Oregon AWHONN

Promoting the Health of Women and Newborns

March 2018 Vol. 5 No. 1

In This Issue

Find Your Anchor in Times of Change

by Becky Moore, RNC-MNN, BSN


Breaking news in the healthcare industry! Our practice environments and the overall industry have changed dramatically in recent years. And the speed of change is anticipated to keep pace and even accelerate.


Of course, the "breaking news" comment is made with my tongue firmly implanted in my cheek. Nurses practicing today are only too aware of these realities. In February, Oregon section leaders attended the AWHONN leadership conference with 120 other AWHONN leaders from across the country. Industry and workplace change was a topic that could be heard frequently in hallway and table conversations. 


How can nurses anchor themselves when the familiar industry foundation we stand on seems to be shifting, incessantly leaving us disoriented? From my perspective, anchoring comes from standing on something other than the familiar foundation of previous industry environment. We can do this by focusing on what doesn't change to steady us. What doesn't change? 

  • What first drew us to nursing. Finding ways to remember and act on this love each day fills the soul and reminds us we can make a difference.
  • Our bedrock commitment to promote the health of women and newborns. This commitment can be expressed in many ways, from the touch at the bedside to engagement in workplace governance, to doing research, to public and political advocacy. Even small steps change the perspective from being swept along to steering the course.
  • The power of the AWHONN organization. AWHONN helps define and promote best practice, drive public policy, strengthen the nursing profession, improve outcomes through research and provide the finest in education and clinical resources to nurses and other healthcare professionals. Individuals can and do make a difference. But together as united members of our professional organization, the effect is even greater.

The 488 members of the AWHONN Oregon section demonstrate their commitment to women and newborns by the work they do every day and their alignment with their professional organization. Let us each find ways large and small to thrive as professionals and continue to improve the health of women and newborns. The power of many just may help to build a new, and better foundation that will carry us into the future.

Women's Health Update

Cardiovascular Disease in Pregnancy and Postpartum - CMQCC Toolkit Now Available

Image source: cmqcc.org

by Kara Johnson, DNP, RNC-OB, CNS


Many of us are familiar with and use the California Maternal Quality Care Collaborative (CMQCC) toolkits as resources, including Improving Health Care Response to Obstetric Hemorrhage, V2.0 (2015), Improving Health Care Response to Preeclampsia (2014), and Toolkit to Support Vaginal Birth and Reduce Primary Cesareans (2016). A new toolkit is now available -- Improving the Health Care Response to Cardiovascular Disease in Pregnancy and Postpartum (2017) -- and can be downloaded for free at https://www.cmqcc.org/resources-tool-kits/toolkits.


The CMQCC Maternal Quality Improvement Toolkits were developed by key experts from across California from various health systems. The intent of the toolkits are to improve the response to leading causes of preventable morbidity and mortality in pregnant and postpartum women.


Cardiovascular disease accounted for the highest percentage (15.5%) of pregnancy-related deaths in the United States from 2011-2013 (Creanga, Syverson, Seed, & Callaghan, 2017). Review of maternal mortality cases in California, from 2002-2006, revealed that only a small number of women had a known diagnosis of cardiovascular disease prior to death. Twenty-five percent of the cardiovascular disease-related deaths were determined to be preventable if heart disease had been included in the differential diagnosis and timely treatment had occurred, which was especially evident with cardiomyopathy deaths (Hameed, Morton, & Moore, 2017). Morbidity due to delay in diagnosis and treatment is also impacted by cardiovascular disease as demonstrated by the fact that one of every three intensive care unit admissions in the pregnancy and postpartum period are related to cardiac disease (Small, James, Kershaw, Thames, Gunatilake, & Brown, 2012).


Many signs and symptoms of a normal pregnancy and symptoms that women may experience due to cardiac disease are similar; including shortness of breath, swelling, exercise intolerance, and fatigue. Nurses and providers must be familiar with risk factors, signs and symptoms, and physical exam findings suggestive of cardiac disease to ensure timely diagnosis and prompt treatment. The first presentation of cardiovascular disease may be during the pregnancy or postpartum period and the highest risk period for patients with preexisting cardiac conditions is generally late in the second trimester or in the postpartum period (Hameed, Morton, & Moore, 2017).


The CMQCC Improving the Health Care Response to Cardiovascular Disease in Pregnancy and Postpartum (Hameed, Morton, & Moore, 2017) toolkit includes:

  • An algorithm to categorize and initial evaluation of symptoms or high risk pregnant or postpartum women
  • Clinician and facility resources when caring for women with congenital or other cardiovascular disease, contraception counseling, and appropriate medications during pregnancy and breastfeeding
  • Patient information
  • Signs and symptoms of cardiovascular disease, future risk, and pregnancy planning
  • Information on racial and ethnic disparities in cardiovascular disease prevention and diagnosis
  • Teaching slide set for providers, nurses, educators, and healthcare organizations

What can you do to impact cardiovascular disease-related morbidity and mortality in pregnancy and postpartum?

  • Identify risk factors and signs and symptoms for cardiovascular disease and advocate for prompt evaluation which may include maternal fetal medicine and primary care/cardiology consultations
  • Provide patient education on warning and signs and symptoms and when to seek urgent/emergent care
  • Share resources with colleagues and talk with your team about ways to improve care of patients with suspected or diagnosed cardiovascular disease

References


American College of Obstetricians and Gynecologists and the Society for Maternal–Fetal Medicine, Kilpatrick, S.K., & Ecker, J.L. (2016). Severe maternal morbidity: Screening and review. American Journal Obstetrics Gynecology, 215(3):B17–B22.


Creanga, A.A., Syverson, C., Seed, K., & Callaghan, W.M. (2017). Pregnancy-Related Mortality in the United States, 2011-2013. Obstetrics & Gynecology, 130(2).


Hameed, A.B., Morton, C.H., & Moore, A. (2017). Improving Health Care Response to Cardiovascular Disease in Pregnancy and Postpartum. Developed under contract #11-10006 with the California Department of Public Health, Maternal, Child and Adolescent Health Division. Published by the California Department of Public Health.


Small, M.J, James, A.H., Kershaw, T., Thames, B., Gunatilake, R., & Brown, H. (2012). Near-miss maternal mortality: Cardiac dysfunction as the principal cause of obstetric intensive care unit admissions. Obstetrics & Gynecology, 119, 250-255.

Neonatal Update

Cytomegalovirus and Newborn Hearing Screening

Image source: periodontal.com

by Pat Scheans, DNP, NNP-BC


Goodbye Winter and Hello Spring!


Sprouts and shoots are beginning to appear everywhere, even in the Oregon AWHONN newsletter. Here is a budding topic that may go into full bloom in the next few months.


Cytomegalovirus and Newborn Hearing Screening

Have you taken care of a newborn with congenital cytomegalovirus (CMV) infection? The answer is “Yes”, whether you knew it or not, since one out of 200 infants are born with CMV. That’s 20,000 a year in the US!

CMV is a member of the herpes virus family. It is a widespread virus that large numbers of the population have contracted. The prevalence is shocking: one third of children are infected by five years of age, as well as 50% of women, with the highest rates in the childbearing ages of 15-35 years. Infection rates approach 100% in emerging countries.


An otherwise healthy child or adult might experience a mild flu-like or mononucleosis-like syndrome with fever, pharyngitis, lymphadenopathy, and/or polyarthritis. Greater risk is to immunocompromised individuals (such as preterm infants) or in-utero infection. CMV can cross the placenta and cause damage to the developing fetus/newborn. It can be acquired via body fluids, and like other herpes viruses, remain latent with sporadic reactivation. CMV is the most common intrauterine infection with 1% of infants infected and excreting CMV at birth. One half to three quarters of congenital CMV occurs due to reinfection or a reactivation during pregnancy, with 1-4% of neonatal CMV caused by primary infection during pregnancy. Risk of transmission to the fetus is greatest in the third trimester, but risk of fetal/neonatal complications is highest during the first trimester. Risk of transmission for primary infection is 30-40% in the first and second trimesters, and 40–70% in the third trimester.


Although CMV can be detected by viral culture or polymerase chain reaction (PCR) of infected blood, urine, saliva, cervical secretions, or breast milk, serologic testing is used for diagnosis. Rise in CMV IgM titer is used to diagnose congenital infection, but is only present 25-40% of the time. Serum samples collected one to three months apart can be used to diagnose primary infection, but maternal CMV IgG (the pneumonic is IgG Goes across the placenta) complicates diagnosis in newborns.


Neonatal viral infections scan be sneaky. They can present as fulminant sepsis (fever, DIC, liver failure, RDS, shock, myocarditis, or meningitis), or the baby may initially be asymptomatic, yet develop disabling sequelae. Around 10% of newborns with congenital CMV infection display problems at birth such as prematurity, low birth weight, microcephaly, hepatosplenomegaly and/or seizures. Forty to sixty percent of symptomatic newborns will develop long-term problems, such as loss of vision and hearing, and neurodevelopmental disabilities. There is no effective therapy at this time; treatment is focused on specific issues/symptomatology. A vaccine is in development.


Now, here’s the aforementioned bud to watch as it blooms:


There is no universal newborn screening for CMV currently. Hearing loss may be present at birth, but even after passing newborn hearing screening, 10-20% of infants with congenital CMV infection later develop hearing loss. In fact, 5%-20% of moderate to profound hearing loss is due to congenital CMV infection.


Because of the prevalence of congenital CMV infection and its effect on hearing, new rules are coming out to allow for/improve early detection and intervention (early intervention improves outcome). In June 2017, the Oregon Legislature (following some other states’ lead) passed legislation about CMV testing and newborns who fail their hearing screen. At first it seemed that the bill would require CMV testing for all newborns who fail their hearing screen within 21 days of birth. But, the final bill doesn't require that we test or treat babies, but it does say that the Oregon Health Authority (OHA) must create and disseminate information about CMV that will be provided to families of babies who fail newborn hearing screening.


A regional, multi-site, multidisciplinary group is being developed to discuss this mandate and determine a good systematic approach for hospitals to follow. Stay tuned for more as this blossom unfolds.

Resources


Centers for Disease Control and Prevention. (2017). Cytomegalovirus (CMV) and congenital CMV infection. Retrieved from https://www.cdc.gov/cmv/clinical/features.html


Oregon Legislature bill:

https://olis.leg.state.or.us/liz/2017R1/Downloads/MeasureDocument/HB2754

Announcements

Oregon AWHONN is now on Facebook and Instagram!

We've moved from a private group to an open, public Facebook page! It's now easier to find us on Facebook. Just search for AWHONN Oregon or go to facebook.com/oregonawhonn. Like us, follow us, or just say hello. We'll use the platform to raise awareness of the health issues facing women and newborns and to show the world what a great organization we are. 


And don't forget to follow us on Instagram too! instagram.com/oregonawhonn

Thanks to all the donors to Every Woman, Every Baby in 2017, 
Oregon AWHONN has won the Section Challenge once again! That's 4 years in a row!
This year, we won for highest participation rate.

One lucky winner from those who donated will be chosen to receive 
complimentary registration for the 2018 AWHONN Convention in Tampa, FL. 
The winner will be announced in next quarter's newsletter.

Oregon AWHONN Fall Conference Call for Posters

The 2018 Oregon AWHONN Fall Conference Program Committee is seeking poster presentations for the annual fall conference to be held September 30 - October 2, 2018 at Salishan Spa and Golf Resort in Gleneden Beach, Oregon.


Oregon AWHONN invites all staff nurses, students, and researchers who have implemented a best practice idea, found an innovative solution to a clinical problem, or conducted a research study, to create a poster about a research or quality improvement project that is either in process or finished within the last year. We welcome anyone, including students that you my be mentoring, to make their first attempt at a poster presentation in our supportive conference environment.

Upcoming Events

Registration Opens April 1, 2018!

In the meantime, check out our Conference website for updates on conference pricing, lodging, and poster presentation applications.

Tuesday, May 1 All Day
Saturday Jun 23 - Wednesday Jun 27
Monday Sep 10 - Tuesday Sep 11
Wednesday Sep 26 - Saturday Sep 29

Have an anchor so that life doesn't toss you around.

Debby Ryan