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).

When I became pregnant with my first child, I did everything I could to prepare—from research on cribs, bottles, breastfeeding, you name it. Having suffered miscarriages in the past, I was very concerned and anxious about SIDS. I made sure that my daughter’s crib had nothing but the mattress and sheet. I even contemplated buying one of those boards that detects movement and alerts you when a baby stops moving.

Once my daughter was born, she slept in the bassinet in our bedroom. I was still recovering from my cesarean, so my husband was there to help put her in and take her out of her bassinet when it was time to nurse. I was very good about following the safe sleep guidelines, but we would sometimes take naps together while I nursed on my side. I knew in the back of my mind it wasn’t the best option, but we were both able to get rest.

Fast forward 2 years, and my son is born. Again, I was cautious as I prepared for a new baby: I purchased a firm mattress and was sure not to have any toys, bumpers, or blankets in his crib. I told myself I was going to be much better with following safe sleep guidelines than I was with my daughter.

He, too, was born via cesarean, and in the beginning I was very good about not allowing him in bed and always putting him back in his bassinet. When he was about 3 months old, it became harder and harder to follow the guidelines. My son wasn’t sleeping at night, he refused any kind of pacifier (I tried six different brands), and the only thing that soothed him was nursing.

Baby Maxwell in his sleepsuit

Around this time, I returned to my full-time job. I found it easier to nurse him while lying down and returning to sleep. He also seemed to sleep better when he was next to me. I knew it wasn’t right, but I just wanted him to sleep—and I wanted to sleep myself. I tried swaddling, sleep suits, white noise… everything. It’s not supposed to be this hard the second time around, I thought. I’d already been through this; they say the second kid is easier!

When he was about 8 months old, I woke up to a boom and a baby screaming: He had fallen out of the bed, and I felt like the world’s worst mother. Luckily he was ok, but it could have been worse. He could have really gotten injured, or worse, I could have lost him. I knew the rules, I knew that babies were supposed to sleep in their own space, but I ignored them because I wanted my baby to sleep during the night and I was exhausted.

After my son’s fall, I knew something had to change; my son could no longer sleep in my bed at night. I decided to move his crib from our room into another room, and I gave the pacifier another shot. While sleep training hasn’t been successful, he is now taking a pacifier. Instead of bringing him into my bed when he wakes up at night, I offer him his pacifier if it’s before 3 a.m. If he wakes up again, I stay in his room to nurse him and then place him back in his crib. In addition, I had to make the decision to go to sleep earlier to ensure that I got my rest, too.

This got me thinking: What are some ways to help moms follow safe sleep practices after the baby is home? I enlisted the help of nurse Sharon Hitchcock, DNP, RN-C and some fellow moms.

Sharon is an obstetrics nurse and teaches at the University of Arizona. She is quite passionate about the topic of SIDS and safe infant sleep as she now knows why most of these deaths occur and, more importantly, how to prevent them (at least most of them).

She routinely talks about the American Academy of Pediatrics (AAP) safe sleep recommendations to students as well as parents and nurses. She’s also gotten a recent taste of some of the struggles, as she’s the happy grandma of a 9-month-old!

Naomi is mom of 9-month-old Samuel and became a safe sleep advocate long before having her baby. Heidi is almost finished with nursing school and has two kids, 3-month-old Eli and 4-year-old Sophia. Melanie, a mom of three, teaches obstetrics at the University of Arizona and is a childbirth educator at the local hospitals.

I shared with them my struggles of following safe sleep practices with my son and asked several questions about how parents can better follow safe sleep guidelines. Here’s what they had to say:

1. Night feedings can be exhausting, especially when breastfeeding. What are some best practices to help resist the urge to nurse while lying down?  

NAOMI: I resisted the urge to nurse while lying down simply because I didn’t want to bring the baby into bed with me. There were some times when I nursed while sitting up in bed, but I also nursed in a rocking chair in my son’s room, just next to his crib, so I could immediately put him back to bed when he finished eating. I’m a light sleeper and didn’t worry much about falling asleep while feeding him, but I’ve heard it’s a good idea to use a timer, like the one on your phone, if you’re worried about falling asleep.

HEIDI: I was aware of the risks of breastfeeding while lying down from my OB classes in nursing school and had heard the horror stories of parents falling asleep with their infants and accidently suffocating them during their sleep. This was enough to make me take precautions the majority of the time that I was breastfeeding at night. I would feed him in my bed, sitting up, with him in the cross cradle position. I would set alarms just in case I did fall asleep with him, as studies have shown that the longer you are asleep with your infant, the greater the risk of SIDS. If mothers are truly so exhausted that they feel like they need to lie down while nursing, they should remove all pillows and blankets from around the baby and set alarms that will wake them should they fall asleep

2. What are some ways to keep baby warm at night without using blankets?

NAOMI: Our son was born at the end of November, just when it really started to cool down here in southern Arizona. We kept the room warm and comfortable, and he wore footed pajamas.

HEIDI: For both of my children, I used sleep sacks that are available to buy online or in any baby store. They have worked well for me both times. I made sure the house was kept warm enough that they would be comfortable throughout the night.

MELANIE: It is recommended to keep the bedroom at a temperature that is comfortable for a lightly clothed adult. Overheating a baby is very dangerous, as they cannot just push the covers off.

3. The risk of SIDS goes down once a baby turns 6 months—is it okay to bed-share then?

HEIDI: No. The baby can still roll over and suffocate on the softer mattress, pillows, and thick blankets that we have. In addition to the suffocation risks, I believe that getting the baby into a routine of sleeping in their parents’ bed will be one that is hard to break. Neither of my children have been able to sleep in my bed with me, mostly due to my concern for their safety. I am a hard sleeper and would not wake up if I rolled onto them. I also always wanted them to be able to sleep in their own rooms, once old enough.

MELANIE: It is true that most SIDS deaths occur before 6 months, but the infant is still at risk for SIDS until 12 months of age, and adult beds are not designed for infants. Most babies are rolling over by 6 months, and adult beds are usually too soft and have too many blankets and pillows. The other risks include the parents rolling onto the infant or the infant falling out of the bed.

4. My baby has reflux and spits up during the night. Can I place a wedge or pillow in his crib?

HEIDI: No. This is another thing that infants could suffocate on if they rolled over. My son spits up a lot, too, but thankfully I knew from my OB class that it was safer for him to be on his back when he sleeps than on his stomach or wedged if he spits up. A baby is less likely to choke when on their back if they spit up because their airway sits above their esophagus (the tube going to their stomach), making it easier for the fluid to stay away from the airway and easier to swallow.

MELANIE: The AAP recommends that infants are always placed on their backs and not on their sides. Infants are quite good at protecting their airways while on their backs (unless they have a swallowing impairment, which your doctor would tell you). The U.S. FDA has stated that infant sleep positioners are not recommended as there have been several cases of infant deaths from the use of side positioners after the baby rolled to the stomach position or when their face got wedged into the positioner. Keeping the infant upright on a parent’s shoulder for 20–30 minutes after a feeding can decrease reflux.

SHARON: Some parents may think it’s a good idea to elevate the head of the crib to help with the reflux. However, multiple studies have shown this does not help and actually puts the baby at risk for sliding down to the foot of the bed and getting into an unsafe sleeping position.

5. If I nurse while lying down, should I remove everything from my bed in case we fall asleep?  

NAOMI: This is what the newest recommendations advise you to do. Make sure all the blankets, pillows, etc., are moved out of the way, so that in the event you fall asleep, the bed will be a little bit safer.

HEIDI: Absolutely. This is the safest practice if you must nurse while lying down. This is what I did. I also asked my husband to adjust his pillow, and if possible, stay awake with me to ensure that I didn’t fall asleep with the baby. We aren’t perfect, though, and there were a couple of times where we dozed off with him, but fortunately I had alarms set to wake me within 15 minutes of beginning nursing. Once I knew he was full and had a clean diaper on, I set him back down in his crib and went to sleep.

6. Sometimes the baby falls asleep on my chest. It’s recommended that babies sleep on their backs, but since he’s on my chest is it okay?

HEIDI: I believe so, as long as you are rested enough that there is no risk of you falling asleep and you are able to monitor the baby while he is asleep on his tummy. I did this a lot with both of my children during the day and think it is the perfect opportunity for skin-to-skin time.

SHARON: Make sure you can see your baby’s face (to make sure it is not covered or does not become wedged into your breasts) and you are awake and attentive to him.

7. The only way to get my baby to sleep is if I nurse him; when I go to transfer him into his own bed, he wakes up and cries. Is it okay to let him cry it out?

NAOMI: This is a hard topic. There are so many opinions out there, and it’s hard not to get discouraged by all the articles in my Facebook newsfeed that highlight how awful it is to let your baby “cry it out.” It became important for me to consider our circumstances and the fact that every baby is different. I didn’t use the formal “cry-it-out” method for sleep training, but there were, and still are, so many times when I have to let my son cry for a while before he’ll give in and go to sleep. He’s fed. His diaper is clean. He has burped. He’s still crying. He’s not comforted by me holding him close. I’m starting to go a little crazy, and my left ear is ringing from his screams. I know he’s exhausted. What he needs is sleep. It’s okay to place him in his crib and walk away. It’s OKAY to let him cry. I had to learn this early on. It’s made a huge difference.

MELANIE: Crying is a baby’s language and the only way they have to communicate. They cry because they are hungry, tired, uncomfortable, and sometimes just because they are fussy and need to get rid of excess energy. If they have burped and their diaper is clean, you can try to console them with rhythmic noise, music, or gently stroking their head. If the baby is tired, they will usually fall asleep quickly.

Safe sleep is harder than it appears, at least for some of the recommendations. This is an extraordinarily complex topic, and we know it’s hard. In order to keep your baby  as safe as possible, learn  the recommendations, start them at birth, do the best you can, and know that you are not alone in your struggle.

Do you have safe sleep tips/advice you want to share with parents? Share them at www.awhonn.org/SafeSleepTips

Resources

• American Academy of Pediatrics Safe Sleep Recommendations – 2016
• American Academy of Pediatrics Safe Sleep Website
• Healthy Mom&Baby article: What’s New with Infant Safe Sleep
• More health4mom.org resources on safe sleep

References

American Academy of Pediatrics. (2016). SIDS and other sleep-related infant deaths: Updated 2016 recommendations for a safe infant sleeping environment. Pediatrics, 138(5), 1–12. doi:10.1542/peds.2016-2938

Centers for Disease Control and Prevention. (2017). Sudden unexpected infant death and sudden infant death syndrome. Retrieved from https://www.cdc.gov/sids/data.htm

Gradisar, M., Jackson, K., Spurrier, N. J., Gibson, J., Whitman, J., Williams, A. S., . . . Kennaway, D. J. (2016). Behavioral interventions for infant sleep problems: A randomized controlled trial. Pediatrics, 137(6), 1–10. doi:10.1542/peds.2015-1486

Hitchcock, S. C. (2017). An update on safe infant sleep. Nursing for Women’s Health, 21(4), 307–311. doi:10.1016/j.nwh.2017.06.007

Moon, R. Y., & Task Force on Sudden Infant Death Syndrome (2016). SIDS and other sleep-related infant deaths: Evidence base for 2016 updated recommendations for a safe infant sleep environment. Pediatrics, 138(5), e1–e29. doi.org:10.1542/peds.2016-2940

Storrs, C. (2016). It’s OK to let your baby cry himself to sleep, study finds. Retrieved from http://www.cnn.com/2016/05/24/health/cry-it-out-sleep-training-ok/index.html

Courtney Duggan is a digital marketing manager in the Washington, D.C. area and is a mother of 2.

Prenatal exposure to alcohol can lead to a range of physical, mental, behavioral, learning, and developmental disabilities, with possible lifelong effects for the child exposed in utero. This range is commonly known as fetal alcohol spectrum disorder or FASD. FASDs are 100% preventable when a baby is not  exposed to alcohol during pregnancy.

Healthcare professionals may tell women that it’s OK to drink alcohol on occasion or even in moderation, when they are pregnant. However, evidence shows that there is no known safe type, safe amount, or safe time to consume alcohol while pregnant.

Additionally, it’s important for healthcare professionals to broach the subject of alcohol consumption, not only with their pregnant patients, but with all women of reproductive age. Women who are sexually active and not using effective contraception may be at an increased risk for alcohol exposed pregnancies, as nearly half of all pregnancies within the United States are unplanned.

It is critical that healthcare professionals educate all women of reproductive age about alcohol use and pregnancy. Alcohol screening and brief intervention (alcohol SBI) is one evidence-based approach to assessing patients for at-risk alcohol use. Screening includes use of a validated tool, such as the Alcohol Use Disorders Identification Test (AUDIT). The AUDIT is a clinically reliable and valid instrument (Bohn, Babor & Kranzler, 1995). The AUDIT has been consistently found to screen and detect alcohol use across a spectrum of low, moderate, and high risk consumption (Reinert & Allen, 2007).  The AUDIT has been found to be valid and reliable with diverse populations and in a variety of settings.

When a patient screens positive for at-risk use, a non-judgmental discussion, called a “brief intervention” occurs with the use of motivational interviewing techniques. For example, the patient is provided with the score on the AUDIT during the health care visit. If a patient scores between an 8 and 15, this score is discussed in relation to their current health condition and presented objectively to the patient as moderate alcohol consumption. If the AUDIT score is between 16 and 19, then brief counseling and continued monitoring are suggested. With a score of 20+ a referral for further assessment is indicated (Babor & Higgins-Biddle, 2001). The main goals of the brief intervention are to increase a patient’s awareness of their alcohol consumption patterns, understand the associated risks and options for reducing or eliminating those risks, and to increase their motivation to make healthy choices.

As nurses, it is our obligation to ensure that women are provided with the knowledge needed to make informed choices regarding their health. For example, giving the patient objective feedback about their score on the AUIDT and then asking them “What are your thoughts about this score?” is a way to elicit their thoughts and feelings about their alcohol consumption in relation to their health and wellness. Further, exploring the pros and cons of the patients current level of alcohol consumption is an excellent technique to elicit the patients thoughts and provides an opportunity for the health professional to provide feedback and health education.  Patients have high trust in confiding to their healthcare provider and in particular nurses.

Additional Resources

• AWHONN’s FASD Resources
• AUDIT Website

Dr. Ann M. Mitchell is professor of nursing and psychiatry at the University of Pittsburgh School of Nursing. She is principal investigator on a CDC-funded project for the implementation of alcohol screening and brief intervention with the ultimate goal of preventing FASDs.

Dr. Holly Hagle is Director of Education for the Institute for Research, Education and Training in Addiction (IRETA) and a partner in the CDC-funded FASD project.

Brayden Kameg is a graduate student in the psychiatric-mental health nurse practitioner DNP program at the University Of Pittsburgh School Of Nursing. She is actively participating in grant-related activities on Dr. Mitchell’s projects.

When a mother is unable to provide enough milk for her own infant’s needs, then donor milk is the next best option. There are basically two business models for human donor milk bank operations; not-for-profit and for-profit. Both models provide safe, processed donor milk for infant consumption. One of the differences lies in the human species-specific properties retained post-processing procedures. The Human Milk Banking Association of North America (HMBANA) is a professional association that supports non profit milk banks by  providing its members with standardized guidelines to screen donors, and process and distribute human milk.⁶ The for-profit milk banks utilize different, but safe, milk processing procedures, yet the end milk product produced by each contains significantly different human bioactive milk immune and metabolic components. HMBANA milk banks utilize holder pasteurization (milk is heated to 62.5°C for 30 minutes then rapidly cooled to 4°C) whereas for-profit milk banks utilize high vat pasteurization (milk is heated to 63°C ≥ 30 minutes), and  sterilization (milk is heated to 121°C for 5 minutes at 15 pounds per square inch). This sterilization process renders significantly less human species concentrations of protein, fat, immune components, and oligosaccharides.⁷ Donor mothers will benefit from knowing  this information to make informed decisions about where to donate their milk.

Another social and commercial pressure is the monetary compensation for donating milk . Donor mothers should know the differences in processing fees between non-profit and for-profit milk banks. A mission of HMBANA milk banks is to contain processing costs so that donor milk can be equitably distributed. One mechanism to contain costs is to not offer monetary compensation for milk donations.  For-profit milk banks offer monetary compensation which is then passed on to the consumer resulting in higher prices for donor milk. Guiding principles to determine whether or not a donor of a biological product can be offered compensation is outlined in an international statement developed by the convention of the Council of Europe   ; only those products created using patents can be distributed for commercial profit.⁸ This guidance protects for-profit milk banking companies. Donor mothers have the right to know how their milk will be processed and sold.

Lastly, for-profit milk banking companies have abundant resources to promote their product using sophisticated, provocative ad campaigns. Donor mothers have the right to receive informed healthcare data regarding the value of donor milk that retains 50-90% of human milk properties post-processing-the milk provided by non-profit human milk banks- which benefits  optimal infant growth and development.

HMBANA mentors those who are developing milk banks in areas where improvement in breastfeeding support is needed. To learn more about how to become a HMBANA- developing milk bank  visit www.hmbana.org . The Mothers’ Milk Bank of Louisiana, a developing milk bank member of HMBANA, would like to express sincere gratitude for the guidance of our mentor bank, the Mothers’ Milk Bank at Austin under the leadership of Kim Updegrove, Executive Director, as well as HMBANA guidance documents. August is National Breastfeeding Month. Let’s join together to honor all donor mothers for their lifesaving donation of miracle milk and pledge to inform and enlighten them of the invaluable impact of their milk donation decisions.

References

1.            American Academy of Pediatrics Committee on Nutrition SoB, Committee on Fetus and Newborn. Donor Human Milk for the High-Risk Infant: Preparation, Safety, and Usage Options in the United States. Pediatrics. 2017;139(1):e20163440.

2.            Medicine AoB. ABM Position on Breastfeeding – Revised 2015. Breastfeeding Medicine. 2015;10(9):407-411.

3.            Agarwal S, Karmaus, W., Davis, S., & Gangur, V. Immune markers in breast milk and fetal and maternal body fluids: A systematic review of perinatal concentrations. Journal of Human Lactation. 2011;27(2):171-186.

4.            UNICEF. #breatfeeding- Breastfeeding A Smart Investment. 2017; https://www.unicef.org/breastfeeding/. Accessed August 5, 2017, 2017.

5.            Labbock ML, Clark, D. & Goldman, A. Breastfeeding: maintaning and irreplaceable immunological resource. Nature Reviews Immunology. 2004;4(7):565-572.

6.            Human Milk Banking Association of North America. Guidelines for the establishment and operation of a donor milk bank. Forth Worth, Texas: Human Milk Banking Association of North America; 2016.

7.            Meredith-Dennis L, Xu, G., Goonatilleke, E., Lebrilla, C., Underwood, M. . Composition and variation of macronutrients, immune proteins, and human milk oligosaccharides in human milk from nonprofit and commercial milk banks. Journal of Human Lactation. 2017.

8.            Council of Europe. Convention for the Protection of Human Rights and Dignity of the Human Being with Regard to the Application of Biology and Medicine: Convention on Human Rights and Biomedicine. Treaty No.164. 1997; http://conventions.coe.int/Treaty/en/Treaties/html/164.htm. Accessed July 27th, 2017.

Shelley Thibeau, PhD, RNC, is the Director of the developing Mothers’ Milk Bank of Louisiana. As a NICU nurse for 38 years, her interest in breastmilk has expanded to exploring breastmilk immunology associated with preterm infant health.

According to the U.S. Department of Health, one in four girls and one in five boys will be sexually abused before they turn 18. One in five women and one in 71 men will be raped at some point in their lives. This is in many ways a silent epidemic. Sometimes victims don’t disclose their abuse to their care providers. The reasons vary, and can range from  ongoing suffering of the traumatic effects of the abuse and  avoiding  reliving it, to a continuing sense of shame that victims  may have never come to grips with.

What are some possible signs of sexual abuse?

According to When Survivors Give Birth: Understanding and Healing the Effects of Early Sexual Abuse on Childbearing Women, having a constellation of these symptoms can indicate a history of abuse. Having one or more of the following should trigger a red flag and considerations for a woman’s  care during childbirth:

• Not able to feel fetal movement. Some women have “numbed” that part of the body
• Hyperemesis gravidarum
• Chronic pelvic pain
• Missed prenatal appointments
• Panic with vaginal exams
• Extreme anxiety with IV starts
• Disassociation that manifests as if she’s going into a trance

Many of these symptoms can understandably occur in women who don’t have a history of sexual abuse, but when a woman has two or more, it’s reasonable to suspect that such a history is possible. These symptoms can stem from PTSD, which is triggered by a woman’s perception of loss-of-control, as well as the physical sensations that occur during pelvic exams, labor, and birth. By rushing through procedures, and not allowing the woman time to process (if possible), understand, and consent to what is happening to her body, we can inadvertently trigger a posttraumatic reaction.

Admittedly, the discussion of sexual abuse is a tough topic for those on either end of the conversation. We often just touch on the subject while reviewing women’s admission histories, and then move on. Fortunately, we don’t need the admission of abuse to employ strategies developed for survivors. It’s actually much more common for caregivers to pick up on non-verbal cues and then tailor their care. A real tragedy is the guilt and shame survivors can feel after giving birth. So, like we would do for any woman,  it’s best to acknowledge the struggle of labor and birth, the strength a woman demonstrated, and the effort and precious reward she  achieved.

What are interventions that nurses and other caregivers can provide?

• Explain as much as you can in advance, for example “If we run into an emergent situation there might be unfamiliar nurses coming in to help. I know this can cause anxiety, but I want to prepare you ahead of time in case it happens.”
• Always start with asking permission. From starting an IV to turning on the overhead lights, make sure to obtain permission before doing any procedures or making changes to the environment
• Go slowly with everything you do–this can be helpful in relation to a woman’s  fear of losing control. Fast movements can be triggers. This is especially important when uncovering a woman or assisting her with positioning.
• Limit vaginal exams. These are especially traumatic and should be minimized. If a woman is having difficulty in relaxing enough to complete an exam, try making an agreement about when and why you can perform one. If a woman understands that the exams are being performed only when necessary, and with her consent, her anxiety is often more controllable during exams.
• Minimize people in her room. She might have issues with nursing students or residents, especially if they are male. Obtain her permission before any new staff come into the room, unless there’s an emergent situation.

What are things not to say?

• Intrusive interest-prying for details or descriptions of the abuse
• Minimizing the abuse: “Well, that’s over now.”
• Exaggerated concern
• Shock or disgust
• Pity

What are good things to say?

• “I can imagine that was very hard to share that with me. It takes a lot of courage to talk about and I respect you for doing that.”
• “Sometimes talking about these episodes can trigger strong feelings. How are you feeling right now?”
• And, it’s always essential to assess the woman’s current well-being “Do you feel unsafe in any aspect of your life?”

Not all survivors of sexual abuse have difficulty with pregnancy or childbirth, for some it can be empowering. For those who do struggle, recognize that we have a powerful opportunity to help them. We can communicate therapeutically to help  change the woman’s focus from feeling out-of-control.  We can employ care practices to avoid the woman feeling re-traumatizatized.  And we can set the stage to promote healing and bonding with the newborn. In many instances it’s our tacit recognition and respectful and supportive care that facilitates healing, more than any words we could utter or medicines we could administer.

Where can I learn more?

• When Survivors Give Birth: Understanding and Healing the Effects of Early Sexual Abuse on Childbearing Women
• Simkin, Penny and Phyllis H. Klaus. Seattle: Classic Day, 2011. Print.

What are resources for my patients?

• National Sexual Abuse Hotline: 1800-656-HOPE
• RAINN: Rape, Abuse, Incest National Network, www.rainn.org

Tasha Poslaniec has been a registered nurse for 17 years. She has been working in obstetrics for over a decade and is currently a Perinatal Quality Review Nurse and Childbirth Educator.

She also writes about nursing and childbirth and has been published in the Huffington Post and the American Journal of Nursing. Pain control in childbirth has long been a topic of study and research for her.

“The history of man for the nine months preceding his birth would probably be far more interesting and contain events of greater moment than for all the three score and ten years that follow it.”

~Samuel Taylor Coleridge

Decreasing the amount of stress that we encounter daily is beneficial to our health.   Stress initiates the body’s ‘emergency response system’ which activates the adrenal glands to secrete cortisol and adrenaline.  Cortisol is important for energy (glucose metabolism), blood pressure regulation, immune function and inflammatory response, but is secreted in higher levels during increased stress.  Heart disease, diabetes, autoimmune disorders, chronic inflammatory disorders, mental health issues, obesity can all in some way be linked to how the chemicals of stress wreak havoc on our bodies.   Statistics paint a grim picture:

• Preterm birth in the U.S. is higher than in other developed countries (Kaiser Family Foundation, 2015).
• Stress is associated with an increased chance of preterm birth (PLos One, 2012)
• High rates of anxiety and depression, according to WHO, the U.S. has one of the highest rate of mental disorders of any other developed country. (U.S. News, 2016)
• High rates of obesity – females affected more than males (World Obesity, 2017)
• Immune and allergy disorders, chronic diseases have increased drastically in the last few decades (overwhelming majority affecting women)(Molecular Metabolism, 2016)

One concern is how these chemicals affect a woman and her growing fetus during pregnancy.  Many pregnant women  are exposed to chronic stress;  examples are the stress of jobs, finances, family responsibilities, the expectation and drive for success, high fat and low nutrient diets, lack of time for physical activity,  lack  of community and family support, intimate partner violence, effects of racism and social marginalization.  Stress chemicals can pass to the developing baby through the placenta.

Watering the Seeds of Peace:

But pregnant women can seek to balance and reduce their stress in order to pass on positive neurological chemicals to their babies.  In particular, mindfulness practices such as yoga and meditation have profound impacts on the human brain and, when practiced in the prenatal period, can also influence the growing brain of the fetus. (PLos One, 2012)These types of practices produce changes in the neural pathways and hormonal centers that support parasympathetic response and as these neural connections are strengthened, sympathetic hypersensitivity is decreased. Mindfulness has the potential to reduce the effect of stress chemicals in the body (Journal of Obstetric, Gynecologic and Neonatal Nursing, 2009) since these chemicals are being sent directly to the fetus, through the placenta.

Mindfulness may also reduce the effects of stress chemicals in the baby.  Research shows increases in gray matter concentration in the left hippocampus, which affects learning, memory, and emotional control.  Infants  born of mothers who practice meditation have been shown to have better self-regulation and more emotional control. (Infant Behavior and Development, 2014)

Practicing mindfulness on a regular basis can also “create change in the brain that support feelings of peace, contentment, self-confidence and joy.  As these connections in the brain are strengthened, states of anxiety, worry and anger are decreased. Consequently, incidence and severity of stress related conditions are decreased and may, at the very least, become easier to manage.  Mindfulness practice has been shown to decrease anxiety, depression, insomnia, hyperactivity, substance abuse and chemical dependency.  It can also increase bonding and connection to others.

Preparation for Birth

In addition to all the above mentioned benefits, mindfulness has the added benefit of decreasing sensation of chronic and acute pain and possible subsequent psychological distress caused by pain.  This effect has been correlated to altered function and structure in somatosensory areas and an increased ability to disengage regions in the brain associated with the cognitive appraisal of pain, basically ‘reframing’ the sensation.  Most childbirth methods are based on meditative techniques (Lamaze and Bradley breathing, Hypnobirthing, etc.)  Mindfulness practices also enhance immune function – extremely important in pregnancy where it is already suppressed.  If there is a complication that is present (obesity, immune disorder, mental illness) or one that is diagnosed during the pregnancy (gestational diabetes, hypertension, multiples) or that happens during birth (prolonged labor, surgical intervention), regular meditative practices can help prime the immune system so that the effects of these events may be milder.

It’s as simple as ‘ABC’

One of the great things about mindfulness is that it can be practiced literally anytime, anywhere.

A is for Awareness:  Simply pause or stop and become AWARE of the present moment. An easy way to do this is just notice the body in space… the arrangement of the legs or arms, the overall tone in the body… the sensations in the body. Use the senses to drive your awareness:  the feel of the coffee cup in your hand, the sound of a bird chirping or the rain on the roof, the warmth of the sun on your skin.

B is for Breathing:  Bring your awareness to your breath.  The breath is always present.  Notice the inhalation and the exhalation.  Just by noticing the breath without changing it in any way, nervous system shifts to parasympathetic activity. You can enhance this shift by guiding the breath to be longer and deeper. Regulating the breath in this way also decreases blood pressure and heart rate.  Imagine your breath bringing oxygen to your growing baby. Imagine your baby listening to your deep rhythmic breaths and the slowing of your heart beat.  Calm, serene.

C is for Consciousness:   Or ‘thinking’. Now you have the space in the nervous system to examine your thoughts. Notice that they come and go like clouds on a windy day.  If there is a particular thought or sensation that is troubling you or seems uncomfortable, you have the ability to CHOOSE your reaction instead of unconsciously reacting with habitual patterns of response.

When we practice in this way, even for a few minutes a day, our nervous system slowly begins to rewire and connections of peace and joy are strengthened.  In the pregnant mom, this benefit is wiring the baby’s brain from the very beginning of development.

Helpful Resources and Links

• Antenatal mindfulness intervention to reduce depression, anxiety and stress
• Fit Pregnancy: 5 Prenatal Meditation Techniques
• Impact of stress and stress physiology during pregnancy on child metabolic function and obesity risk
• Incidence and prevalence of chronic disease
• Mindful Birthing
• Prenatal meditation influences infant behaviors
• Relaxation Response and Resiliency Training and Its Effect on Healthcare Resource Utilization
• The Association for Prenatal and Perinatal Psychology and Health
• The effects of mindfulness-based yoga during pregnancy on maternal psychological and physical distress.
  

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  Holly Lammer is an Obstetric Nurse, Clinical Educator and Childbirth Instructor for St. Luke’s Health System based in Boise, ID.  In addition to teaching credentialed courses through AWHONN and AHA,  she develops and teaches curriculum for prenatal and perinatal specialty courses offered in the St. Luke’s system.  Holly is also registered with the Yoga Alliance as a 500-hr Yoga Instructor and on faculty as a Prenatal Yoga Teacher Training Instructor. She is certified in Inpatient Obstetrics and Electronic Fetal Monitoring through NCC and is in process of obtaining her Pre and Perinatal Psychology Educator through the Association for Pre and Perinatal Psychology and Health.

  Holly has blended her experience in high volume high risk inpatient setting with her training and research in mind-body therapies to form unique educational programs for pregnant women and the providers that care for them, including Intuitive Birth – the area’s only Mindfulness-Based Childbirth Education series. A driving force for patient centered, evidence-based practice, her passion is apparent in her program content and her ability to drive changes at the policy level to improve outcomes for women and babies.

  Holly has spoken regularly at multidisciplinary local and regional conferences on the subjects of physiologic birth, prenatal psychology and health, and mindfulness-based strategies to improve health.  In addition, she provides regular educational opportunities for the public and for inpatients and care providers in her community.

“Your daughter has full-blown fetal alcohol syndrome.”

Those words hit me like a tsunami. I was drowning in waves of grief, disbelief, horror and remorse. For 15 years, I searched to understand why Karli wasn’t learning and growing stronger, like my other two children. Doctors told me ear infections had caused her minor delays, but she would “grow out of it.” Today, Karli is 42 years old; developmentally, she is about 6 years old.

I grew up in the 1960s in an upper middle-class suburban neighborhood. My charismatic father suffered with alcoholism, and my co-dependent mom worked hard to cover his tracks. At 16, I was already experimenting with alcohol and other drugs when I got pregnant, married and dropped out of school. I wanted to have a healthy baby so I gave up all of the drugs and drank apple wine on the weekends.

Effects of Alcohol in Pregnancy
My first child, a boy, was born with a clubbed foot, which the doctor told me was a genetic disorder. I had Karli a year later, when the research describing fetal alcohol syndrome (FAS) was published. A few years later, I gave birth to another daughter and still had never been told not to drink during pregnancy.

I divorced my high school sweetheart and remarried another man who liked to drink. My own issues with alcoholism and addiction spiraled out of control. I had two unplanned pregnancies while on methadone to treat my heroin addiction. No one at the clinic ever mentioned that it wasn’t OK to drink. My second son came prematurely and died the day he was born. After a full-term pregnancy with my third baby girl, I found her breathless in her crib at 10 weeks old: Sudden Infant Death Syndrome (SIDS). I didn’t realize how those years of addiction affected each of my children.

No Safe Amount of Alcohol
Fetal alcohol spectrum disorders (FASDs) are a group of conditions that can occur in a person whose mother drank alcohol during pregnancy. Most people with FASD don’t have intellectual disabilities, but do have attention deficits, behavioral issues, learning disabilities, mental health issues, and problems with memory, judgment and reason. Each person can be affected in different ways and, often, a person with an FASD has a mix of these problems. FAS is the most severe form of FASD.

Alcohol is a leading cause of fetal brain damage, birth defects and both fetal and infant death, including SIDS. While pregnant, there is no safe amount of alcohol, no safe time to drink alcohol, and no safe type of alcohol.

Clean and sober for the last 31 years, I have dedicated my life’s work to increasing awareness and improving services for individuals with FASD and for women dealing with addiction issues. I have a beautiful marriage and 5 wonderful grandchildren. I went on to receive my Master of Human Services (MHS) degree and became a licensed clinical alcohol and drug counselor (LCADC). I know that treatment works, and by encouraging women to get help, we save their children too. Now I am that good mother I always wanted to be.

If you’re struggling or think your child may be affected by FASD, don’t hesitate to reach out to your nurse, midwife or other healthcare provider. There is no shame in asking for help—your child’s life depends on it.

Source: NOFAS.org

Kathleen is vice president of the National Organization on Fetal Alcohol Syndrome (NOFAS).

Resources

• Get Help: Circle of Hope
• Learn More: http://www.health4mom.org/alcohol_in_pregnancy_how_much_is_safe

FASD PREVENTION PROJECT

AWHONN is a national partner on the Fetal Alcohol Spectrum Disorders Prevention Project of the Arc, a non-profit advocacy organization serving people with intellectual and developmental disabilities. The goal of the FASD Prevention Project is to increase health care professional knowledge of the risks alcohol can pose to a fetus, encourage the use of FASD prevention strategies and provide educational opportunities to health care professionals, including nurses, midwives, and nurse practitioners. Learn more about this project and resources you can use. 

My husband and I always wanted a family. The summer before I turned 29, we decided to start trying. Little did we know there would be a roller coaster of a journey ahead.

I got my first positive pregnancy test in September. I knew my life was about to change. I quit smoking, which was a huge deal for me. My husband and I were thrilled. At my first ultrasound, there was silence. The verdict was devastating: I was miscarrying due to a blighted ovum.

My doctor advised me to wait two full cycles before trying to conceive again. I didn’t track anything; I just guessed at when I was going to be ovulating. In February, I got my second positive test. Though nervous, I had a better feeling, thinking the odds were low I would have a second miscarriage.

We picked out names, I looked at birth plans, and at 8 weeks I started building a baby registry. We were cautious to share the news, waiting to tell even our parents. On March 20, one week after announcing our new addition, I went to the restroom and noticed blood. I immediately fell on the floor crying. In that split second, my dreams of our family were crushed.

When they did the ultrasound in the emergency room, they wouldn’t let me see the screen, saying only that they couldn’t detect a heartbeat. I felt like I died inside. My doctor ordered a D&C (dilation and curettage) and told us to wait two cycles.

This time, I took ovulation and trying to conceive (TTC) seriously. I continued taking prenatal vitamins, educated myself, and tracked my ovulation with digital ovulation predictor. The moment I saw the little smiley face letting me know I was ovulating, I told my husband it was go-time! The two-week waiting period after that felt even longer than the two cycles we had to wait to start trying again.

On July 11, I got my big fat positive! I called my husband, and then I called my mom, who was so supportive. I had a form of PTSD after dealing with two miscarriages, and I didn’t want to tell anyone I was pregnant, so as to avoid the embarrassment.

At 6 weeks, I had my first ultrasound. When we saw that tiny little heartbeat, I cried. My doctor put me on progesterone. We had our next ultrasound at 11 weeks, and there was our baby, active and wiggling around. It was amazing! I wasn’t used to seeing my ultrasounds. Every time I saw my baby felt like a miracle. We learned my due date was March 20—the date of my second miscarriage. Everything was coming full circle. Even more exciting, it was a boy!

As badly as I wanted to meet my son, he was even more anxious: At 34 weeks and 4 days, Charles David Poe made his appearance. His birthday is February 9, the same date I had my second positive pregnancy test the year before. Tiny but strong, Charlie came into our lives so fast and has made it indescribably beautiful. It was beyond worth it to have gone through all the turmoil of TTC to get to this amazing part of my life.

Aimee Poe is an experience specialist at Verizon. She loves playing video games, watching movies, hanging out with her family, and flexing her creative muscle with various projects.

1. Newborn screening saves lives.  In the first few days after birth, clinicians screen newborns for over 30 rare but serious diseases, most of which are easy to treat with diet changes or other treatment.  This screening, along with early intervention, can save babies from death or disability. Your baby’s pediatrician works with the state health department to ensure that this screening is done.  Many professional organizations including the Association of Women’s Health, Obstetric and Neonatal Nurses support newborn screening.

2. Newborn screening is simple to do.  There are three things we generally do in the hospital before your baby goes home as part of the newborn screening – a hearing test, congenital heart defect screening (pulse oximetry), and blood sample collection on a special blood spot card. Your baby will probably sleep through the hearing test and the pulse oximetry test; however they may not like the tiny prick on their heel for the blood sample. Ask if you can hold your baby during the blood sample collection so he’s less likely to cry. To learn more about how these tests are done you can watch this video from the March of Dimes.

3. Newborn screening has to get done on time.  We need to get these screening tests done within the first two days of life, and then the results need to be reported to your pediatrician a few days after.  Please give us a working phone number and address in case we need to contact you about the results of these tests after you’ve left the hospital. In some cases, delays can be deadly and hospitals are working hard to speed results to you.

4. Remain calm.  Most screens come back negative, meaning your baby doesn’t have the condition we’re screening for, but a few come back positive and that means that we need to do more testing.  Even if the initial screening test is positive, further follow-up testing may all be negative, or normal.   And if your baby does have the condition, there are treatments.  Listen to this mom’s inspiring story about her son who was saved by newborn screening (“Growing up with Galactosemia”)

5. Everybody’s doing it!  Newborn Screening is part of routine care for all newborns across the U.S. And we’ve been doing it since the 1960’s! It’s also part of routine care in many other countries. Newborn screening is expanding all the time. To check what screening is currently done in your state check the National Newborn Screening State report .  Surveys suggest that most parents are in favor of even more newborn screening.

We want your baby to get off to a good start!  Let’s all work together to make sure your baby’s first tests (newborn screening) get done and that the results get reported to you quickly. Just ask your prenatal provider, pediatrician or nurse if you have any questions – we’re all here to help you make the best healthcare decisions for your baby.

Emily Drake is currently an Associate Professor at the University of Virginia. She focuses her teaching, practice, and research on issues of Maternal-Child Health. She currently serves as a member of the Education and Training subcommittee for the U.S. Department of Health and Human Services’ Advisory Committee on Heritable Disorders in Newborns and Children (ACHDNC).

She is the author of over 20 book chapters and journal publications and has held leadership positions in the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN), Sigma Theta Tau Nursing Honor Society (STTI), and the March of Dimes.

More Information

Baby’s First Test
http://www.babysfirsttest.org

Save Babies Through Screening Foundation
http://www.savebabies.org

Parents guide to Newborn Screening
http://mchb.hrsa.gov/pregnancyandbeyond/newbornscreening/

Wikipedia on Newborn Screening
https://en.m.wikipedia.org/wiki/Newborn_screening

Newborn Screening Technical assistance and Evaluation (NewSTEPs)
https://newsteps.org/

Photo Credit: ChameleonsEye / Shutterstock.com

What you can easily forget in all the excitement is that you take care of yourself too!

To help you focus on YOU, we recently asked our nurses and midwives what postpartum recovery advice they give their patients.

We received advice for you from over 100 nurses!

Take note of the clear themes – limit visitors to take that time to bond with your new baby, accept help from others, do skin-to-skin and sleep when the baby sleeps!

Good luck in all your new parenting adventures!

Top 20 tips from our nurses and midwives:

1. Absolutely choose a hospital for the care you will receive and not the new beautiful building. You’re much more likely to receive a positive birth experience and the education you receive from your postpartum nurses will make all the difference in the world.
2. As a former postpartum nurse, I noticed how often new mothers put their needs last. It seems often families look at postpartum time as party time. I have seen c-section moms sleeping in the same room as 15-20 family members talking loudly and passing baby around for hours. My best advice is for new mothers to have 1-2 designated family helpers to be there to help care for baby while she gets much needed naps throughout those exhausting first days. Baby’s hunger cues are often missed when there are too many visitors for long stretches of time. It is difficult for new mothers to set limits.
3. Don’t be afraid to ask people to leave. I have seen so many new mothers that are worn out from feeling like they cannot turn people away. Turn off your phone too. I wish I did for the first couple of days.
4. Breastfeeding is an acquired skill for you and baby, be prepared to be patient and try, try again. It is a wonderful thing for you both, but needs to be learned. Do not suffer in silence, please contact your OB/midwife for lactation nurse help/referral if you are having difficulty with latching and/or very sore nipples.
5. Sleep when baby sleeps.

6. If you had a cesarean, take a pillow for the car ride home to support your incision for the bumps in the road.
7. Use the Dermoplast (benzocaine topical) spray before having a bowel movement…it’ll make the process a whole lot more comfortable and a lot less scary.
8. If someone offers to come over so you can shower, take them up on it.  For c-section moms remember not only did you have a baby, but you had major surgery.
9. Trust yourself and your instincts. Pick and choose the advice, tips, expert advice etc. that works for you. And know that if you’re worried about being a good mom, you already are.
10. Padsicle! Pad, ice pack, tucks, then a spray of Dermoplast.
11. Know your body. When you get home, use a hand held mirror to look at your perineum or you cesarean section incision. This way, if you experience problems, you will have a baseline to know if something is different, for example: increased swelling, redness, tenderness, or drainage from incision. It is helpful in knowing when to contact your physician with these issues.
12. Limit your visitors. You will not get this time back. Use it to bond as a family, seek help with breastfeeding. Skin to skin is the best bonding tool! We want to help you succeed with breastfeeding. You can press your call light for every feeding if you need to. Your baby needs your love and protection. You are your baby’s primary advocate. Not all mothers’ choose to or are able to breastfeed. How you feed your baby is your decision and your nurse will support you. Ask visitors to wait until you’ve been home for at least a couple weeks. Settle in, recover. Don’t be afraid to ask for help. If someone wants to visit, ask them to leave their little ones at home.
13. Sleep when the baby sleeps. Keep drinking water to flush out the excess fluids and keep hydrated. Accept help from anyone willing to cook a meal, run errands or do housework so you can rest and spend more time enjoying your new baby. Get outside for a walk. Fresh air and activity help to restore and rejuvenate sleep deprived minds and bodies as well as improve the blues!
14. While planning your new routine, ask someone to watch the baby for an hour of each day for you to spend as you please.
15. Good nutrition is key. Have a healthy snack each time you feed baby if you don’t have an appetite. Try to get a good four hour blocks of sleep several times a week. Ask support people to change, burp, comfort baby and only bring baby to you for breast feeding to extend your sleep when tired. Have a good support system and don’t be afraid to ask them for help. Soak up the sun when you can. Have an enjoyable activity to look forward to each week. Try to get out of the house, but if you can’t do something you enjoy at home or pamper yourself. Relax and enjoy your baby. Use what works for you and don’t try to follow everyone else’s advice.
16. Accept offers of help and assistance with meals, cleaning etc. I tell father’s to give moms one uninterrupted hour to herself each day. She can bathe, sleep, read, or anything that she wants for that hour. Daddy needs time to get to know baby too!
17. When you get home, set visiting hours and have each visitor bring groceries or food (they’ll be thrilled to get what you need). And stay in your pajamas. Most people will be less likely to overstay their welcome.
18. Once “settled” in with the baby reach out to a Mother’s group ( stroller club, baby sitting co-op, Mommy and me Gym or Yoga class), to get out of the house and receive and provide support to other new Mom’s.
19. Give yourself a break. Sit at the bottom of the shower and cry if you need to every now and then, parenting is hard work. Learning to breastfeed is hard work and so is incorporating another member into your family. Sleep deprivation and shifting hormones will, in fact, make you feel crazy at times but it will get better. You will find your new norm. It’s not all cute onesies and hair bows, it’s more like poopy onesies and newborn rashes, and that’s ok.
20. You’re stronger than you think! Don’t worry about what others might think. Enjoy every moment.  Parenthood is a beautiful experience. Allow yourself grace & room to grow.

Do you have advice for new moms as well? If so let us know. We’ll keep rolling out the advice.

For additional resources for mom visit our Healthy Mom&Baby website!