Informal Milk Sharing in the United States

August 5, 2016August 5, 20165 Comments

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:

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.
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.
What types of containers will be used for storage (the recipient mother could supply these to the donor mother) and how will the milk be stored (fresh or frozen) and transported from the donor mother to the recipient. Conversations between recipient mother and donor mother should be on-going to ensure safety of the milk. In this area the research literature has also evaluated the use of home heat treatment to “pasteurize” the milk. Research has shown that heat treatment of the milk on a stovetop is not the same as Holder pasteurization, this technique has the ability to destroy viruses. It is important to note that heat treatment also destroys some of the beneficial components of human milk.

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

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

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

Resources for Informal Milk Sharing

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

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

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

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

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

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

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

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

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

Babies Have Back-to-School Needs, Too

July 26, 2016July 25, 2016

by, Summer Hunt

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

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

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

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

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

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

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

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

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

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

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

Ladies on a Mission

July 19, 20161 Comment

Guatemala

by, Lori Boggan, RN

When we enter the medical profession, we make a lifetime commitment to the service of others. As nurses, we serve our patients, our community, our friends, and our family. No other profession has such a deep connection to and is so trusted by society. We are the ones at the bedside day and night. We are the ones that our patients trust with their privacy, their secrets, and their lives.

Volunteer nursing is no foreign concept for American nurses. In fact, the earliest “nurses” were nuns, or family members of those active in the Civil War. They were in the trenches before any formal nursing education or organization existed.

For most, nursing is a calling. Nurses are innate caregivers. What is it about a nurse that is willing to use her own money, travel to an unfamiliar place sometimes lacking basic accommodations, and work long hours without pay? It is the drive to care for those in need.

The following interview is with one of AWHONN’s own that goes above and beyond. Nancy Stephani Zicker, a labor and delivery nurse from Central Florida has journeyed to Guatemala yearly since 2014 to help less fortunate women in need of gynecological surgery. She journeys with her friend and obstetrician, Dr. Cecille Tapia-Santiago, of Volusia ObGyn Daytona Beach. In addition to gynecological surgeries each year, Dr. Tapia sees patients in the mission’s clinic and educates Guatemalan midwives. I interviewed both ladies in hope to inspire others to join mission work.

How long have you been going on missions?

Nancy: I have been going on yearly medical mission trips every March since 2014.

Cecille: I have been doing 1-3 mission trips a year since 2000.

Where has your mission work taken you?

Both: Guatemala

Why Guatemala? Is there any particular need there with regard to women and infant’s health?

Cecille: Absolutely. When we go there we provide contraceptive care, well woman care, and manage surgical conditions (uterine fibroids, large ovarian cysts, and pelvic prolapse being the most common).

Describe a typical day in the life of a volunteer nurse.

Nancy: Each year that I have gone, I have been assigned to work as a circulating nurse (and sometimes scrub in to tech or assist) in the OR. There are clinic nurses, OR nurses, PACU nurses and ward (floor) nurses.

We go in to a completely bare room and make it a functioning OR.

As an OR nurse, we first have to unpack and sort all of our supplies, as well as set up the operating rooms. We arrive on a Saturday late afternoon and get right to work. Sometimes we set up in community centers and sometimes we set up in an actual hospital. This usually takes Saturday evening and all day Sunday to accomplish.

Monday morning, the surgeries begin. Depending on the number of cases scheduled, we usually are in the OR from 8am-5pm. Once all surgeries are done at the end of the week, we have to break down the ORs to leave the space as we found it and inventory all supplies so we can order more for next year. We all have had to improvise and be creative with available equipment and supplies. It’s quite the challenge, but the entire team comes together and we make it work.z

Cecille, describe your work educating midwives in Guatemala

It’s THE BEST PART. Midwives in Guatemala are mostly lay (no formal training at all). Guatemala has one of the highest infant mortality rates in the world. We do 1-2 day seminars and teach basic infant resuscitation as well as basic management of labor, delivery and postpartum complications. The midwives have to deal with a lot of prejudice from the physician community and often won’t get paid for their service if the patient has to be transferred to a hospital. So anything they can do to show their critics that they are furthering their education and are doing right by a patient is helpful.

Is there any one particular patient story that you can share that stands out in your mind where you felt you really made a difference in that patient’s life?

Cecille: One of the midwives came back to a refresher course and told us that she gave CPR to a baby with apnea. Initially the family was resistant and thought the baby was dead. The midwife pulled out her certificate from the seminar and showed the family. She told the family to let her try and do CPR. She successfully performed mouth to mouth and chest compressions and the baby was fine! We also had a young lady with an enormous pelvic mass that was compressing her entire abdomen and pelvis. She had been turned down by everyone and when we saw her, she was cachectic and probably a few weeks away from dying. We removed an enormous yet benign ovarian cyst. It was over 50cm in diameter and weighed 25 pounds.

How has mission work changed your practice?

Nancy: It has made me a better nurse. Seeing and working with the patients I see on my mission trips has renewed my love of nursing and my compassion for people in general. The patients I see on these trips are so profoundly grateful for the care they receive. It helps to renew one’s zest for nursing.

Cecille: It hasn’t really changed how I practice at home, but you have to be a particular type of person to do well on these trips. In order to do this type of work you have to be patient, flexible, meticulous, and creative. You can’t go to these trips if you’re going to expect U.S. standards of equipment, timeliness and availability of things you have every day at home (for example blood, cautery, suction, light). I have seen time and time again physicians, nurses and staff struggle because they have unrealistic expectations of what it’s like to operate in third world conditions. And by the same token seen plenty (like Nancy) that just sail, adapt and just sail.

How has mission work changed you as an individual?

Nancy: Personally it has made me realize that as humans we all want the same things- we want our children healthy, we want access to quality healthcare, we want to be able to be happy in our daily lives, and we want a peaceful existence.

Cecille: It refreshes my choice and faith in my profession. Medicine has changed so much. The physician/patient relationship many times is not what it used to be. We live in a defensive medicine environment that often plays in to how we practice here. Over there, patients and families trust and believe that, just like at home, I do my very best to provide the very best care my skill set allows, and that I will never go above that skill set and take unnecessary risks. That trust factor makes any responsibility tolerable.

Guatemala

What advice would you give a nurse contemplating mission work?

Nancy: It’s important to choose the right organization to join, one that interests you. Each one has a different application process and requirements, as well as when and where they go on their trips. They all differ with their missions and what they offer. I have gone on 3 trips so far, and have applied for my 4^th with the same group. It’s called Cascade Medical Team, whose parent organization is Helps International. I have friends that have used various other organizations. It’s important to choose one that fits your interests and your budget, as well as the dates you’re available to go. Also, for me on my first trip, it really helped that I went with someone I knew and who had experience with volunteering for medical mission trips. Not only was she able to give me a heads up on what to expect, but it is just amazing to be able to share the experience with someone you know- someone who understands why you would want to, or should want to, volunteer for such a trip
.

How can a nurse prepare for his/her first mission?

Nancy: Be open-minded. Prepare to go out of your comfort zone and learn new things, both in the nursing/medical field and also culturally.

Where to next?

Nancy: To date, I have only been to Guatemala. At this point in time, I only volunteer for one mission trip each year and I have found that I really enjoy helping the people there and so have concentrated my trips to Guatemala.

Thanks for sharing, Nancy and Cecille! And thank you for your service! For more information on their work with Cascade Medical Team, visit www.cascademedicalteam.org.

Lori 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/ or on Instagram.

Specialty Training for Novice Nurses

July 12, 2016

by, Heretha Hankins, MSN-Ed, RNC

Twenty-five years ago when I was a young, new nurse there was a lot of talk about the nursing shortage. Every nursing magazine speculated on how patient care would suffer if we didn’t train more nurses. Several years ago I looked around and saw tangible evidence of this looming shortage for the first time in my career. At first limitless overtime was available and then came incentive pay and bonuses as an effort to cover the shortage. Finally, nursing broke the unwritten golden rule. We started accepting new grads into specialty areas.

When I started nursing school I knew I wanted to work in L&D but my instructors explained that I must first work “general nursing” (med-surg) before I could even consider a specialty like OB. Today there is such a low pool of applicants for multiple open positions we are seeing a growing trend of graduate nurses entering specialty areas. After six months they are expected to possess critical thinking skills; one year later they train another new graduate. As we see an increase in the hiring of graduate nurses into critical practice areas such as OB, ICU and ER there needs to be a change to the training approach. The “each one teach one” approach is no longer effective.

OK, so here is where I want to really talk to nurse leaders. How do you know when a nurse is successfully trained? Can you measure the progress? Is the retention rate of your unit impacted by turn over from the nurses with less than two years experience? When I asked myself these questions I was inspired to design and implement the Perinatal Nurse Training Program (PI.N.T).

Developing the Program

The PINT Program is a 16 week program which includes 72 hours of didactic information in the classroom setting with a curriculum and reading assignments. Peer-reviewed books are required purchases (build a practice on research not hearsay). We also incorporate AWHONN’s basic and intermediate fetal monitoring courses into the training to assure the information received is consistent with national standards. Yes, it sounds and looks like going back to school. Didactic hours are spaced throughout the 16 weeks building on concepts as the nurse builds in practice.

Use of a focus plan and checkpoints makes progress measurable. The checklists are tasked-based because a new learner has concrete thought processes. Consistent feedback in 1:1 sessions helps to promote progress or strategize about practice opportunities. In the last four weeks there are two to three novice nurses assigned to one preceptor. This gives the novice an opportunity to strengthen a solo practice while keeping that preceptor safety net nearby. After the 16 weeks, periodic monitoring is used to assure practice assimilation, answer questions and offer support. By the one year anniversary of practice the novice must pass the National Certification Corporation (NCC) exam for fetal monitoring to be considered successful.

Prior to PINT unit based orientation was largely completed with using preceptor pairing. Small amounts of didactic were used but were generally attached to vendor presentations for products used in the practice. Many things such as fetal monitoring and high risk pregnancy care were covered by use of self-learning modules. It is also worth noting, prior to my arrival the educator position was vacant for approximately five years.

Road Blocks

The greatest obstacle identified was seen in the change with preceptor assignments. Traditionally a novice was assigned to one preceptor for all of orientation. In the PINT program the preceptor assignment is fluid but generally stable for two weeks. My philosophy for this approach is based in inherent human error and autonomous practice. No one is perfect and sometimes what works well for one may not work for another. Seeing multiple different practices allows the novice to build his/her own autonomous practice.

Measuring Success

My measurement of success for this program is in the pass rate of the exam and the increase retention of new hires on the unit. With a total of 71 novices trained to date we boast a 98% pass rate by one year of practice on the NCC exam, a two year retention rate of 75% and a one year of near 90%. Program evaluation surveys provide feedback from the participants regarding what they gained and what could be improved. The participants noted the program worked well for them and they appreciated the structure. I am most proud to know that this leads to increased patient safety and healthy moms and babies. As I recall that was what motivated me to want this practice when I was a new graduate nurse.

Advice For Nurses Wanting to Start A Specialty Training:

Provide didactic training on the routine patient type starting with normal before sending the novice to the unit or training on complex procedures.
Make time for didactic classroom throughout the process so time if given to build on concepts.
Start the process with cohorts so that each participant can connect with someone in the group.
Encourage journaling because it helps develop critical thinking.

Heretha Hankins MSN-Ed, RNC is a Professional Development Specialist at Holy Cross Hospital in Silver Spring, MD, affiliate of Trinity Health System. She is the creator/facilitator of the Perinatal Nurse Training (PiNT) Program which she has presented to the Central Virginia Nursing Staff Development Organization, Maryland Patient Safety Perinatal Collaborative and Trinity Health Perinatal Summit. With 20+ years of nursing experience she also freelances as a Nurse Education Consultant. Her professional passion is to train the best nurses to provide the best patient care. She is always willing to discuss this at [email protected] or any other forum.

Confidence Building for Nurses

June 7, 2016

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.

Thank You Nurses

June 1, 2016June 6, 2016

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by, Pampers Swaddlers
Anne Gallagher-Photo The 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.

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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

May 26, 2016May 27, 2016

by, Donna Weeks

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

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

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

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

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

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

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

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

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

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

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

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

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!

May 17, 20163 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.

With 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 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.

Nurses Save Lives

May 5, 2016May 5, 20162 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

May 5, 2016May 5, 2016

by, Elizabeth McIntire

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

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

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

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

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

Baby Cora

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

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

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

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

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

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

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Category: Nursing