Category: Obstetrics

Ladies on a Mission

1 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.

FullSizeRender-100We 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


20140306_102410Cecille, 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 4th 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.

FullSizeRender-101Where 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.

Five Easy Steps to Save Lives and Promote Healthy Families

by, Donna Weeks

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

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

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

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

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

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

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

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

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

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

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

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

 

 

Citations

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

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

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

Resources

Get free postpartum hemorrhage resources from AWHONN.

Learn more about AWHONN’s Postpartum Hemorrhage Project

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

TOLAC and VBAC and Rupture! Oh My!

3 Comments

by, Bree Fallon

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

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

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

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

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

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

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

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

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

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

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

Nurses Save Lives

2 Comments

by, Christine Douglass, RN
Florida Hospital Heartland Medical Center

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

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

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

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

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

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

A Nurse Making History

3 Comments

By, Lori Boggan

Organ transplantation, according to the U.S. Department of Health and Human Services, dates back as early as 1869 with the first skin transplant. The first kidney transplant occurred nearly one hundred years later in 1954. Organ transplantation has saved countless lives. In 2014, transplantation history was made. It was the year the first transplantation bore life. Continue reading →

See You In Grapevine!

4 Comments

Victoriaby, Bree Fallon, BSN, RNC-OB, C-EFM

When I was told my administration would be sending three of us to the AWHONN Convention, my heart skipped a beat. Actually, I squealed like a child and jumped up and down. It was a dream come true! I couldn’t help but compare Convention to a labor and delivery nurse’s Disneyland. It’s funny to me now remembering that day, as I would have had no way of possibly knowing what a tremendous impact the trip to Convention would have, both on my own nursing career as well as my unit. Continue reading →

What Children with FASD Want You to Know

by, Marilyn Pierce-Bulger, ANP

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

Standardizing Postpartum Oxytocin Administration

13 Comments

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

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

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

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

Top 10 Posts of 2015

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

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

Here’s Our 2015 Top Ten Round Up! Continue reading →