate University for the Realization of Human Potential in Transformational leadership and coaching.

“It is my privilege as a nurse to accompany, educate and support people on this journey … to facilitate their development, and expression, and tune into their instincts and inner wisdom in partnership with their babies and staff,” says Gallagher.

We are proud to announce Anne Gallagher, staff nurse at the University of Illinois Hospital & Health Sciences System, as the grand prize honoree of the Pampers Swaddlers Thank You Nurses Awards program. Her understanding of what it means to become a brand-new parent, and the specific needs of newborns and mothers during labor, delivery and the first few days that follow, made her stand out. With this award we celebrate Anne’s contributions throughout her career and her ongoing commitment to the care of babies and mothers.

Anne beautifully describes how babies transform and even empower us. “It’s important for moms to understand that all the instincts are right there. A mother’s body is a baby’s natural habitat … the baby is going to help her. It’s a little being that wants to live and survive … when they see that, they are empowered, they know what to do! It’s a magnificent moment.”

At Pampers our mission is to care for the happy and healthy development of babies.  We know that nurses share this mission, and that’s why we proudly recognize and honor the essential role nurses play in improving the lives of babies and families through the work they do each and every day. In partnership with the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) we developed the Pampers Swaddlers Thank You Nurses campaign and awards program.

Through this campaign, we’ve encountered the stories of many nurses who embody the caring spirit and dedication of this very special career, and every single story has inspired us. To shed light on the integral role that nurses play in the first few minutes, hours and days of babies’ lives and the vital support they provide to their parents, the unique and compelling stories of three nurses were shared through short documentary videos: Anne Gallagher, RN, MSN; Capt. Navy Nurse Corps (Ret.) Trice Harrold, BSN, RN; and K. Michelle Doyle, RN, CNM, NYS, LM, each of whom deeply impacts the lives of families every day.

With this award and the entire Pampers Swaddlers Thank You Nurses campaign, we want to recognize the hard work and dedication of Anne, Trice, Michelle and all nurses everywhere.

Anne’s documentary video is available for viewing, here.

For more information about the Pampers Swaddlers Thank You Nurses campaign go to Pampers Facebook Page and join the conversation via #ThankYouNurses.

ADVERTISEMENT

Any mention of a product in this post or any pages linked from this blog post does not represent an endorsement or verification by 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.

DonnaDonna 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.

 

 

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.

TOLAC and VBAC and Rupture! Oh My!

3 Comments

by, Bree Fallon

As a brand new labor nurse fresh out of school, I distinctly remember visiting with a seasoned traveling nurse, Pam Spivey, during an afternoon of monitoring women on the antepartum unit years ago. One of the preterm women I was caring for that afternoon was planning to attempt a vaginal birth after cesarean (VBAC) with this pregnancy when the time came.  I was pretty green and knew what the acronym stood for, and that was about it. Pam and I began to converse about VBAC and she shared a story of hers from years prior.

She told me about a woman who had been admitted to L&D. The woman had delivered her previous baby in another country by C-section and the plan for her was to allow a trial of labor after cesarean (TOLAC). Pam said her labor progressed beautifully and soon it was time for her to push. I leaned forward on the edge of my seat as Pam recounted the details. She called the provider to come for delivery. “The fetal head crowned up so nicely, and then it was gone!” I felt my eyes grow large. “Where did it go, Pam?!” I thought. She explained the next moments were a mad dash. She pulled all of the cords and plugs out of all of the devices and outlets, grabbed the nursery nurse and down the hall they went with the woman in the bed, snagging the physician on the way as they ran to the OR. Pam even remembered losing her shoe along the way to the OR, but she did not slow down. Confused, I sat in disbelief of this story. Pam recalled the team got the woman to the OR, rapidly delivered her baby via C-section, and both mom and baby survived the ordeal and did well. Still perplexed, I asked out loud this time, “Where did the head go, Pam?” The kind nurse looked at me and explained when a woman’s uterus ruptures, there is no pressure inside the uterus or on the baby anymore. The instant that the head was gone, Pam knew the woman had ruptured her uterus and the lives of both mom and baby were at stake. Horrified, I logged this story away in my brain, vowing to remember what to do when this happened while I cared for a woman.

My first year flew by. Plagued by a horrible cloud of bad luck that followed me on and off of my floor daily, whenever I saw my name assigned next to a woman attempting VBAC, I would swallow the lump in my throat, and Pam’s story would flash in my head. I would mentally prepared myself, ensuring I had my A game for this woman, should any signs or symptoms of uterine rupture arise at any point in the day. The woman would either be successful in delivering vaginally or would not be successful. The only thing that mattered to me at the end of the day was healthy baby, healthy mommy.

A couple years later, my very best friend in the world and an exceptional labor nurse, Kelsey, was pregnant with her first baby. Her baby was breech and was delivered by cesarean. I remember Kelsey laying behind the drape, asking for updates, if her baby girl was ok. Having the privilege of caring for her sweet infant in the OR that day, I swaddled her newborn up as fast as I could. Kelsey had already waited 9 months to meet her daughter, so the extra few moments it took for me to wrap the baby and hand her to Kelsey’s husband before Kelsey could even see her seemed cruel. They snuggled with their new little one while doctor finished the surgery. In the PACU, Kelsey felt pukey and could not hold her infant. Recovery was not easy, but she didn’t know any different. Still today, Kelsey remembers having a difficult time bonding with her infant, and wonders if her delivery by cesarean had anything to do with it.

IMG_6993With Kelsey’s second baby, after discussing the risks and benefits with her provider, Kelsey wanted to attempt VBAC. I was very hopeful for her, but sick to my stomach a little too. Remembering Pam’s story, I was incredible apprehensive and ultimately didn’t want anything bad to happen to Kelsey. Her pregnancy flew by and was induced at 39 weeks and 5 days. I raced to the hospital with the very important job of taking pictures. Kelsey’s labor progressed and she delivered quickly with no complications. Watching my best friend get to see her baby immediately and hold and soothe her right away is one of my most favorite memories of my career. I had taken care of many women who had successful VBAC, but did not really understand its significance until seeing first hand Kelsey and her husband experience both types of delivery.  Never having a cesarean myself, but circulating hundreds, I considered them routine. It was very powerful for me to see the difference between a vaginal birth and a cesarean for the same woman.

Just this week I was asked to review some literature to develop patient education on VBAC. Here are a few facts that stuck out to me taken from ACOG Committee Opinion 342 as well as ACOG VBAC Guidelines.

  • 60-80% of appropriate candidates who attempt VBAC will be successful. The odds are in your favor that a woman will have a vaginal birth.
  • The risks for both elective repeat cesarean and TOLAC include maternal hemorrhage, infection, operative injury, thromboembolism, hysterectomy, and death. Both have their risks.
  • Overall benefits for a VBAC is avoiding major abdominal surgery. This lowers a woman’s risk of hemorrhage and infection, and shortens postpartum recovery too.
  • The most maternal injury that happens during a TOLAC, happens when a repeat cesarean becomes necessary if the TOLAC fails. Maternal injuries can include uterine rupture, hysterectomy, or even death.
  • There are risks for baby too. Both elective repeat cesarean delivery and TOLAC neonatal complications can include admission to the NICU, hypoxic ischemic encephalopathy, and even death. One study found the composite neonatal morbidity is similar between TOLAC and elective repeat cesarean delivery for women with the greatest probability of achieving VBAC.
  • If a woman has had a prior vaginal birth or goes into labor spontaneously, she has an increased probability of successful VBAC.
  • If a woman had an indication for her initial cesarean that may reoccur with subsequent labors such as labor dystocia or arrest of descent, she has a decreased probability of successful VBAC. If a woman  is of non-white ethnicity, is more than 40 weeks gestation, is obese, has preeclampsia, has a short interval between pregnancy or increased neonatal birth weight, her probability of successful VBAC is also decreased.
  • Women pregnant with twins attempting VBAC have similar outcomes to women with singleton gestations and did not have a greater rate of rupture or perinatal morbidity. (I have never had a twin mom attempt VBAC but it can be done!)
  • On the topic of induction, one study on 20,095 women attempting VBAC found a rate of uterine rupture of 0.52% with spontaneous labor, 0.77% for labor induced without prostaglandins and 2.24% for prostaglandin-induced labor. Prostaglandins should be avoided in the third trimester in women who have had a previous cesarean section.

As years went by, I cared for more women who wanted a vaginal birth after cesarean. I cheered hard for each of them to be able to experience a vaginal birth. Any healthy birth is always a miraculous moment to have the privilege to be a part of. However, caring for women who had only experienced a cesarean before the days of skin-to-skin in the OR and then watching them birth vaginally, and being able to instantly see, touch, hold their infant, is priceless.

In my 12 years of bedside care I worked in facilities delivering on average 4,000- 5,000 babies a year, and a uterine rupture during labor had never happened to one of the women in my care  I was in charge once where one of the nurses correctly identified that the scar on her patient’s uterus was beginning to pull apart. The woman had a cesarean immediately and delivered a healthy baby without any complications. We have had cases of uterine rupture since on my floor. It can happen and if it happens, it becomes an emergent situation that must be resolved swiftly and seamlessly for a good outcome. However, it doesn’t happen very often. In fact, ACOG cites the risk for uterine rupture for woman attempting TOLAC is low, between 0.7-0.9%.

There are many indications where a cesarean delivery is absolutely necessary. In the case of an elective repeat section or a TOLAC, it is imperative that women review the risks and benefits of both with their provider to ensure they make the right choice and promote  a healthy, happy mom and a healthy, happy baby.

Bree FallonBree Fallon, BSN, RNC-OB, C-EFM
Bree Fallon is a Clinical Educator for Perinatal Services at Shawnee Mission Medical Center, the busiest delivering hospital in Kansas City. She graduated from nursing school in 2004 and started her career in a tertiary care facility, providing high risk intrapartum and antepartum care. In 2010, she moved to Children’s Mercy in Kansas City who was looking for experienced L&D nurses to help open the their new Fetal Health Center.

Happy Blogiversary AWHONN Connections!

When we posted our first blog below one year ago today we could not have imagined the wide-spread direct impact it has made on the lives of nurses and families based on the stories told directly from nurses and families.

THANK YOU to each of our 300,000 visitors for reading our 62 blogs on important, but difficult topics as Perinatal Bereavement in the ER, Nitrous Oxide from both the nurses and mom’s experiences, Postpartum Depression, challenges and opportunities for a better NICU experience, and the many many times Nurses have changed lives.

We have had our bloggers asked to speak on their blogs at hospitals around the country, to share their research to help improve the lives of others and to be used as education for upcoming nurses.

You can access our full history of topics from the drop down bar at the left – explore and enjoy!

WELCOME TO AWHONN CONNECTIONS

Who are we?

 

We are registered nurses, nurse practitioners, certified nurse-midwives, researchers, and clinical nurse specialists who work in hospitals, outpatient settings, universities and community clinics.

We are just starting out, mid-career or executive leaders who all share a passion for healthy women and healthy babies.

We are parents whose lives have been touched by nurses.

We all have a story to tell. And we will be telling them once a week at AWHONN Connections.

Stories about nutrition, birth defects, breastfeeding, postpartum depression, touch, newborn screening, pre-term babies and full term babies, leadership, healthcare advocacy, and anything that touches the lives of women and babies.

Our stories will be empowering, heartbreaking, humbling, laugh-out-loud funny, and occasionally maddening.

Our stories will be real. Real nurses, real moms, real dads. Reals moms and dads that are nurses and nurses that everyday touch lives.

Every nurse has a story and every parent has had a nurse who has touched and impacted their lives. We thank you for your interest in our stories and your commitment to the health of women and babies.

Tell us your story or ask us more about ours in the comments below. You can always reach out at [email protected].

Here is where you can learn more about AWHONN, who we are, and what we do.

Nurses Save Lives

2 Comments

by, Christine Douglass, RN
Florida Hospital Heartland Medical Center

As a charge nurse on a busy Labor & Delivery unit I am responsible for the nurses on my team that work each day with me. On one particular day we had a patient who was scheduled for a repeat cesarean section for her second baby. Everything was going fine with her recovery in PACU, until I heard an unfamiliar alarm sounding on the unit.

I looked up at the fetal monitor board to see if the monitors indicated anything wrong. I saw that the patient in room 202, who was also in PACU, had a blood pressure of 70/40 and a heart rate of 160. I ran into the room and asked the nurse if she had seen the monitor.

She stated that she had just given the patient IV pain medication and that was why her heart rate was high and blood pressure was low. I said that is unusual for that to happen, it looks more like she is going into shock. I told her to start a second IV line and open both line wide. I checked her fundus to find out that her uterus was boggy and when massaged a mountain of clots came out.

I rang the call bell and asked OB tech to get the scale to weigh the clots and had another nurse, who had since come into the room, to call the doctor and get me an order for methergine. Methergine was given and in 15 minutes more clots were expressed and weighed. By this time we had weighed a total of 1200-1300 mls, not including the 800 mls she had lost in the OR. I asked the nurse to call the doctor back and when she did she said to prep the patient and take her to the OR, the doctor was on her way to the hospital. The patient was taken to the OR and given several units of blood and FFP.

Her uterus was saved for the time being and she was sent to the ICU for the night to be closely monitored. Two days later when she returned to our unit she told me her side of the story. She stated that while everything was happening to her she felt like she was above the room looking down and then she saw her grandparents sitting on a park bench. She told them that she wanted to stay with them and they told her she had to return to take care of her little girls. When she left she told me that we were her angels and we had saved her from death and she appreciated all we did for her and her family.

Later that day the doctor thanked me for “catching” the change in vital signs before she had gotten any worse and that I had probably saved her life. It makes be proud to be able to save someone’s life and reaffirms to me that I made the right career choice many years ago. I love what I do.

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

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/ 

 

McIntire_Elizabeth_2015%5b1%5dElizabeth 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.