The best hair day I ever had was the morning I walked into the AWHONN office with my newly grown out, close-cropped hair. It felt luxurious to me after losing my hair to chemo even if it was less than an inch long.

A breast cancer diagnosis is scary. Treatment is intense and nerve-wracking. To me, the hardest part was when treatment was over. Even when breast cancer is found early, as mine was, there’s a chance it can come back. I’ve been blessed to be healthy for 13 years.

Catherine “Cathy” RUHL, DNP, CNM, is the Director of Patient Education and Outreach at AWHONN.

I was two months away from my 50th birthday, and I had decided that I was going to have a big birthday celebration. What would I do now? I decided I’m not going to spend the money on a party — I’m going to celebrate living. So, I went on with preparing myself with MRI’s and more biopsies and finally on to meet the surgeon. I asked my best friend, April, to go with me to meet the surgeon. I’m so glad that I did. There was so much information given, and under the circumstances with my nerves on edge, all I could think about was when my mother had breast cancer. She had to have chemotherapy and was very sick, and I watched her hair fall out. I was afraid that I would need the same treatment. How thankful was I when the surgeon said that because of the type of cancer, I would be having a lumpectomy and 37 treatments of radiation with a five-year plan of hormonal therapy. So, at the end of the conversation with the surgeon, he said to me, “Why are you delaying your surgery?” I told him one reason was that I was scared and the second was that I wanted to celebrate my birthday. He responded by asking when my birthday is, and I said, “It’s December 15 — I turn 50.” He said, “Oh, well you can celebrate up to 12:00 am and after that, no food or beverages. I will meet you for surgery at 7:30 am on December 16.” We had a good laugh, but I did as he instructed.

I had my surgery, and it was a huge success. He removed the cancer and 27 lymph nodes. I started my recovery process at home. I had six weeks to recover before I started my radiation treatment. After six weeks, I was ready to start my treatment. My best friend, who had been with me to every appointment, surgery, and follow-up appointment, said to me on my first day of treatment, “Do you want me to go with you to radiation?” “No,” I responded, “I think I can manage this by myself.” As I was walking up to the building, I read the sign on the building that reads Cancer Treatment Center — it stuck out like a neon sign to me at this point! Mind you, I have been going to this same building the entire time. I stop walking, and it seemed like I was frozen in time as I was looking at this sign thinking to myself: I have cancer. Why was it hitting me so hard now? I have had the surgery, which was the hard part, but now I am alone. I realized that I’m here alone, and I need to do this. So, I got myself together, stopped the crying, and went into the building for my treatment. During the surgery prep, the doctor marked the locations where the radiation would be focused and would leave three permanent tattoos. Once I had collected myself and went through with the radiation, the experience wasn’t bad at all.

I will be celebrating 10 years of being cancer-free on December 16, 2019 — the day after my 60th birthday this year. I will never forget the love and support that AWHONN showed toward me during my journey, and I am still here with such a wonderful association after 24 years.

Pearl Thorpe is a Senior Graphics Manager within the Strategic Partnerships, Communications and Meetings Department at AWHONN. Pearl has been with AWHONN for 24 years.

For several hours on Sunday afternoon, speakers shared their own accounts with near-death experiences or the death of a loved one due to pregnancy-related causes. Several people from AWHONN’s office attended. You may have seen some of the social media posts.

The stories are heart wrenching. I find myself wishing Congress would take action on Maternal Health Accountability Act and the Preventing Maternal Deaths Act so that we can make progress on reversing the rising maternal morality trend so no more stories of maternal deaths will have to be told on the National Mall. If you haven’t yet done so, please call your Senators and Representative and ask them to support S. 1112 and H.R. 1318. And, if they have already cosponsored these bills, a thank-you call is always appreciated. Your call can make a difference.

Sincerely,
Seth A. Chase

Updates for Monday, May 14, 2018

Budget and Appropriations
President Donald Trump’s Office of Management and Budget has sent to Congress a request to rescind $15.4 billion in appropriated funds. The request must be approved by Congress, which has 45 days to do so. Authorization for federal agencies to spend the money is on hold until either the 45 days run out or Congress takes a vote on the request. The largest single area the president asks to rescind is $7.0 billion from the Children’s Health Insurance Program–with $5.1 billion from unspent Fiscal Year 2017 funds that can no longer be spent and the remainder from a contingency account which likely will not be used.

Fiscal Year 2019 Appropriations
The Agriculture, Rural Development, Food and Drug Administration, and Related Agencies Subcommittee unanimously approved its Fiscal Year 2019 appropriations bill last Wednesday. The bill would appropriate $6 billion for the Women, Infants and Children nutrition program.

Senate Labor, Health and Human Services, Education and Related Agencies Subcommittee Meeting
I joined other representatives of the associations in the Coalition for Health Funding last week in a meeting with the staff director for the majority (Republican) Senate Labor, Health and Human Services, Education and Related Agencies Appropriations Subcommittee. From this meeting we learned that the subcommittee hasn’t yet received an allocation for Fiscal Year 2019 from the full Appropriations Committee. The subcommittee cannot begin crafting their bill until they receive the allocation.

The staff director expressed that she does not expect large increases for public health and health research programs–especially with a $500 million hole created by the expiration of 21st Century Cures money for opioids. The Senate will be begin marking up bills at the end of this month–starting with non-controversial bills such as Subcommittee on Agriculture, Rural Development, Food and Drug Administration, and Related Agencies. The Labor, HHS, Education bill will likely be marked up toward the end of June.

Briefings and Hearings
The Senate Subcommittee on Labor, Health and Human Services, Education and Related Agencies held a hearing May 10 with Secretary Alex Azar on the Department’s the Fiscal Year 2019 budget request.

Coming Up:

• Today and tomorrow, Jacque will be attending the Task Force meeting on Research Specific to Pregnant and Lactating Women via webinar from the National Institutes of Health. Recommendations from this meeting are used to shape and inform policy.
• We are soliciting input from AWHONN’s Public Policy Committee and Research Advisory Panel in order to respond to comments due 5/21/18 on draft recommendations for Screening for Intimate Partner Violence, Elder Abuse and Abuse of Vulnerable Adults and Behavioral Counseling to Prevent Sexually Transmitted Infections.   Public comment can also be made at https://www.uspreventiveservicestaskforce.org/Page/Name/us-preventive-services-task-force-opportunities-for-public-comment. You can also submit your comment to us at [email protected] to be included in AWHONN’s response.
• On Wednesday, I’ll be attending the Women’s Health Empowerment Summit.
• On Friday, I’ll be joining Friends of Title V Maternal and Child Health Services Block Grant Program in meeting with Laura Kavanagh, the acting associate administrator for Health Resources and Services Administration’s Maternal and Child Health Bureau.

Seth A. Chase is the director of government affairs at the Association of Women’s Health, Obstetric and Neonatal Nurses.

Sign up to get AWHONN Legislative Update delivered directly to your inbox every Monday when Congress is in session by sending an email to [email protected].

Create a Routine
By establishing a wellness routine, you’ll be more likely to stick with it. Any of the following little tips can easily be added to your day—it’s not all or nothing! Most will take just a few minutes, and some can be incorporated during your commute to work. Creating a wellness routine only requires a commitment from you to take better care of yourself.

Just Breathe
The act of conscious, deep breathing can actually change your mood from tired, anxious, and unnerved to energized and calm in virtually no time. Sit tall, draw your shoulders back and down, and lengthen through the crown of your head. Eyes opened or closed, begin breathing deeply in and out through the nose. Take about 20 rounds of breath and notice how you feel.

Make a Mantra
This could be something as simple as “I am enough” or even “It’s going to be a great day.” Your mantra could even be a single word such as “peace” or “serenity.” Write it on your mirror, put it on a Post-It, say it when you first wake up or when you’re feeling stressed. There are several studies that suggest that having a personal mantra allows you to reduce stress and anxiety naturally.

Fall in Love with Lavender
Studies have shown that lavender can help with stress, depression, and anxiety. Buy pure, organic essential oil at your local health food store. Diffuse it in your home, or put three to four drops on a tissue and keep it in your car console so you can get a few whiffs during your pre-shift deep breathing. You might even consider dabbing a drop or two on your scrub top mid-shift for a little pick-me-up.

Epsom Salt Soaks
Pour a cup of Epsom salt into a warm foot bath and soak for 5-10 minutes. Your feet will thank you! Epsom salt (magnesium sulfate) relaxes the muscles and may reduce swelling. If you have a little more time, add 2 cups to a warm bath before bed. Add a few drops of lavender oil and you’ll sleep like you never have before.

Elevate Your Legs
Give swollen, aching feet a lift to reduce swelling at the end of a long shift.  You might also consider compression socks keep the blood flowing. While your legs are elevated, gently stretch your feet and calves. For a quick massage, try rolling a tennis ball (or frozen water bottle) under your foot, paying special attention to the arch.

Stretch It Out
This is good for before, during, and after work: Take 5 minutes or so to do some gentle stretches for your neck, arms, wrists, back, and legs. Try this: Grab a chair and place it in front of you. On an inhale, reach your arms up overhead, lengthening through your spine and crown of head. On an exhale, fold forward, placing your hands or forearms on the chair. Take 10 or 20 deep breaths here. Bend your knees and slowly roll back to a standing position as you inhale. Do your best to practice good posture during the day.

For when you have more than a few minutes, these tips are vital for overall health, too:

Prioritize Nutrition
Keep prepacked snacks available to grab and go, especially high-protein options like nuts, dried fruit, or protein bars. Don’t skip your lunch break, if at all possible—fill up on water and filling fruits and veggies. Look into using a slow cooker to have meals hot and ready when you get home after a long shift, or build up a stash of freezer-friendly meals. And please try not to deprive yourself of a much-needed bathroom break!

Maintain Your Mental and Emotional Health
Caring for women and babies can be stressful enough—don’t let anyone or anything else add unnecessary discomfort to your day. Find support for your challenges. Identify someone you can trust at work. Everyone deserves to know that someone has their back. If you have issues with workplace bullying, depression, or addiction, don’t let another day go by without reaching out to a trusted source of support, be that a friend, family member, employee assistance program, helpline, or spiritual community.

Keep Your Skills Sharp
Yes, part of wellness means continuing to grow and excel in your chosen field! AWHONN offers more than 40 hours of free CNE activities in the Online Learning Center on a wide variety of topics. When you just have a few minutes, check out Nursing for Women’s Health or JOGNN articles—you can even read them using the app! AWHONN members can access the full archives of these two scholarly journals online at AWHONNjournals.org.

Lori is a registered nurse with years of experience in newborn intensive care and postpartum nursing. She writes regularly for AWHONN; American Nurse Today; and her blog, Neonurse. She has also been featured in The Huffington Post. She is a 200-hour Yoga Alliance-certified yoga teacher, a certified prenatal and postnatal yoga teacher, pediatric CPR instructor, and a member of International Childbirth Educators Association (ICEA). Her passion is teaching new parents about their babies and guiding them in the process of becoming a family.

Tobacco
According to a story run by BuzzFeed News, the Food and Drug Administration is cracking down on the sale of JUUL brand e-cigarettes, which are very popular among teens and young adults. The FDA has sent warning letters to 40 retailers after federal inspectors found that they sold JUUL e-cigarettes to minors, and asked JUUL for data on its marketing of the product and any potential side effects. AWHONN supports comprehensive tobacco control initiatives. In addition, nurses should screen women for tobacco use (including e-cigarettes), counsel them about the effects of tobacco use and tobacco exposure, and have access to referral information that supports cessation efforts. In case you missed it, in September 2017 AWHONN published an updated position statement on Tobacco Use and Women’s Health which can be accessed here.

Maternal Mortality
Senate Health, Education, Labor and Pensions Committee ranking member Sen. Patty Murray (D-WA) said in a Committee hearing on April 24 that the Committee will consider S 1112, the Maternal Health Accountability Act during a hearing in May. The Committee has not yet announced a date for the hearing. AWHONN advocates for expanding research funding and opportunities to investigate and alleviate the causes of maternal morbidity and mortality and will attend the hearing if it’s scheduled.

Teen Pregnancy Prevention Program
According to a story in The Hill, the Department of Health and Human Services has announced an abstinence-focused overhaul of the Teen Pregnancy Prevention Program. The funding announcement reads that “projects will clearly communicate that teen sex is a risk behavior for both the physical consequences of pregnancy and sexual transmitted infections; as well as sociological, economic and other related risks…Both risk avoidance and risk reduction approaches can and should include skills associated with helping youth delay sex as well as skills to help those youth already engaged in sexual risk to return toward risk-free choices in the future.”

In total, tier one will award up to $61 million in funds, ranging from $200,000 to $500,000 per year. The second tier solicits applications to develop and test “new and innovative strategies” to prevent teen pregnancy while improving adolescent health and addressing “youth sexual risk holistically by focusing on protective factors.”

Health Insurance
A new Kaiser Family Foundation analysis of short-term, limited duration health plans for sale through two major national online brokers finds big gaps in the benefits they offer. Through an executive order and proposed new regulations, the Trump Administration is seeking to encourage broader use of short-term, limited duration health plans as a cheaper alternative to individual market plans that comply with the Patient Protection and Affordable Care Act’s requirements. Repeal of the individual mandate penalty – which currently applies to people buying short-term plans – is also expected to boost enrollment starting next year.

Religious Refusal
According to a story in The New York Times, the Trump administration plans to implement the proposed rule, Protecting Statutory Conscience Rights in Health Care; Delegations of Authority, which seeks to permit discrimination by providers in all aspects of health care without adequately protecting patients from discrimination in accessing health care services. This new rule would roll back an Obama Administration rule that protects transgender people from discrimination by doctors, hospitals and health insurance companies. AWHONN submitted comments opposing the rule.

This proposed rule is not necessary to protect the rights of providers. It is the position of AWHONN that the existing rule issued in 2011 adequately protects the conscience of providers and patients. AWHONN asserts that nurses have the professional responsibility to provide nonjudgmental nursing care to all patients, either directly or through appropriate and timely referrals. AWHONN recognizes that some nurses may have religious or moral objections to participating in certain reproductive health care services, research, or associated activities. Therefore, AWHONN supports the existing protections afforded under federal law for a nurse who refuses to assist in performing any health care procedure to which the nurse has a moral or religious objection so long as the nurse has given appropriate notice to his or her employer. Additional information can be found in our position statement Rights and Responsibilities of Nurses Related to Reproductive Care.

Opioids Crisis

• The Senate Health, Education, Labor and Pensions Committee marked up S. 2680, the Opioid Crisis Response Act on April 16. The bill included measures to make it easier for opioids to be prescribed in smaller amounts, develop nonaddictive alternatives to opioids and strengthen border security to stop drug trafficking. It was passed by the subcommittee unanimously and will proceed to the full committee for a vote to go to the Senate floor. The bill also includes provisions to address treatment for pregnant and postpartum women in an effort to reduce instances of neonatal abstinence syndrome.
• On April 25, the House Energy & Commerce Health Subcommittee approved a package of 57 bills addressing the opioids epidemic, sending it to the full committee for their consideration.
• On April 24, the Trump administration renewed its 90-day emergency declaration regarding the ongoing opioid crisis. This is the second renewal since President Trump first declared the opioids epidemic a public health emergency in October 2017. The declaration extends the authority of federal health agencies to quickly hire more treatment specialists and reallocate resources to respond to the drug abuse epidemic.

National Guideline Clearinghouse Going Offline

The Agency for Healthcare Research and Quality National Guideline Clearinghouse web site will not be available after July 16 because federal funding through AHRQ will no longer be available to support it. The NGC is a repository of clinical practice guidelines.

Breastfeeding
On Friday, April 27, the House of Representatives voted to pass HR 4, the FAA Reauthorization Act. No, AWHONN hasn’t expanded the legislative and policy agenda to include regulating civil aviation. Rather, the FAA bill included provisions from HR 2375, the Friendly Airports for Mothers Act. This bill would direct large and medium hub airports to maintain a lactation area in each passenger terminal to provide a private and hygienic location for mothers to breastfeed their children.

AWHONN supports, protects, and promotes breastfeeding as the ideal and normative method for feeding infants, including the provision of human milk for preterm and other vulnerable newborns. Women should be encouraged and supported to exclusively breastfeed for the first six months of an infant’s life and continue to breastfeed for the first year and beyond. AWHONN partners with other maternal‐child health organization to improve cultural, institutional, and socioeconomic systems so that more women and newborns can experience the numerous physiologic and psychosocial benefits of breastfeeding. Our breastfeeding position statement can be reviewed here.

Abortion Care
According to a story in The Hill, Iowa lawmakers passed a bill on May 2 that would ban abortions once a heartbeat is detected in the fetus, effectively prohibiting the procedure by the sixth week of pregnancy. Gov. Kim Reynolds (R) has signed the bill. AWHONN’s position is that any woman’s reproductive health care decisions are best made by the informed woman in consultation with her health care provider. AWHONN believes these personal and private decisions are best made within a health care system whose providers respect the woman’s right to make her own decisions according to her personal values and preferences and to do so confidentially.

Therefore, AWHONN supports and promotes a woman’s right to evidence-based, accurate, and complete information and access to the full range of reproductive health care services. AWHONN opposes legislation and policies that limit a health care provider’s ability to counsel women as to the full range of options and to provide treatment and/or referrals, if necessary.

Title X Family Planning Programs
According to a story from Reuters, Planned Parenthood and the National Family Planning and Reproductive Health Association have filed lawsuits against the Trump administration to prevent the Title X Family Planning grant program from favoring groups that are faith-based and that promote abstinence. The lawsuits, which were filed in federal court in Washington, take aim at the guidelines the Department of Health and Human Services issued in February, which provided new criteria in evaluating applications for grants under the Title X family planning program.

Seth A. Chase is the director of government affairs at the Association of Women’s Health, Obstetric and Neonatal Nurses.

Sign up to get AWHONN Legislative Update delivered directly to your inbox every Monday when Congress is in session by sending an email to [email protected].

Parents consider health care professionals one of the most trusted sources in answering questions and addressing concerns about their child’s health. A recent survey on parents’ attitudes, knowledge, and behaviors regarding vaccines for young children — including vaccine safety and trust — found that 82% of parents cited their child’s health care professional as one of their top 3 trusted sources of vaccine information.

“Nurses can begin talking to parents about childhood immunizations during prenatal care when asking parents about plans for their newborn’s pediatric care,” said Catherine Ruhl, MS, CNM,  director of women’s health programs for AWHONN. “Messages can be reinforced  during a woman’s postpartum stay when confirming plans for the baby’s follow-up care.”  With so many parents relying on the advice of health care professionals about vaccines, a nurse’s recommendation plays a key role in guiding parents’ vaccination decisions.

“A nurse’s expertise, knowledge, and advice are vital in creating a safe and trusted environment for discussing childhood immunizations,” said Dr. Nancy Messonnier, CDC’s director of the National Center for Immunization and Respiratory Diseases. “How you communicate with parents during routine pediatric visits is critical for fostering parental confidence in the decision to vaccinate their children.”

The survey also found that 71% of parents were confident or very confident in the safety of routine childhood immunizations, although parents’ most common question is what side effects they should look for after vaccination. Twenty-five percent are concerned that children get too many vaccines in one doctor’s visit, and 16% of survey participants are concerned that vaccines may cause autism.

“Reinforcing vaccine safety messages can go a long way towards assuring parents that they are doing the best thing for their children,” says Patsy Stinchfield, a pediatric nurse practitioner who represents the National Association of Pediatric Nurse Practitioners. “One of the best ways you can establish trust with parents is by asking open-ended questions to help identify and address concerns they may have about vaccines. Also, restate their questions and acknowledge concerns with empathy.”

Make sure to address questions or concerns by tailoring responses to the level of detail the parent is looking for. Some parents may be prepared for a fairly high level of detail about vaccines—how they work and the diseases they prevent—while others may be overwhelmed by too much science and may respond better to a personal example of a patient you’ve seen with a vaccine-preventable disease. A strong recommendation from you as a nurse can also make parents feel comfortable with their decision to vaccinate.

For all parents, it’s important to address the risks of the diseases that vaccines prevent. It’s also imperative to acknowledge the risks associated with vaccines. Parents are seeking balanced information. Never state that vaccines are risk-free and always discuss the known side effects caused by vaccines.

If a parent chooses not to vaccinate, keep the lines of communication open and revisit their decision at a future visit. Make sure parents are aware of the risks and responsibilities they need to take on, such as informing schools and child care facilities that their child is not immunized, and being careful to stay aware of any disease outbreaks that occur in their communities. If you build a trusting relationship over time with parents, they may reconsider their vaccination decision.

To help communicate about vaccine-preventable diseases, vaccines, and vaccine safety, the Centers for Disease Control and Prevention, the American Academy of Family Physicians, and the American Academy of Pediatrics have partnered to develop Provider Resources for Vaccine Conversations with Parents. These materials include vaccine safety information, fact sheets on vaccines and vaccine-preventable diseases, and strategies for successful vaccine conversations with parents. They are free and available online.

As we close out Women’s History Month, and I want to take this moment to discuss an issue that is not only dear to my heart but also takes the lives of more than 700 women each year—maternal mortality.

A maternal death is defined as the death of a woman during pregnancy or within one year of the end of pregnancy. The death is determined to be pregnancy-related if the cause of death is related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes.

Of the 5,259 deaths within a year of pregnancy completion that occurred during 2011–2013 and were reported to the Centers for Disease Control and Prevention (CDC), 38.2% were found to be pregnancy-related. In the United States, more than half of all maternal deaths occur after birth—often after discharge from the hospital. This doesn’t have to happen. In fact, at least half of all pregnancy-related deaths are preventable when the warning signs of pregnancy or childbirth complications emerge and a mom can get the timely care she needs from her healthcare providers. The reality is that many women do not receive consistent messages or adequate guidance on identifying the warning signs of complications, or instructions about when, and where to obtain necessary medical attention.

AWHONN has created specific instructions for acting on these warning signs called “SAVE YOUR LIFE: Get Care for These POST-BIRTH Warning Signs.” Here are the specific signs you should watch for and act on during the first year after birth:

• Pain in your chest
• Obstructed breathing or shortness of breath
• Seizures
• Thoughts of hurting yourself or your baby
• Bleeding that is soaking through one pad/hour, or blood clots the size of an egg or bigger
• Incision that is not healing
• Red or swollen leg that is painful or warm to touch
• Temperature of 100.4 °F or higher
• Headache that does not improve, even after taking medicine, or a bad headache with vision changes

For moms: If you are experiencing any of these post-birth warning signs, contact your health care provider or go to the nearest urgent care or hospital as soon as possible. For serious and potentially life threatening warning signs like pain in your chest, obstructed breathing, seizures, or if you have thoughts of hurting yourself or your baby, call 911. Let all responders know that you gave birth within the past year.

Recognizing and acting on these warning signs and complications that can lead to a mom’s death or injury is essential to reducing maternal deaths in the United States. Share this information with pregnant women you care for. AWHONN is committed to working together with nurses and moms to reduce maternal mortality rates. Let’s help women to be aware and to recognize the signs of post-birth complications in order to begin reversing this alarming trend.

Additional resources:

• Discharge Education on Maternal Morbidity and Mortality Provided by Nurses to Women in the Postpartum Period (JOGNN)
• Improving Postpartum Education About Warning Signs of Maternal Morbidity and Mortality (Nursing for Women’s Health)
• FOR CONSUMERS: Learn These Post-Birth Warning Signs (Healthy Mom & Baby)

Jennifer Doyle is the 2018 AWHONN President and a women’s health nurse practitioner with nearly 25 years of experience in obstetrics. She is the APN of the Women’s Service Line at Summa Health in Akron, OH, as well as faculty and coordinator of the WHNP program at Kent State University in Kent, OH.

These truly alarming numbers are why during Black History Month and beyond the nurses of AWHONN want healthcare providers and moms alike to learn and share post-birth warning signs that have been shown to help new moms and their caregivers recognize potential problems and get the help they need—perhaps even saving their lives.

AWHONN has created specific instructions for acting on these warning signs called “SAVE YOUR LIFE: Get Care for these POST-BIRTH Warning Signs.” Here are the specific signs women should watch for and act on during the first year after birth:

• Pain in your chest
• Obstructed breathing or shortness of breath
• Seizures
• Thoughts of hurting yourself or your baby
• Bleeding that is soaking through one pad/hour, or blood clots the size of an egg or bigger
• Incision that is not healing
• Red or swollen leg that is painful or warm to touch
• Temperature of 100.4 °F or higher
• Headache that does not improve, even after taking medicine, or bad headache with vision changes

If you are experiencing any of these post-birth warning signs, contact your healthcare provider or go to the nearest urgent care or hospital as soon as possible. For serious and potentially life-threatening warning signs like pain in your chest, obstructed breathing, or seizures, or if you have thoughts of hurting yourself or your baby, call 911. Let all responders know that you’ve just given birth within the past year.

Recognizing and acting on these warning signs and complications that can lead to a mom’s death or injury is essential to reducing maternal deaths in the United States. Currently, maternal mortality rates—the number of women dying during or within 1 year of childbirth—are increasing, climbing 27% to 24 maternal deaths per 100,000 births since 2000. In the United States, more than half of all maternal deaths occur after birth—often after discharge from the hospital. This doesn’t have to happen.

For black moms, it’s even bleaker. Black mothers in the United States die during or within 1 year of giving birth at 3-4 times the rate of white mothers. This difference in maternal deaths and injury among black women is a serious issue that needs our action. At least half of all pregnancy-related deaths are preventable when the warning signs of pregnancy or childbirth complications emerge and a mom can get the timely care she needs from her healthcare providers.

Share this information with other nurses and pregnant women you care for so that moms and nurses can work to reduce maternal mortality rates, especially the higher rates among black women. Together, we can help women recognize the signs of a post-birth problem to prevent unnecessary injury or death.

Mary Elizabeth Elkordy is the Communications and Public Relations Manager for the Association of Women’s Health, Obstetric & Neonatal Nurses (AWHONN).

The author in her natural habitat.

As far back as I can remember, I’ve wanted to be a nurse—I had no intentions of doing anything else! I always thought nursing was the field for me because I could care for others and be a teacher and counselor, all at the same time. I originally thought I was going to work in the emergency department; I had no idea that the NICU existed. One day, our class took a tour of one of the largest hospitals in Alabama, and one of the units we visited was the NICU. I was immediately drawn to these tiny babies.

After that tour, I decided to do my preceptorship in the NICU, and it was then that I fell in love with neonatal nursing. I was very fortunate after nursing school to be offered a position in the NICU. I could not imagine working in any other area of nursing—and that’s where I’ve been since January 2004. I initially worked as a bedside nurse and then decided to further my education and become a neonatal nurse practitioner (NNP), a role I’ve had for the past 5 years of my career.

What I love about the NICU is that premature infants are fighters. I see them defy the odds every day. If you don’t believe in miracles, come visit the NICU. I also love that from the beginning, each one of these little babies has their own personality. They cannot tell you when something is wrong; you have to depend on your assessment skills and their cues to figure out what they need. It’s such a joy to see these infants grow and thrive. What I love most, though, is watching the parents get more and more comfortable caring for their child.

I’ve met so many wonderful families during my years in the NICU. They entrust you with their most precious possession, their child. It’s hard not to bond or connect with these people who spend weeks and months in the unit. When I’d been a NICU nurse for about a year, there was a baby I cared for who was born at 23 weeks and spent months in our unit. As I cared for this infant on a regular basis, I really bonded with the family. I remember many times over the months thinking that this patient was not going to survive. This family had the strongest faith I’ve ever seen, and eventually they did go home with their baby. Years later, they brought that child up to the NICU to see me. I was shocked that I touched their lives that much! They recalled specific things I had said or did, and it was one of those moments when I realized that my job makes a difference. I don’t do this job for recognition, but it’s nice to know I made such an impact.

Shortly before Rilee’s birth.

After spending so much of my time around other people’s babies, I was excited when I found out my husband and I would be welcoming our own child into the world. I had no complications during my pregnancy, and my only risk factor was advanced maternal age, as I would be 35 years when my son was due to be born. However, Rilee had different plans—I went into labor at 29 weeks and 4 days, and just like that, I went from NICU nurse to the mother of one of those tiny, vulnerable babies.

My labor happened so quickly that there wasn’t much time to process it. I didn’t sleep well the night before. I just could not get comfortable but assumed it was normal. I was scheduled to work, so I decided to go ahead and get up early since I wasn’t sleeping anyway. While in the shower, I began to hurt and feel nauseated. Even then, I still didn’t process that I might be in labor. I figured if I was still hurting when I got to work, I would go to Labor & Delivery and get checked out.

Rilee made his appearance more than 10 weeks early.

While trying to get dressed and ready for work, the pain was worsening. I began to vomit and feel the urge to go to the bathroom. That’s when it finally hit me that I might be in labor. I woke my husband up, and he drove us as fast as possible the 75 miles to the hospital. About halfway there, my water broke in the car. The contractions were coming every 2 minutes, and I was focusing on trying to keep my legs crossed because I could feel the baby’s head. When we arrived at the hospital at 6:15 a.m., I was completely dilated. There was no time for any medications or an epidural; I pushed twice, and Rilee was born at 6:30 a.m. I was in complete shock, and it took a little while for me to really process the fact that I had given birth more than 10 weeks ahead of schedule.

Having worked in the NICU for so long, I had some idea of what would happen next. I knew he would require oxygen and have apnea/bradycardia episodes, and I was prepared for him to not be a great PO feeder. What I was not ready for was the pain I felt as he struggled to breathe and had episodes. As a nurse, I knew it was totally normal, but as a mom, I was disappointed every time he took a step back and that he was not progressing at the pace I wanted him to.

April and husband Thomas visiting with their son, Rilee.

Working in the NICU may have prepared me for what to expect medically, but it did not prepare me for what I was going to experience emotionally. I had no idea the guilt I would have for not carrying Rilee to term. I felt my body had failed me, and I had failed my child. I mourned those last 2.5 months I missed out on and my lost chance at a full-term pregnancy. It may sound silly, but I felt cheated out of normal experiences like maternity pictures or being pregnant at my two wonderful baby showers.

One of the hardest things I had to do was to leave my baby. When I was discharged and had to leave Rilee for the first time, I sobbed the entire ride home. It’s just not natural to leave your child. I had envisioned giving birth and leaving the hospital with my baby in my arms. It’s also difficult letting others care for your child. As an NNP, I’m used to making the decisions and caring for the patient. It’s hard to just sit back and feel so helpless. I felt like I had to put on a brave face because I worked in the NICU, but there were days I felt like I was falling apart. I was stressed, exhausted, and anxious.

I went back to work when Rilee was 9 days old. That may sound quick, but I wanted to save my maternity leave for when he was discharged. My hospital was great, and I was allowed to come back even though Rilee was a patient in my unit. I did not care for, round or make decisions on my son, but it was nice to be able to go back to work and visit him on my breaks and during my downtime.

April checking in on Rilee’s progress in the NICU.

My sweet coworkers were wonderful to Rilee, as well as to my husband and me. We both felt like my son was given extra-special care and attention. The nurses celebrated his accomplishments and milestones with us; they also let me cry and vent to them. A few of my coworkers have had premature infants, and they understood exactly how I was feeling.

One particular experience with my nurses will always stick with me: When Rilee was about 3 or 4 weeks old, the night shift nurse asked me if I wanted to help bathe him. I know this may sound silly to some, but I appreciated it so much. Working in the NICU, I have bathed many babies—but this time, I got to bathe MY baby. This little thing really meant a lot to me.

Knowing what to expect as a NICU nurse was a blessing and a curse. I knew Rilee was doing well for 29 weeks, but I also knew all of the things that could go wrong. I was constantly waiting on something bad to happen. I had a hard time enjoying my baby and how well he was doing for the fear of the “what ifs.” I remember saying multiple times during his NICU course that I couldn’t believe how well he was doing, but that I didn’t trust him. I also got anxiety when it was time for a test, such as a head or cardiac ultrasound. When all was said and done, Rilee was in the NICU for 50 days. He was discharged home at 36 weeks and 5 days.

Finally going home!

Being a NICU mom has definitely made me change my way of thinking when it comes to talking to parents. I know each and every mother’s experience is different, but I feel like I can empathize now. Sometimes when mothers are having a hard time or feel like no one understands them or their situation, I just sit down and talk to them. I let them vent and tell them I understand. My experience may be different, but I do understand. Sometimes I do share my experience with a mother if I feel led to or if I think it will help.

Skin-to-skin care is good for baby and mommy.

I’m also quick to make sure mothers are holding their babies or doing skin-to-skin as soon as medically possible. I felt like this helped me to bond with Rilee and with my breast milk production. I also encourage moms to start pumping right away. I think pumping made me feel like I was actually doing something for my son at a time when I was virtually helpless—I was unable to care for him, so making milk was my contribution. It was the one thing that only I could do for him.

To women who find themselves in the NICU, I would say to take it one day at a time. Your baby will have good and bad days—you will have good and bad days. It truly is a roller coaster ride. Lean on friends and family for support. Find a NICU support group, which is great for parents to bond and share their experiences with one another. Don’t be afraid to ask questions or voice your concerns. You are the voice for your child; you are their advocate.

For fellow NICU nurses: Talk to the parents of these tiny, vulnerable babies. Listen to their concerns, and ask them how they’re doing. Sometimes they just need someone to talk to. Also, get them involved wherever possible. Encourage touching and holding. Ask them if they would like to help you take a temperature or change a diaper. It’s their baby, and they would like to feel like they are contributing. I will always remember when I got to bathe my son while he was in the NICU. Small gestures like this will mean more than you will ever know.

April Farmer, CRNP, NNP-BC, is a neonatal nurse practitioner in Birmingham, AL.

While the diagnosis of GDM can be scary for moms, it can usually be managed under the care and guidance of their health care team. We recently sat down with Allison Penny, a mother of two who was diagnosed with GDM with both of her pregnancies. We asked Allison questions on how she was able to navigate her diagnosis and what advice she would give to mothers in a similar situation.

How did you feel when you were told you had diabetes with your first pregnancy?

I was surprised, but my healthcare provider assured me it was pretty common. They also told me that the diabetes goes away after the baby is born for most women. When I was diagnosed during my second pregnancy, I was a bit more worried. This pregnancy was unexpected, but thankfully I was already working out and trying to get into shape, and I was able to continue with my workouts. I was definitely more cautious with diet and working out the second time around. My first vaginal birth was complicated and scary, and I think a lot of it had to do with the large size of the baby. Larger babies are a definite risk with GDM.

What concerns did you have following your diagnosis? 

By the time I found out, I had been fulfilling all my cravings So I had concerns about limiting junk and controlling my diet for both my baby and me.

What did your treatment plan consist of?

I had to measure my sugar first thing in the morning before eating anything. I also had to test my levels 30 minutes after my scheduled meals, like breakfast, lunch, and dinner. While monitoring and tracking my levels, I was able to determine what foods I could eat and which ones I couldn’t. For example, after eating pasta or bread, I found that my levels would elevate. On the other hand, when I ate rice, my levels were at the appropriate number. As a lover of food, I found it frustrating not being able to indulge in cravings and the food that I wanted, but the health of my child was the priority.

Did you have to take medication? 

The first time I had GDM, I was able to control my glucose levels with diet. The second time I had it, I had to take pills throughout the rest of my pregnancy. I felt frustrated and defeated that I couldn’t control my glucose levels with diet alone like I had the first time, but later I accepted that pregnancy impacts and changes a woman’s body whether I liked it or not!

Who taught you about what GDM is, about checking your blood sugars, taking any medications? 

The doctor, nurses, and nutritionist taught me about GDM. The nutritionist demonstrated how to check blood sugars during my first pregnancy. I opted to not see the nutritionist for the second pregnancy. When I couldn’t control my glucose levels with diet for my second pregnancy, the doctors and nurses explained what dosage to take, how and when to take the medicine, and how it was affecting me.

Did you feel your healthcare providers answered all your questions about diabetes during prenatal visits? 

Yes, definitely—during prenatal visits and during labor. Afterward, they didn’t seem to address the diabetes. However, the doctors and nurses regularly pricked my baby girl post-birth to ensure her glucose levels were within a normal range.

Do you have any helpful information or advice for pregnant women who are in your shoes?

Definitely drink a lot of water, and try to exercise daily. Be sure to follow up with your primary care provider after you give birth. Less than 6 months after having my daughter, I went for a routine annual physical and learned that my glucose levels were slightly elevated, among some other health-related and perhaps postpartum-related issues. I also think it’s really important for pregnant moms and nurses to encourage other moms to get themselves thoroughly checked out—bloodwork, EKG, etc.—within a few months of having a baby, because it’s important that moms stay as healthy as possible for their little ones. (See also: Learn These Post-Birth Warning Signs)

You may also be interested in these AWHONN resources:

• Evidence-Based Guideline: Nursing Care of the Woman with Diabetes in Pregnancy covers evidence-based recommendations for care of women with all types of diabetes during pregnancy, labor, birth, and the postpartum Immediate hospital care of the newborn of the woman with diabetes is also covered.
  • Enter promotional code DIABETES17 at checkout for a 10% discount (offer valid 11/14 only, expires at 12:00 midnight EST)
• Webinar: Nursing Care of Women with Diabetes During Pregnancy: An Evidence-Based Approach (available in AWHONN’s Online Learning Center—just login and search for the webinar’s title)
• Additional Publications: Manual of High Risk Pregnancy & Delivery, 5th edition describes how to screen for risk factors, provide preventive management, and intervene appropriately when problems arise.

AWHONN Journals:

• Strategies for Managing GDM in Women with Obesity
• Antenatal Depression and GDM
• Inhaled Insulin: New Delivery for Old Drug
• Nurse Home Visiting Services for Women with Diabetes, Hypertension
• Educational Intervention for Women with GDM
• Diabetes Education and Counseling for Women with Diabetes

Healthy Mom&Baby Resources

• What Is Gestational Diabetes?
• Understanding Gestational Diabetes in Pregnancy
• Eating with Gestational Diabetes
• How to Deal with Gestational Diabetes

References & Resources

American College of Obstetrics and Gynecology. (2005, reaffirmed 2016). ACOG practice bulletin. Clinical management guidelines for obstetrician-gynecologists. Number 60, March 2005. Pregestational diabetes mellitus. Obstetrics and Gynecology, 105(3), 675–685.

Centers for Disease Control and Prevention. (2017). National Diabetes Statistics Report, 2017. Atlanta, GA: Centers for Disease Control and Prevention, US Department of Health and Human Services. Retrieved from http://www.diabetes.org/assets/pdfs/basics/cdc-statistics-report-2017.pdf

American College of Obstetrics and Gynecology. (2013). Practice Bulletin No. 137: Gestational diabetes mellitus. Obstetrics and Gynecology, 122(2 Pt. 1), 406–416. doi:10.1097/01.AOG.0000433006.09219.f1

DeSisto, C. L., Kim, S. Y., & Sharma, A. J. (June 19, 2014). Prevalence estimates of gestational diabetes mellitus in the United States, pregnancy risk assessment monitoring system (PRAMS), 2007–2010. Preventing Chronic Disease, 11. doi:10.5888/pcd11.130415

HAPO Study Cooperative Research Group, Metzger, B. E., Lowe, L. P., Dyer, A. R., Trimble, E. R., Chaovarindr, . . . Sacks, D. A. (2008). Hyperglycemia and adverse pregnancy outcomes. New England Journal of Medicine, 358(19), 1991–2002. doi:10.1056/NEJMoa0707943