The Power of Touch & Infant Massage

Lori Boggan, RN, Certified Infant Massage Instructor

The power of human touch is unmatched and irreplaceable.  It is an innate need of every human being, especially the infant.  I recently sat down and picked the brain of an expert in the field of infant massage.  Peter Walker, a London based physical therapist, who has been working with babies, children, and their parents for over 40 years. He travels the world and has trained nearly twenty thousand or more midwives, nurses, and other health professionals through his Developmental Baby Massage and Movement program. In his words “touch is the newborn’s first language-it is her prime means of communication and plays an essential role in the forming of early parent-child relationships.”  The following are just a few of the many benefits of touch and massage to both the infant and parents.

Skin to Skin

Study after study has shown the unbelievable benefits of placing an infant skin to skin with its parent.  The power of touch is evident from the first moments after birth when the infant is placed skin to skin. Remarkably, the infant’s temperature, heart rate, breathing, and blood sugar stabilize while being comforted on their mother or father’s chest.  Touch begins here.  A bond between parent and infant begins here.

Enhanced Immunity

The simple act of skin to skin with the mother sets forth an intricate orchestration of colonization and antibody formation that is transferred from mother to baby through the breastmilk.  A study done at John Hopkins University found a significant reduction of nosocomial infections in  infants massaged daily with sunflower seed oil however a Cochrane review of this practice published in 2016 found the evidence lacking that emollient therapy would prevent invasive infections and cautioned that more research was needed..

Hormonal Influence

Done regularly, massage may reduce the level of the stress hormone, cortisol circulating in an infant’s bloodstream.  In turn, it may increase the level of endorphins, the body’s natural opiates as well as oxytocin, the love hormone.  Both leave the infant with a sense of well being and further promote attachment between parent and child.

Colic & Gas Relief

The jury is still out on the exact the cause of colic.  Colic starts as early as the few weeks after birth and results in crying for long periods of time-particularly at night.  Massage may relieve a distressed and colicky baby.  Regular tummy time and massage of the stomach may ease gas, constipation, and aid in digestion.  It is best to avoid tummy time and massage directly after a feed.

Joint Flexibility & Increased Muscle Strength

 According to Peter, developmental massage, practiced according to his program “releases ‘physiologic flexion’ imposed by the fetal position from the time the infant spends in utero.  Gentle massage together with soft stretching can allow the infant to relax and coordinate their muscles to improve the circulation to their body’s extremities, open the chest to deepen their breathing volume, relax the tummy to assist digestion and disposition, and strengthen the muscles of the head, neck and back in preparation for (upright postures and movement).”

Develops Trust & Confidence

Infants learn through touch.  The gentle, reassuring hand of a parent teaches the infant early on that his or her needs will be met.  Touch and massage further foster a deep bond between infant and parent.  The infant learns to trust and the parent develops confidence in his or her ability to care for the infant.

Benefits to Parents

A 2011 study in the Journal of Perinatal Education found “participating fathers were helped by increasing their feelings of competence, role acceptance, spousal support, attachment, and health and by decreasing feelings of isolation and depression.”  Other studies have shown that mothers that massage their infants have improved mood and decreased symptoms of depression.

Educating Parents

Nurses and midwives at the bedside have an excellent opportunity to teach the benefits of skin to skin and massage.   Early education should start right at birth by encouraging immediate and regular skin to skin contact.  In addition, parents can be taught simple techniques as seen here.  It is best to use oil for massage so the hands move nicely against the skin. For sick or unstable infants in the Neonatal Intensive Care, teaching parents and family members the importance of touch in the form of a gentle hand is essential.  By simply placing and holding a steady hand over the infant that is confined to an incubator or radiant warmer, we are still able to convey trust and reassurance.  Early massage can begin when the infant is stable and willing.

Peter sums it up perfectly, “from the very beginning, the mother should remain at the center of any “treatment” offered to her baby.  Most mothers want to hold their babies and establish skin to skin contact before the baby is removed, weighed, measured, bathed, or dressed.  From his mother’s womb into her arms, touch becomes the primal language of the newborn, and it is through holding and caressing that a baby is made to feel welcomed and loved.”

 

AWHONN Resources

Additional Resources


Lori is an American Neonatal Intensive Care nurse that has made her way to Sweden.  Her passion is maternal and infant education.  She incorporates her years of work in maternal and infant health with a passion for wellness through her Prenatal Yoga, Mommy & Me Yoga, and Developmental Infant Massage classes in Gothenburg, Sweden.  Follow her adventures on Instagram or through her nursing blog, Neonurse.

 

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

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.


evgeniya-headshotEvgeniya 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.

When A Baby Dies

by, Debbie Haine Vijayvergiya
Stillbirth Parent Advocate • Founding Member of The Action for Stillbirth Awareness and Prevention Coalition • Founder of the 2 Degrees Foundation Fund

I won’t lie, I cringe when I think back to how frustrated and concerned I was when after two months of trying, I still wasn’t pregnant.

A friend had recently told me how she achieved pregnancy success with the help of a pricey fertility monitor so I tried that and luckily for me, I found out I was pregnant soon after.

My first pregnancy and delivery were the definition of text book. My post birth complications, which consisted of a late presentation of Group B Strep, C. difficile, and a blood clot, were not in my birth plan BUT I quickly made peace with it. I refused to allow myself to be consumed by my unexpected hospital stay or my lengthy recovery period ahead of me. I had a beautiful baby girl to focus my energies on; I would heal and get better; life was good.

I didn’t have a problem getting pregnant after that. Actually the opposite happened. When we weren’t trying; I would get pregnant. After two miscarriages, the second which occurred after a two week period of bed rest, ended in an ambulance ride, D&C, and 10 hour ER visit, I didn’t think much worse could happen. When I became pregnant for the 4th time in four years I was very anxious, but by the time I rolled into my 2nd trimester I was able to settle into the excitement of being pregnant and was finally able to feel confident that we were in for smooth sailing. At that point I had convinced myself that I had paid my dues to the pregnancy gods and nothing else could go wrong.

Unfortunately that wasn’t the case. During a routine 2nd trimester checkup my obstetrician could not detect my baby’s heartbeat. It was any expectant mom’s worst nightmare. Nothing can prepare you for the moment you find out that your baby is laying lifeless inside of you. Nothing. My life has never been the same since….

Unbeknownst to many, stillbirths cause approximately 24,000 deaths a year in the United States resulting in approximately 2000 babies dying each month – more than deaths resulting from SIDS and prematurity combined. Even with numbers like these, stillbirth remains one of the most understudied and underfunded public health issues today.

I was completely overwhelmed and unprepared to handle the unthinkable tragedy that I was facing. And I quickly learned I wasn’t alone. Soon after I was admitted to the hospital, I realized that the hospital staff – doctors, nurses, psychologists and social workers – didn’t always know what to say or how to say it. In retrospect I realized that many were lacking the tools needed to handle stillbirth. It seemed that my nurses found it difficult to switch gears between the “lively” hustle and bustle of the Labor & Delivery floor and the “barren” dark hole that my room signified. I felt neglected by my nurses. Not once did any of my nurses stop to see how were coping. I felt like a leper; as if my stillbirth was contagious.

With that being said, if I take a step back, I completely get it. The death of an unborn baby is completely out of most people’s comfort zones.

Nurses play such an integral part of the recovery process; it is critical that they are provided with the most relevant and appropriate training. In my case it would have made such a difference in my journey if the nurses were better equipped to handle the delicate nature of my experience while in their care.

There’s no such thing as one-size-fits-all advice on how to help a family suffering through a stillbirth. But what I can suggest to a nurse faced with a patient (or family member) who is struggling is to not be afraid to find the empathy and compassion that is needed to address the situation. Nurses are some of the most caring people on the planet – they went into one of the hardest and most caring professions out there. That said, even the most caring people benefit from refreshers on the effective and sensitive responses when patients have difficult circumstances. There is a lot of pressure to offer up the perfect words that will make the family “feel better” but the truth is, just being a caring presence is what is most necessary.

Stillbirth is a taboo subject across all levels of society, but if we work together to break the silence and remove the stigma around stillbirth, we will be better equipped to further the care needed to improve stillbirth outcomes for all involved.

There are many resources for nursing and parents including:

Additional Resource Lists

Some Helpful Tips from a Mom to Nurses

  • Acknowledge their loss; tell the grieving family that you are sorry for their loss.
  • Be patient with them.
  • Refer to the baby by their name, if one was given.
  • Make yourself available to the family if they want to talk
  • And if they do want to talk, listen to the family. Don’t feel like you need to have a response.
  • Let them cry, offer tissues.
  • Please continue to be patient.
  • Wait to talk about “arrangements” until after labor and the family has some time to let their new reality settle in.
  • Continue to offer to the family the option to hold the baby, any sort of mementos, pictures such as Now I Lay Me Down To Sleep
  • Please be respectfully persistent. Don’t give up. The family may say they don’t want pictures, a memory box, or to hold the baby- but that could change. There are no “do-over’s”.
  • Please make sure that all hospital staff that enters the mothers room is aware of the situation and are sensitive to it.
    It’s ok to not have the answers; no one is expecting you to.
  • Please don’t say- “sometimes these things just happen” or “you’re young, you can have more”.
  • Please encourage them to consider a perinatal autopsy or additional extensive testing. It is in the best interest for them with regards to subsequent pregnancies and for the future understanding for us to understand why stillbirths occur and how we can begin to improve outcomes.
  • Never forget to validate their feelings.
  • And one of the most important things you can do is to reassure the mom that they are not at fault. I can assure you, they are blaming themselves and you have the power to take that weight off their shoulders.

The Benefits of Prenatal Yoga

by, Lori Boggan, RN

The popularity of yoga has grown exponentially over the last many years in the western world. More and more studies are proving the benefits of a regular yoga practice. So how can yoga benefit the expectant mother? A 2015 study from Brown University suggests that yoga can be an effective alternative treatment for women suffering from depression during pregnancy. Another study from The University of California, Irvine, showed decreased cortisol levels and higher affect on the days the pregnant yoga group practiced. While most women can safely practice prenatal yoga during pregnancy, there are some conditions that may preclude yoga so women should always ask their midwife or doctor before starting. Conditions such as increased risk for preterm birth, placenta previa, premature rupture of membranes, or preeclampsia are other likely contra-indications. The following are just a few of the many benefits of prenatal yoga.

Connection to Breath

Prenatal yoga teaches the mom-to-be how to connect deeply to the breath, a breath that taps into the parasympathetic nervous system. In this state of deep relaxation, the baby benefits as well. The breath is the earliest bond that connects mom and baby on the deepest level. Also, the deep breathing that is practiced in prenatal yoga can relieve stress and anxiety and improve sleep. The breath learned and practiced week after week in prenatal yoga class can be used as a tool to guide her through the labor process.

Increased Flexibility

Gentle stretching and opening of the hips and pelvic floor muscles prepare the body months in advance to yield for the baby’s passage. Regular modified squatting as practiced in prenatal yoga can open the pelvic outlet by as much as 30 percent. The mom-to-be learns positions in class that can be used in labor to ease baby’s passage and possibly shorten labor.

Mental Preparation & Increased Strength

I tell my prenatal students to imagine they were about to run a marathon and had not prepared physically or mentally in any way. While they would of course make the finish line, had they prepared they will have been more apt and conditioned to face the challenges along the way. Prenatal students are guided through poses that test their strength and breath in preparation for their journey through labor. The added benefit of these exercises is strong legs for pushing and strong arms for baby holding.

Connection to Baby

Showing up every week to yoga class allows the expectant mom an hour of uninterrupted connection with her baby. Prenatal yoga allows her to connect to the living, growing being in her womb. It is a sweet meditation between mom and baby in anticipation of their first encounter.

Alleviation of Pregnancy Aches

Depending on the ailment of the day, there is almost guaranteed a yoga pose that can in some way alleviate it. Prenatal class allows a woman to practice in a safe environment guided by a teacher with knowledge of the common aches and complaints of pregnancy. From headaches to heartburn, carpel tunnel, constipation, low back pain, and/or achy feet, the yoga instructor guides the students through poses that can help relieve and soothe some of their complaints.

Creation of Community

Prenatal yoga brings women together during the most exciting, challenging and, rewarding days of their lives. Friendships are made out of the sheer desire to know that the mamas truly are not alone in this journey. These friendships and their support continue to grow long after their babies arrive.

While more research will likely prove the benefits, it is easy to witness in a class full of focused, happy mamas. Childbirth educator and Prenatal Yoga Teacher/Director of Mama Tree in San Francisco, Jane Austin, sums it up perfectly. “It is very common that when a woman gets pregnant, she looks outside of herself and her own experience for answers. Yoga gives women the opportunity to look within, to pay attention to how she is feeling not only physically but mentally and emotionally as well. When a mama tunes into her own experience and really pays attention, it often amazes her what she discovers. She has a wealth of wisdom and an inner knowing that can surface if she creates the space to listen. Yoga helps create that space.” Stay tuned for my interview with Jane on the benefits of postnatal yoga.

img006Lori is a neonatal nurse that has made her way to Sweden. She is also a Yoga Alliance Certified Yoga Teacher and Certified Prenatal/Postnatal Yoga Teacher. Follow her adventures working and traveling through Europe in her blog, Neonurse, or on Instagram.

References

Yoga during pregnancy: effects on maternal comfort, labor pain and birth outcomes.
The effect of prenatal Hatha yoga on affect, cortisol and depressive symptoms.
Potential for prenatal yoga to serve as an intervention to treat depression during pregnancy.

https://www.ncbi.nlm.nih.gov/pubmed/24767955
https://www.ncbi.nlm.nih.gov/pubmed/25747520

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!

RRWJMS20150428

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.

 

 

 

Like Mother, Like Daughter: Working to Wipe Out Diaper Need

by, Jade Miles

Michelle and Corinne

Michelle Delp and daughter Corinne

Helping mothers and babies comes naturally to mother-daughter team Michelle and Corinne Delp. This dynamic duo has made a big impact on families experiencing diaper need in their hometown of Rome, PA.

Michelle Delp, RN, has been a nurse for 30 years, and for the last 7.5 years she has worked as a maternal-child home visiting nurse for Nurse Family Partnership (NFP) of Bradford, Sullivan, and Tioga counties in Pennsylvania. She works with first-time low-income moms beginning in the second trimester of pregnancy through their child’s second birthday. NFP nurses offer the support these women need to deliver healthy babies, become confident parents, and achieve their life goals. Michelle is certified as a childbirth educator, birth and bereavement doula, and lactation counselor.

It’s no wonder that the apple doesn’t fall far from the tree; Michelle’s daughter Corinne starts nursing school at Arnot Ogden Medical Center this fall. Corinne has had many opportunities to learn from her mother. She shadowed her mother when Michelle was a camp nurse, and they have even found themselves helping out side by side at the scene of several accidents. Corinne’s natural caring instincts and up-close-and-personal experiences with her mom have put her on the path to becoming a nurse.

Before graduating from North Rome Christian School this past spring, Corinne needed to complete a senior year service project. Driven by her love for babies and children, Corrine—who also works as a nanny—chose to organize a diaper drive for the Endless Mountain Pregnancy Care Center (EMPCC) in Towanda, PA. She called it “Bottoms Up for EMPCC.”

delp photo 1Corinne first learned of EMPCC when they came to speak at her church and became increasingly familiar with the organization by serving at their yearly fundraising banquets. Knowing that EMPCC is frequently in short supply of diapers and moms can’t use food stamps to pay for them, Corinne felt certain that a diaper drive would be perfect for her project and would also serve a great need in the community. She fulfilled her 30-hour requirement while working tirelessly to market and organize the drive, as well as collect, transport, and stock diaper donations at EMPCC.

They advertised the diaper drive on Facebook for just under a month, and word soon spread about the event. The volume of donations exceeded Corinne’s expectations: The grand total came to 6,212 diapers; they had also had several people donate wipes. Michelle credits their success to the true sense of community in her small town.

Another clever idea? Add a little incentive to encourage folks to donate. Michelle and Corinne took advantage of a Target promotion and created a Target registry with diapers in a variety of sizes and also some wipes to help people reach the free shipping total. The promotion the first week was to purchase three packs of diapers and receive a $20 gift card; the second week, it as a $30 gift card with a purchase of two bulk packs or a $10 gift card with the purchase of two giant packs.

delp photo 3All items were delivered to Michelle and Corinne’s home, and they personally delivered everything to EMPCC. Both ladies said that hearing the UPS truck come by was always exciting because it signaled the arrival of more donations. In fact, North Rome Christian School administrator and EMPCC board member Lee Ann Carmichael decided to request that more shelves be built to accommodate the influx of diapers at EMPCC. At the end of the drive, Corinne’s senior class of 10 students filled those shelves to the brim, all as a result of the kindness and generosity of their friends, neighbors, and colleagues.

The experience left a lasting impression on this mother-daughter pair, and they were both touched to see people coming together to make a difference. “People are generous, even when they don’t have enough for themselves,” said Michelle, referring to several of her clients from NFP who wanted to donate leftover diapers from their children as they had changed sizes (Note: Most banks will accept loose diapers or open packs; just call ahead to ask).

“I learned that being able to reach out and communicate with others outside of my normal social circle is an excellent skill to develop,” said Corinne. “I live in a community that is very supportive of others’ endeavors. It’s beautiful to see a large number of people rally behind a cause.”

 Corinne and Michelle’s diaper donations are just one example of what nurses are doing to end diaper need—and their efforts will count toward our 2016 Healthy Mom&Baby Diaper Drive goal of 250,000 diapers donated. We want to hear your story, too! Go online to AWHONN.org/diaperdrive to let us know what you’re doing to help the 1 in 3 families who experience diaper need.

For more information on how you can start a diaper drive in your community, contact Healthy Mom&Baby Diaper Drive consultants Jade Miles (jmiles@awhonn.org) and Heather Quaile (hquaile@awhonn.org).

Jade HeadshotJade K. Miles, BA, BSN, RN, is a nurse consultant for the Healthy Mom&Baby Diaper Drive and lives in Raleigh, NC. 

 

 

 

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 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

 

Water Exercise for Pregnant Women

by, Lizzy Bullock, WSI

Exercise goes a long way to promote to a healthy pregnancy.  Exercise has many benefits for mom and baby but in the summer months, it can be difficult to find an activity that doesn’t cause you to overheat. In fact, the American College of Obstetricians and Gynecologists advises pregnant women not to exercise outside when it’s extremely hot or humid and to drink plenty of water before, during and after exercise to avoid dehydration.

Benefits of Swimming During Pregnancy

Many land-based exercises become difficult to participate in as you continue to gain weight, and if your legs begin to swell. This is especially true of exercises like running and cycling that require more effort to carry your increasing weight. The resulting discomfort and fatigue often deter women from continuing their exercise routines during the third trimester, according to a study published in Medical Science & Sports Exercise. However, a study published in the Journal of Nurse Midwifery found that pregnant women who swam for exercise were able to maintain their routine’s intensity and saw no decline in performance, even late into gestation. This continued exercise allows for a lowered risk of gestational diabetes and a shorter, easier labor, according to a study by the International Journal of Obstetrics and Gynecology.

And, thanks to water’s naturally cooling effect, it’s difficult to overheat in a pool as long as the water is not excessively warm. The Australian Physiotherapy Association reports that swimming and water aerobics are safe for a pregnant woman’s body and will not cause fetal hyperthermia when the pool is heated to 33 degrees Celsius or less (91.4 degrees Fahrenheit).  Do remember to drink fluids before and after swimming as you may not notice sweating as much when in the water.

A few other precautions: wear non-slip footwear when poolside to avoid slipping and avoid crowded pools because your risk of accidentally being kicked in the abdomen increases the more swimmers are in the pool. Wear sunscreen if swimming outside to protect your skin and prevent development of the mask of pregnancy (darker areas of skin which can develop on the face during pregnancy and be made worse by sun exposure).  Don’t swim so vigorously your heart rate exceeds 140 beats per minute. Finally, don’t dive or jump feet first from any height into a pool when pregnant.

Tried-and-True

Success stories from pregnant women worldwide are an inspiration to get in the pool. Kristi Lee, 36, competed in the United States Masters Swimming Nationals while pregnant in 2011. She noted a decrease in her lung capacity but still managed to take home a silver medal in her age group. She gave birth to a healthy baby girl and was back in the water three weeks postpartum.

Another successful pregnant swimmer, Natasha Bertschi, competed in a triathlon in her 34th week of pregnancy. She elected to stick with water exercise because she found that it relieved first-trimester nausea, helped her to give birth naturally (rather than by Cesarean) and kept her weight to a healthy level.

But, you don’t have to be an elite athlete to benefit from the effects of being in the water during your pregnancy. As a pregnant swimming instructor, I spend at least 30 minutes in the pool every day. Sometimes just walking back and forth; sometimes swimming gentle laps alongside a student. The result is significant. My body feels cooler even after I get out. I’ve also managed to avoid varicose veins) and foot and ankle swelling (caused by sluggish circulation in the lower legs during pregnancy). In fact, the Mayo Clinic specifically recommends walking in the pool to keep swelling at bay. On days that I don’t teach lessons, I feel a marked difference in my body: increased abdominal tightness, lower back pain, and a general heaviness that’s tough to bear.

Things to Consider Before Getting in the Pool

Can I Exercise?

With so many considerations, it’s hard to know what’s safe for you and your baby. If you’re unsure about exercising during pregnancy, know that the American Pregnancy Association recommends moderate exercise for nearly every pregnant woman. Research by the Mayo Clinic indicates that, when carried out safely, exercise during pregnancy results in many attractive benefits such as preventing excess weight gain, increasing stamina, allowing for easier sleep and easing back pain. Additionally, doctors at California State University found that regular exercise during pregnancy led to the formation of more hardy, resilient vascular muscles in the child. There are certain circumstances, such as when a woman has preeclampsia, placental complications, or cervical insufficiency, when your midwife or doctor may advise you to avoid exercise and take it easy.  It’s always a good idea to discuss exercise with your provider at your first prenatal visit.

Accommodating Your Changing Body

Every day you’re baby is growing and your body is changing – making traditional exercise less manageable and, let’s face it, less appealing. Research by Thomas W. Wang, M.D. published in the American Family Physician Journal points out the many bodily changes that affect a pregnant woman’s ability to work out. As your uterus and fetus develop, your center of gravity shifts, resulting in less stable balance. A larger midsection leads to lumbar lordosis (swayback) which can be painful, and hormone production is thought to soften joints, increasing the risk of sprains and strains. Wang also notes that pregnant women who perform weight-bearing exercise may report pain and discomfort in the pelvis and abdomen, likely due to tension on the round ligaments that have stretched immensely to provide space for your growing child.

Thankfully, when you swim water provides a resistive force without the demands of  load-bearing exercise. And, because water provides a low-gravity workout environment, women who are expecting can exercise without worrying about risks like falling, joint stress or abdominal trauma. What’s more, water’s weightlessness removes the sense of heaviness in the back, legs, and feet – providing you with much-needed relief.

When beginning any exercise, it’s always best to first check with your midwife or doctor before undertaking any workout activity. Once the go-ahead is given, get in the pool and enjoy.

Lizzy1-HeadshotLizzy Bullock is a swimmer, Red Cross certified swimming instructor (WSI) and swimming coach with over a decade of experience working with infants, children, and adults. Lizzy currently works as a swimming instructor and staff writer for AquaGear, a swim school and online swim shop.

 

What You Need to Know About Hepatitis B

by, Leslie Hsu Oh

You’ll be fine. Don’t be selfish. This was Mā Ma’s last words to me. Even though she hadn’t been able to eat anything for days and liver cancer caused by hepatitis B had coated the insides of her abdominal cavity, I still didn’t believe it was possible that I could lose her. A year earlier, she had been diagnosed with liver cancer a week after my eighteen-year-old brother died of the same disease.

Dropping my college textbooks, I grabbed her hand and said, “I won’t be fine. Today is your wedding anniversary. In a few weeks, I turn twenty-one. There’s no way that God would take both you and Jon-Jon.”

No matter what I said, her eyes remained closed against the crisp white hospital pillow. Desperate, I said the most hurtful thing I thought I could say, “If you die, I won’t get married. I won’t have kids without you.”

Her eyes fluttered. I knew the words upset her because she once told me that becoming a mother was the best thing that ever happened in her life. An hour later, a chocolate brown bubble escaped from her mouth and she was gone.

For years, I thought that Oath was meant to punish Mā Ma for leaving me. But when I finally realized it was because I was afraid hepatitis B would claim another person I loved, I understood that I was only hurting myself.

My two daughters (11 and 3) are as feisty as my mother and my son (8) dotes upon me the way I thought only my brother could. They are free of hepatitis B because nurses like those of you who belong to AWHONN worked with me to ensure that all my kids were given the hepatitis B vaccine at birth, even though I am not chronically infected with hepatitis B. This is something that parents need to request.  I’ve spent the last 19 years since founding The Hepatitis B Initiative educating parents about how they can protect their children from hepatitis B.

Today, The Hepatitis B Initiative operates in several states preventing liver diseases caused by hepatitis B and C among Asian Americans and Pacific Islanders, African Americans and other high-risk groups. We have served Chinese, Vietnamese, Korean, Cambodian, Laotian, Thai, Filipino, Nigerian, Ethiopian, Cameroon, Sierra Leone, Indian, Pakistani, Egyptians, Sudan, Syrian, Afghanistan, Bangladesh, Indonesian, Ghanaian, Moroccan, Saudi Arabian, Brazilian, Nepalese, Burmese, Salvadorian, Guatemalan, Ecuadorian, Sri Lankan, Mexican, El Salvadorian, and Honduran communities who are not accessing health care due to a lack of affordable treatment options, employment in industries which expose workers to hepatitis (such as nail salons, health care work, etc.), language barriers, and a lack of culturally competent care.

Because we bring services directly to places where the community gathers (51 events held in 2015) like mosques, schools, churches, temples, health fairs, ESL classes, clients are willing to share the reasons why they have never heard about or been screened or vaccinated for hepatitis B.

Hepatitis B is an easily preventable disease and yet it kills 2 people every minute. In the United States, 1 in 10 Asian Americans is chronically infected with hepatitis B. It is one of the greatest health disparities.

First, most who are infected feel perfectly healthy. As many as 75% of the Americans living with hepatitis B or C do not know they are infected.

Second, even though like my family’s situation, most Asian Americans contract hepatitis B from mother to child during birth, there is a stigma that it is a sexually transmitted disease and therefore most people living with hepatitis B choose to remain silent about their condition.

  • They are worried that they will lose their jobs or ruin their chance of finding a partner.
  • Immigrants believe they will be deported since hepatitis B is a reportable disease.
  • Many believe that it’s better not to know whether they have hepatitis B or liver cancer or cirrhosis.
  • Or worse no one ever told them that hepatitis B was a serious disease.

Third, many cultures enforce silence. I’ve been told all my life not to talk about the bad stuff. Pretend everything is fine. Save face.

My mother was a photographer, journalist, and painter. She taught me that art could say the things that we are afraid to say, how it could heal long after the life of its creator. With the weight of a camera around our necks, my mother would ask as we waded through white waters or leaped onto the back of a horse: “What story are you trying to tell?” In nearly fifty national parks, my aesthetic developed in the natural world, places woven with indigenous knowledge, bled in streambeds, trapped in rock layers, eroded in the earth.

While The Hepatitis B Initiative has had a life-saving impact, I realized that the transformative power of art does more. People tell me that my story saves lives. That’s why I’m working on a memoir which I hope will inspire others to find their voice. That perhaps together we can end the silence and stigma cloaking hepatitis B and other diseases.

On October 15, 2016, the Hepatitis B Initiative will be throwing a Gala at the Willard Hotel in Washington, D.C. to celebrate 10 years as a nonprofit. For more information, please visit hbi-dc.org or contact janepan@hbi-dc.org.


Losing her mother and brother to hepatitis B at the age of twenty-one inspired her to found the Hepatitis B Initiative in 1997, which she later expanded to the Maryland, Virginia, and Washington, D.C. area with Thomas Oh. Today, this award-winning nonprofit continues to operate in several states mobilizing communities to prevent liver diseases caused by hepatitis B and C among Asian Americans and Pacific Islanders, African Americans and other high-risk groups.

Leslie Hsu Oh
lhsu@post.harvard.edu
www.lesliehsuoh.com