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.

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

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.

There are many great reasons why hospitals choose to work toward and achieve Baby-Friendly hospital status. There are also plenty of ways to encourage breastfeeding in line with the World Health Organization’s (WHO) guidelines without having that official Baby-Friendly Hospital designation. In fact, research has shown that implementing Baby Friendly practices such as early breastfeeding after birth, skin-to-skin care , and rooming-in,  in hospitals that do not have this designation, resulted in higher rates of breastfeeding initiation and duration.

Whether or not you’re pursuing Baby-Friendly status, your hospital can effectively support and promote breastfeeding among staff, mothers, and their families. Here are just 5 of many ways to go about it:

1. Start educating women about breastfeeding early.

Setting expectations and goals early in the care process that a mother will achieve desired health objectives. This is true of breastfeeding, as well.

• Educating mothers about the benefits of breastfeeding is most successful when it starts during pregnancy. Indeed, Step 3 of WHO’s 10 Steps to Successful Breastfeeding—the key criteria for formal Baby-Friendly hospital status—requires that hospitals “inform all pregnant women about the benefits and management of breastfeeding.”
• Educating parents proactively, rather than waiting for them to request information, ensures they have the education they need when they need it.
• Educating parents electronically means the information can be shared in small, consistent pieces that don’t feel overwhelming. It’s also a time savings for staff and providers who would otherwise need to use medical appointments for breastfeeding education.

2. Incorporate breastfeeding education into your ongoing staff training.

Keeping your staff updated on supportive breastfeeding practices doesn’t have to be time-consuming or require organized training classes. Consider providing electronic breastfeeding education for staff to access anywhere and at their own convenience. Choose a solution that lets you track their progress, so you know when they’ve read the required information.

3. Stay in touch with women and their families about breastfeeding support opportunities, even after they’ve returned home.

In the U.S., 74% of babies have breastfed at least once, but only 23% are still breastfeeding by 1 year of age, according to the CDC’s Breastfeeding Report Card. Once new mothers are discharged, a strong connection with your hospital can encourage them to take advantage of available support, overcome challenges and stick with breastfeeding.

When following up with women who’ve recently had babies invite them to schedule a session with a lactation consultant or attend a  breastfeeding support group at your hospital. These opportunities not only provide additional revenue sources,  but also nurture relationships with women and their families, who will be more likely to return to your hospital in the future—whether for obstetric or other medical care.

4. Ask new moms for feedback about your hospital’s breastfeeding support practices.

Breastfeeding is an emotional topic for new mothers. With patient experience and satisfaction so important to a hospital’s bottom line these days, you want to know where you stand in patients’ minds.

Surveys are a great way to measure patient satisfaction with your breastfeeding education practice and policy. Send a quick survey by email or text message, asking new moms specifically about how your breastfeeding support has helped them and where you can improve.

5. Collect data on how many women who had their babies at your hospital continue breastfeeding.

Healthy People 2020, the population health measures created by the federal Office of Disease Prevention and Health Promotion, set goals for how many infants are breastfed by the year 2020, including 34% of infants breastfeed at 1 year and 26% breastfed exclusively through 6 months.

If you want to work toward or even surpass this goal, you need to measure how your patients are doing after they leave the hospital. Providing patients education in a digital format, i.e. on their mobile device, combined with data collection technology can help you gain insight.

Baby-Friendly status remains the gold standard for many hospitals encouraging breastfeeding. But if your facility has limited resources, these 5 strategies can help your hospital successfully support and encourage breastfeeding.

For additional information on becoming a Baby-Friendly hospital, visit www.babyfriendlyusa.org

AWHONN Resources

• Breastfeeding Support
• Perinatal Nursing
• Breastfeeding Rates Improve with Support and Education for Mothers
• Increasing Initiation and Exclusivity of Breastfeeding in the Hospitalized, Postpartum Dyad (JOGNN)

Deirdre Wilson, Senior Editor for UbiCare, is an award-winning writer and editor with 30 years’ experience researching and writing on a wide range of health, wellness and education topics for newspapers, magazines and a news wire service.

I could feel the excitement in the room as I entered. The couple was receptive to my questions and suggestions; and the woman was more than happy to involve me in her care.  I tried to build rapport even though I was nervous in my role as a nursing student. This was the first time I had assisted a woman in labor and, after her membranes were artificially ruptured, her contractions started to come about two minutes apart.  At one point, I had my hand on her back and her husband smiled at me across the room and signaled for to me to remove my hand!  It was a great moment in which the support person and I connected!  I remained quiet during her contractions and I asked her if she wanted me to breathe with her but she said she had it under control. I kept thinking back to my own labors and what I felt I wanted from support people so I asked her if she would like lower back counter pressure but she refused.  The family had not done a childbirth preparation course so I assumed that their interest or skills with working through labor was limited.  I thought that they would need my help more yet her prenatal yoga practice seemed to have given her the tools she needed to get through her labor. The tools I offered her personally were meditative.  I told her to focus on her favorite place, to discuss her needs and frustrations with us in between contractions and reassured her that I was there for her to breathe with her and regulate her breathing as needed.

Reflecting on the Nursing Care Women and Babies Deserve virtues I used during this experience, I believe they were humility and engagement. Humility in that I had to understand I did not know what was best for this family. I assumed they would want and need what I needed during childbirth or skills I learned from the comfort measures video I used to prepare for this clinical experience. The woman decided what she needed and I was there to support her. In respecting their wishes I could engage with the family. Before I left them for the day they commented, “We felt like we had our own doula”.  It was easy and a pleasure to engage with this couple and follow their commands and offer suggestions. I told them I had never wanted to stay at clinical so much as I did with them. I will always remember this family.

Additional Resources

AWHONN’s Nursing Care and Women Babies Deserve Poster –  AWHONN’s statement on ethical nursing practice, Nursing Care Women and Babies Deserve, is rooted in the American Nurses Association’s Code of Ethics for Nurses, and provides nurses with core elements of ethical nursing practice for our specialty and corresponding examples of the virtues of ethical practice in action.

Read a commentary about Nursing Care Women and Babies Deserve in AWHONN’s journal Nursing for Women’s Health. Consider submitting your own story of how you or your colleagues practice nursing care that women and babies deserve at https://www.awhonn.org/?NursingCare

Amy is an ABSN student at MGH Institute of Health Professions, Boston.  She was a stay at home mother for 12 years,  a community coordinator for a non profit kids running program and a volunteer at Dana Farber Cancer Institute in Boston before deciding to enter the nursing field.  With extensive volunteer experience from a camp for blind & visually impaired adults and children, to co-president of an elementary school PTO, she enjoys working with diverse groups of all ages.  Amy aims to work in labor and delivery after graduation in August 2017 but is also interested in global health and epidemiology.  She has intentions to keep making a difference in the lives of those she may never meet again.

“We may have different religions, different languages, different colored skin, but we all belong to one human race”. –Kofi Annan (Ghanian Diplomat, 7th UN Secretary-General, 2001 Nobel Peace Prize winner)

What is exactly childbirth? Some people compare it to a miracle, a heroic act, or a surge of love accompanied by strenuous and intense hours of labor. It’s absolutely one the most unique experiences that can happen to a woman’s body. The time when she is particularly vulnerable and in need of much support and care.

For me, a nurse practitioner student on labor and delivery floor at Massachusetts General Hospital, witnessing childbirth was something that I would never forget. Thrown into the action on a first clinical day, I had mixed feelings of joy, excitement and a slight nervousness. I felt extremely privileged and grateful to witness a natural delivery and I was hoping to help a future-to-be mom during the process.

From the morning report I found out that the woman I was assigned to follow was a recent immigrant from Guatemala who belongs to the indigenous Mayan population. Mayan was the patient’s native language but she was also able to understand Spanish. Her husband had been residing in the United States for 5 years. She moved here a year ago and the family has finally reunited.

My patient was accompanied by a traditional nurse midwife known as comadrona. Comadronas are trusted women leaders in their communities who accepted a spiritual calling. They usually don’t receive any formal training but have years of experience delivering babies. Comadronas regard birth as a natural process and rely heavily on God and prayers. The nurses established a plan of care recognizing my patient’s spirituality and personal support system. The Mayan midwife was present during labor and helped with comfort measures. The nurses also invited a qualified interpreter.

When I entered the room, a nurse and a midwife, along with the comadrona, surrounded the tiny woman. One of the nurses was checking her vital signs and the nurse-midwife was encouraging the woman to take slow deep breaths and relax. The comadrona, wearing a traditional colorful embroidered dress, was gently massaging her back. The room was dimly lit and the scent of fresh lavender floated in the air. My patient’s contractions were increasing steadily and were becoming more regular. This was active labor –she was ready to give birth.

The whole atmosphere struck me. There was no other language present in the room but the language of trust, respect and compassion between these women. I immediately wanted to become connected with what was happening- just by holding this woman’s hand and talking to her.

Reflecting back on this experience, I understood that nurses not only created the environment that made this woman feel comfortable and that was respectful of her spirituality but that the environment also had a significant impact on the labor and birth process. Although childbirth is unique and at the same time a unifying biological event for any woman; providing therapeutic communication, physical, emotional, spiritual care and comfort during the labor process is crucial.

The comadrona shared her knowledge and experience with the American nurses. It was important for my patient to have a traditional midwife near the bedside who comforted and prayed with her. There was interplay between modern and traditional medicine that contributed to the positive outcome. Nurses in this particular case were not only culturally sensitive and able to understand cultural values, beliefs and attitudes of clinicians and patients, but also culturally competent and had knowledge, capacity and skills to provide high-quality care (Jernigan et al, 2016).

It’s essential for any nurse in such a unique, heterogeneous country like the United States to be cognizant and open-minded of cultural diversity and the patient’s cultural perspectives. I will take this amazing experience to my future nursing practice and strive to always treat my patients with dignity, respect and compassion. I also hope to continue to integrate a holistic model and culturally sensitive care into our modern childbirth practices.

This woman gave birth to a beautiful baby daughter whom she named after a nurse taking care of her during her labor and birth.

Additional Resources & References
http://prontointernational.org/
https://he-he.org/en/
http://www.mayamidwifery.org/
http://midwivesformidwives.org/guatemala/
http://www.birth-institute.com/study-abroad-guatemala/
http://www.acog.org/
Jernigan, V. B. B., Hearod, J. B., Tran, K., Norris, K. C., & Buchwald, D. (2016). An Examination of Cultural Competence Training in US Medical Education Guided by the Tool for Assessing Cultural Competence Training.Journal of Health Disparities Research and Practice, 9(3), 150–167.

Evgeniya Larionova received her Bachelors of Science in Nursing from MGH Institute of Health Professions. She is a founder and an Artistic Director of AMGITS Drama&Poetry Club at the Boston Living Center. She is a member of the student Leadership Committee of the Harvard Medical School Center for Primary Care. Evgeniya is passionate about infectious diseases, community health and integrating holistic care in modern practices.  In her spare time she plays in the Russian theater, enjoy reading, playing the guitar and hiking.

Intimate partner violence (IPV) has devastating effects on a pregnant woman and her unborn child.

Intimate partner violence may be more severe and more frequent during pregnancy which poses health risks to the mother and her baby. The effects on a woman’s health due to IPV during pregnancy may extend long after the pregnancy and post-partum period. One in four women are victims of IPV and 324,000 pregnant women experience IPV each year and 1600 maternal deaths each year are the result of intimate partner violence.

This blog post is part of our IPV series and covers the effects on mother-infant bonding, maternal and fetal outcomes, and our role as nurses.

The last in our blog series coming out in winter 2015 will cover screening details for nurses.

Mother-Infant Bonding

The mother-infant bond is the first social tie an infant will experience. This bond is essential as failure for a mother and infant to bond may have long term effects on the infant and affect child functioning making it more difficult to form meaningful relationships.

The moments and days following birth are necessary to establish a positive bond. Women who are abused during pregnancy may be emotionally and physically unavailable to their infants and unable to take advantage of the first moments after birth which may jeopardize initiating bonding with their infant.

“I was supposed to enjoy her infancy and I had to worry about abuse. I took no pictures. I did not capture the experience of being a mother”

After birth a mother is drawn to her infant and when she begins to respond to the infant’s behaviors, at that moment a reciprocal relationship has begun.

“I don’t feel connected to my baby”

Infant behaviors such as crying, eye contact, and facial expressions are strong social elicitors of the mother’s response and facilitate the mother’s emotional connection.  These infant behaviors encourage the mother to hold, rock, kiss and gaze at her infant while keeping the infant at close proximity.

The reciprocal relationship between the mother and her infant is necessary for the establishment of the mother-infant bond. Many abused women cannot or do not experience these necessary connections.

“I had to remind myself every day to tell my baby I love him, I did this because I know babies need to hear that”

“When I look at my baby I see him (the abuser)”

“I felt insecure with my baby, more fear”

“[The abuse] kept us distant, but not really, I loved him but was distraught over life.”

” I still feel guilty”

“I resent my baby”

Maternal and Fetal Outcomes of Women Abused During Pregnancy

Pregnant women typically have between twelve to thirteen prenatal visits with 96% of women receiving prenatal care (CDC). It is not uncommon for abused women to have a late entry into prenatal care[2] which may compound the health risk to both mother and fetus.

Physical violence during pregnancy has been associated with increased maternal risk of:

• antepartum hemorrhage
• intrauterine growth restriction
• prenatal death
• depression and PTSD in the postpartum period

Poor fetal outcomes have been associated with increase risk of:

• low birth weight
• preterm births
• stillbirths

Our Role as Nurses

As nurses and midwives we are often the main and most trusted contact our pregnant women have during and after their pregnancy.

We must ask ourselves how we can intervene early and offer supportive care that will enhance the bonding experience between the mother and her infant especially if she has experience IPV during her pregnancy.

The nurse’s role is three-fold:

1. Assess: create a safe environment that allows for assessment and screening for partner abuse in private setting; use a validated IPV assessment tool that ask questions targeting abuse, safety, and especially abuse during pregnancy.
2. Refer: be knowledgeable of community resources and make referrals to community agencies that support women who are experiencing IPV.

3. Treat: be prepared to treat the physical or psychological consequences of IPV.

Intervening in these ways offers opportunities for the new mother to receive support and services she needs while attending to her immediate physical and psychological needs.

Maternity nurses must be mindful that some routine assessments and exams during labor may be threatening to a woman who has been abused. The routine procedure of vaginal exams may trigger negative experiences causing anxiety which can affect labor progression.

Explaining and talking through the assessment or exam allows a woman to be apart of her care and shows sensitivity towards her past experiences. This approach  may decrease a woman’s fear. Epidurals can also trigger memories of past negative experiences especially for women who have been raped or approached from behind and sexually assaulted. With a disclosure of abuse and a better understanding of IPV and its affects on pregnancy, labor, and birth nurses are better prepared to offer care that meets the woman’s needs and allows the woman to maintain control over her own birth experience. This may be the moment she feels empowered to take on the role of motherhood.

Nothing is more satisfying than watching the first moments when the mother and her newborn meet face-to-face for the first time. Maternity nurses get to experience this moment everyday. Maternity nurses are in an ideal position to advocate for abused women and their infants so all new mothers can begin motherhood with a positive bonding experience.

Ann Bianchi, PhD, RN
Ann L. Bianchi is an Associate Professor, College of Nursing , The University of Alabama in Huntsville, Huntsville Alabama.

Additional Information

This year AWHONN released a position statement titled: Intimate Partner Violence and recommended women should be universally screened in a safe and private setting. This position statement also supports refining existing screening tools, regular IPV training and competency validation, and enhancing documentation of IPV screening.

Helpful resources on intimate partner violence

• The National Domestic Violence Hotline
  1-800-799-7233
  http://www.thehotline.org/
• National Resource Center on Domestic Violence
• Types of Violence against Women from the Office on Women’s Health at the U.S. Department of Health and Human Services
• Centers for Disease Control and Prevention’s Intimate Partner Violence: Definitions
• Futures Without Violence
• Break the Cycle (Empowering Youth to End Domestic Violence)

AWHONN’s Position

The Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) opposes laws and other policies that require nurses to report the results of screening for intimate partner violence (IPV) to law enforcement or other regulatory agencies without the consent of the woman who experiences the IPV. Nurses and other health care professionals, however, should become familiar with laws on mandatory reporting in their states and comply as applicable.

Women should be universally screened for IPV in private, safe settings where health care is provided. Nurses are ideally positioned to screen for IPV for the purpose of initiating a referral for services and support when applicable. To protect the woman’s safety, AWHONN supports policies that require a woman’s consent before reporting occurs.

Read our Position Statement on IPV.

References

Center for Disease Control. Intimate partner violence during pregnancy: A guide for clinicians. 2006. Available at:  http://www.cdc.gov/reproductivehealth/violence/intimatepartnerviolence/sld001.htm#2 Retrieved June 4, 2015 .

Figueiredo, B., Costa, R., Pacheco, A., & Pais, A. (2009). Mother-to-infant emotional involvement at birth. Journal of Maternal Child Health Nursing,13, 539-549.

Flach, C., Leese, M., Heron, J., Evans, J., Feder, G., Sharp, D., & Howard, L.M. (2011). Antenatal domestic violence, maternal mental health and subsequent child behaviour: a cohort study. British Journal of Obstetrics and Gynaecology.118, 1383-1391.

Huth-Brooks AC, Levendosky AA, Bogat GA. (2002). The effects of domestic violence during pregnancy on maternal and infant health. Violence and Victims,17:69-85.

Klaus, M, H. & Kennel, J. H. (1976). Maternal-infant bonding. Saint Louis: The C. V. Mosby Company.

Spinner, M. R. (1978). Maternal-infant bonding. Canadian Family Physician, 24, 1151-1153.

Taylor, A., Atkins, R., Kumar, R. Adams, D., & Glover, V. (2005). A new mother-to-infant bonding scale: links with early maternal mood. Archives of Women’s Mental Health, 8, 45-51.

Tjaden, P. & Thoennes, N. (2000). Extent , nature, and consequences of intimate partner violence: findings from the National Violence Against Women Survey. Washington D.C.: Department of Justice (US); 2000. Publication No. NCJ 181867.

Tjaden, P. & Thoennes, N. (2006). Extent , nature, and consequences of rape victimization: findings from the National Violence Against Women Survey. Washington D.C.: Department of Justice (US):  Publication No. NCJ 210346.

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.

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!