Oregon AWHONN

Promoting the Health of Women and Newborns

June 2019 Vol. 6 No. 2

In This Issue

Providence Oregon Nurses Win Outstanding Research Study Poster Award

by Donna Talain, RNC-OB, BSN, MBA


Three Oregon nurses took home the Outstanding Research Study Poster Award at AWHONN Convention this year. Congratulations to (pictured L to R) Cindy Kenyon BSN, RNC,  Sofia Costas BSN, RNC, and Sherry Hutton BSN, RN from Providence St. Vincent Medical Center in Portland, OR for their study titled Ibuprofen Does Not Increase Blood Presssure in Preeclampsia. They will be featured in our Spotlight segment in an upcoming special edition newsletter. In the meantime, join me in congratulating them for a job well-done!


Interested in growing your career, knowledge, and expertise? Get your feet wet with poster presentations at our Oregon AWHONN Fall Conference. It's not too late to submit your research study, innovative idea, or practice solution. Visit oregonawhonn.org/posters to learn more.


Know someone who deserves to be in the spotlight? Nominate her/him for our next newsletter in September. She/He could be entered to win a fabulous prize at the end of the year. 

Nominate a Colleague

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Or Nominate Yourself

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Women's Health Update

Optimizing Postpartum Cesarean Pain Management While Decreasing Opioid Use

by Kara Johnson, DNP, RNC-OB, CNS


An estimated 1 in 300 opioid naïve women exposed to opioids after cesarean birth will become persistent users of opioids (ACOG, 2018). Studies also demonstrate that the amount of opioids prescribed after cesarean birth often exceeds the actual amount needed or consumed after discharge. The median number of dispensed opioids tablets was 40, while the median number consumed was 20 (ACOG, 2018). Leftover tablets raises safety concerns regarding nonmedical use and diversion which has become a national opioid epidemic concern. As a result, many hospitals in Oregon are working on decreasing postpartum opioid administration for cesarean births while optimizing postpartum pain management.


Background

Cesarean delivery accounts for 31.9% of all deliveries and is the most common surgical procedure in United States (Macones et al., 2019). The most common complaints reported in the early postpartum period are pain and fatigue. Pain can interfere with a woman’s ability to care for herself as well as her baby and can lead to increased risk of opioid use, postpartum depression, and persistent pain (ACOG, 2018). Post-operative pain can also prevent early mobilization which increases risk of thromboembolism. Many recent studies have focused on ways to decrease opioid use in the immediate postpartum period after cesarean delivery while optimizing pain management.


Multimodal Pharmacological Analgesia

Multimodal analgesia combines the use of two or more analgesics that act by different mechanisms. Acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDs) have different mechanisms of action and can be used simultaneously. They are effective for mild to moderate pain and have been shown to have opioid-sparing properties when treating moderate to severe pain. Studies have demonstrated that using acetaminophen or NSAIDs with opioids results in less post-operative pain or opioid consumption than using opioids alone (Lamvu, Feranec, Blanton, 2018). If acetaminophen and NSAIDs are ordered and administered independently of opioids (not combination formulations), it is easier to schedule around-the clock and use opioids for breakthrough pain. Oral preparations are recommended over intravenous whenever possible because intravenous has not proven to be superior over oral (Lamvu, Feranec, Blanton, 2018).


Enhanced Recovery After Surgery (ERAS) standardized protocols have been used for other surgical procedures and have resulted in reductions in length of stay, complication, readmissions, and healthcare costs. In December of 2018 through April 2019 the ERAS Cesarean Delivery Guideline (Parts 1-3) was published defining a focused pathway that starts 30-60 minutes prior to delivery for both scheduled and unscheduled cesarean deliveries until discharge. The post-operative section (Part 3) focuses on the completion of the cesarean procedure until maternal discharge. The guideline reviews post-operative analgesia and discusses multimodal analgesia as a key component as part of an enhanced recovery protocol resulting in fewer side effects and faster post-operative recovery (Macones, et al., 2019).


Since an estimated 89.4% of postpartum women in Oregon breastfeed (CDC, 2018) it is important to consider the effects of maternal medications on the mother and baby. Maternal opioid use can cause drowsiness and is associated with an increased risk of newborn falls (Fahey, 2017). Opioids can also cause constipation and exacerbate pain. Duration of use of opiate prescriptions should be limited to the shortest reasonable course expected to treat acute pain. Data on opioid use for relief of uterine cramping is inconclusive (ACOG, 2018). Postpartum women with opioid use disorder, have chronic pain, or are using other medications or substances that may increase sedation need additional support and an individualized plan in managing pain (ACOG, 2018). It is important to provide education to patients that emphasizes that opioid medications are to be used for severe pain related to their surgery and for a short time period. Other types of education should include how to assess and report pain, realistic expectations and goals for pain control, misconceptions about pain, and proper disposal of unused medications.


Studies found the amount of opioids prescribed after cesarean birth often exceeds the actual amount needed or consumed after discharge. The median number of dispensed opioid tablets was 40, while the median number consumed was 20 (ACOG, 2018). Unused tablets raise safety concerns regarding nonmedical use and diversion, however it is critical that pain management not be affected by under prescribing. A shared decision-making approach to discharge opioid prescription can optimize pain control while decreasing the number of unused tablets. An “optimal” number of tablets or duration of therapy has not yet been identified and discharge prescriptions should be individualized.


Conclusion

Interdisciplinary multimodal analgesia planning and implementation can provide an effective and standardized strategy to reduce post-operative pain and overall opioid use in women with cesarean deliveries. Perinatal nurses play a key role in assessing pain, administering multimodal medications, offering nonpharmacological therapies, and providing education to optimize cesarean pain management while decreasing opioid use.

References


American College of Obstetricians and Gynecologists (2018). ACOG Committee Opinion number 742: Postpartum pain management. Obstetrics & Gynecology, 132, e35-e43. doi: 10.1097/AOG.0000000000002683


Centers for Disease Control (2018). Breastfeeding report card. Retrieved June 22, 2019 fromhttps://www.cdc.gov/breastfeeding/data/reportcard.htm


Fahey, J.O. (2017). Best practices in management of postpartum pain. Journal of Perinatal Nursing,31(2), 126-136. doi: 10/1097/JPN.0000000000000241


Lamvu, G., Feranec, J., Blanton, E. (2018). Peri-operative pain management: An update for obstetricians and gynecologists. American Journal of Obstetrics and Gynecology, 218(2), 193-199.

doi: 101016/j.ajog.2017.06.021


Macones, G.A., Caughey, A.B., Wood, S.L., Wrench, I.J., Huang, J., Norman, M., Pettersson, K., Fawcett, W.J., Shalabi, M.M., Metcalfe, A., Gramlich, L., Nelson, G., & Wilson, R.D. (2019). Guidelines for postoperative care in cesarean delivery: Enhanced Recovery After Surgery (ERAS) Society Recommendations (Part 3 ). American Journal of Obstetrics and Gynecology, doi: https://doi.org/10.1016/j.ajog.2019.04.012

Neonatal Update

If Cuba Can Do It, Why Not Oregon?

by Pat Scheans, DNP, NNP-BC

WHO validates elimination of mother-to-child transmission of HIV and syphilis in Cuba

News release

30 JUNE 2015 ¦ GENEVA ¦ WASHINGTON - Cuba today became the first country in the world to receive validation from WHO that it has eliminated mother-to-child transmission of HIV and syphilis.

It has been two years since Oregon AWHONN’s newsletter published an article on the syphilis epidemic (https://www.oregonawhonn.org/july2017). SO, how are we doing?


Well, June is Rose Festival month, and with it comes Fleet Week. The birth rate is down in Oregon, but not the sexually transmitted illness rates. Not to cast aspersions on our city’s biggest party, but party safely, people!


No, that’s not a new rose variety, it’s Treponema pallidum, the bacteria that causes syphilis.

Left: Credit: Portland Rose Festival | Right: Credit: National Institute of Allergy and Infectious Diseases, National Institutes of Health

Our lovely and lively Oregon continues to struggle with unprecedented levels of congenital syphilis despite a broad public campaign and intensified testing since the epidemic was declared a few short years ago. Oh, and it’s not just a Portland problem (see graphs below).

Source: https://jacksoncountyor.org/portals/11/HHS/Public%20Health/images/Syphilis.png

This is not what we mean when we ask for female equality!

Source: https://jacksoncountyor.org/portals/11/HHS/Public%20Health/images/Syphilis2.png

Congenital syphilis in the United States has increased 154 percent increase since 2013. The maternal-fetal transmission rate approaches 80%, occurring at any stage of syphilis, but the risk is higher in the primary or secondary stage (CDC, 2018). A truly tragic and preventable disease, fetal/neonatal morbidity and mortality is high. Almost half of fetal infection ends in miscarriage or stillbirth. Mortality may also be due to complications of pre-term delivery or generalized systemic disease. Congenital syphilis morbidity includes blindness, deafness, bone deformities, and/or brain, liver and kidney damage.


What can we do about this?

Keep up the good work! All women should have access to quality prenatal care, including syphilis screening and adequate treatment. Test newborns thoroughly, and provide adequate treatment as indicated. Follow the new Syphilis Investigative Guidelines(see the link below).


Syphilis testing is strongly recommended for all pregnant women at the first prenatal visit, the beginning of the third trimester (28–32 weeks), and at delivery. Nontreponemal testing (RPR) may take up to 12 weeks to become reactive after exposure, so providers should strongly consider screening at post-partum visits, as well (OHA, 2019).

“To protect every baby, we have to start by protecting every mother,” said Gail Bolan, M.D., director of CDC’s Division of STD Prevention. “Early testing and prompt treatment to cure any infections are critical first steps, but too many women are falling through the cracks of the system. If we’re going to reverse the resurgence of congenital syphilis that has to change.” (CDC, 2018).

Jane Doe - Another Company, LLC

Resources


Centers for Disease Control and Prevention. (September 2018). Newborn syphilis cases more than double in four years, reaching 20-year high. Retrieved from https://www.cdc.gov/nchhstp/newsroom/2018/std-surveillance-report-2017-press-release.html


Oregon Health Authority. (ND). Oregon STD statistics: HIV, STD & TB section. Retrieved from https://www.oregon.gov/OHA/PH/DiseasesConditions/HIVSTDViralHepatitis/SexuallyTransmittedDisease/pages/index.aspx


Oregon Health Authority. (April 2019). Syphilis investigative guidelines. Available at https://www.oregon.gov/oha/ph/DiseasesConditions/CommunicableDisease/ReportingCommunicableDisease/ReportingGuidelines/Documents/syphilis.pdf


Syphaware website: https://www.syphaware.org/

Legislative Update

From April 7 to 9, 2019, AWHONN hosted a public policy conference with a lobby day to advance legislation to promote the health of women and newborns. This year, Oregon AWHONN had 3 representatives attend AWHONN on Capitol Hill -- our Legislative Coordinators, Nancy Alt and Amy Brase, and Emerging Leader Alumna and our Membership Coordinator, Michelle Hirschkorn. Here are their stories.

From L to R: Amy Brase, Nancy Alt, Michelle Hirschkorn

Membership Has Its Privileges

by Michelle Hirschkorn, MSN, RNC-OB, CNS


Participating in the 2019 AWHONN on Capitol Hill Conference made me prouder than ever to be an AWHONN member.  Joining my voice with hundreds of other women’s health, obstetric and neonatal nurses to promote legislation that will improve the health of families and newborns felt amazing! 


I am always talking about the benefits of being an AWHONN member.  For example: 

  • Excellent journals.
  • Networking opportunities to share best practices with respected colleagues across the country.
  • Supports my professional development and helps me keep my practice up to date.  
  • Now, after experiencing AWHONN on Capitol Hill, I know that being an AWHONN member amplifies my voice as an advocate for women and newborns.

Advocating for our population of patients does not happen just once a year!  Seth Chase and Jacqueline Rychnovsky at AWHONN headquarters work year-round to keep members abreast of potential national and state policy changes that will affect the patients we care for.  They write a newsletter any member can subscribe to that will update you on the advocacy efforts AWHONN is focusing on.  When important issues arise, AWHONN will even make it easier to send a letter to your member of congress.  At the state level, Oregon AWHONN has Amy Brase and Nancy Alt serving as legislative coordinators.  They help keep us informed about what is happening in our own state.  I really appreciated Amy Brase’s article in our last newsletter that explained Oregon’s CCOs and the impact on our patients.  

I think all nurses feel it is their duty to advocate for our patients, but beyond the bedside, it can be difficult to know where to start.  That is part of why being a member of a professional organization is so important. How do I know what bills are being proposed?  How do I engage with my government officials?  AWHONN helps us figure out these complicated issues and supports us with what can be intimidating situations.  If you want to learn more about advocacy through AWHONN, contact our legislative coordinators at legislative@oregonawhonn.org and check out https://www.awhonn.org/page/Advocate.

My Trip to AWHONN on the Hill

by Nancy Alt, BSN, RNC-OB


My involvement in Oregon AWHONN has provided me with several opportunities to visit and sightsee in our Nation’s Capital.  D.C. has so much to offer I have seldom visited any attraction twice. On this trip, we visited the Black History Museum. Amy got up at 6am Sunday morning and succeeded at getting tickets for entrance at 11am (thanks Amy, you rock!) We were both so excited to visit this museum. It was Amy’s second time visiting and my first.  We decided to separate and tour at our own pace.  We spent four hours there, which seemed like a split second.  I was unable to completely visit the entire museum and definitely plan to revisit and finish what I missed. 


Next, we visited the Holocaust Museum. This museum also requires tickets for entrance to the permanent exhibits and unfortunately, none were available. We were able to see a new exhibit at the museum called American’s and the Holocaust. It was very well done and sobering.  I hope to return to this museum and visit the permanent exhibits. 


It was Cherry Blossom season in D.C. and the amount of people there for the festival was unbelievable. I had no idea how many people visit D.C. to see the cherry blossoms. I must say the trees are beautiful but lucky for us Oregonians; we have the same beautiful cherry blossoms at our state capitol. 


After enjoying D.C. for a couple of days, we began the work of learning about the legislative issues affecting women and children in 2019.  AWHONN provided a full day of teaching topics like Government 101, how to talk to your Legislators, and basic information on the issues we were presenting to Legislative staff members the next day.  AWHONN somehow managed to make eight hours of sitting and listening both interesting and fun.  At the end of the day, we had the privilege to hear from Lauren Underwood, a nurse and a freshman representative from Illinois. She was so inspiring. She gave us all ideas about how to make a difference in our communities.


The next day, it was time to talk to our Legislators.  AWHONN made all the appointments for us—which was no small task!  I must say I was nervous about talking to the office staff about our agenda, but with the education and support from AWHONN, it really was not a big deal.  I would happily, and confidently, do it again. 


At the end of the day with the Legislators, Amy, Michelle, and I attended a meeting of the Black Mamas Matter Alliance. We listened to several dynamic women speak about the Mission, Vision and Goals of the BMMA. Please visit the Black Mamas Matter Alliance website (https://blackmamasmatter.org) to learn more about this amazing organization and how they are tackling the maternal health crisis of black women in our country.


I thank AWHONN for this opportunity to learn about our government and history. It was a very exciting five days. Experiencing the big city, riding the Metro, and trying out new food is always fun!

AWHONN Nurses Make a Difference on Capitol Hill

by Amy Brase, MSN, RN, CNE


After a full day of training on a Monday in April, 100 AWHONN nurses from across the Nation descended on Senators and Representatives on a Tuesday to discuss three important bills that AWHONN identified as extremely important to both our patient population and AWHONN Nurses.


H.R. 1897/S.916 Mothers and Offspring Mortality and Morbidity Awareness Act or MOMMA’s Act

AWHONN supports this bill because it provides technical support to states and health care providers to combat the rising maternal morbidity and mortality rates in the United States. The MOMMA’s Act would:

  • Provide funding to the CDC to provide technical assistance to improve sharing of maternal mortality data.  Currently there is no national standard for reported maternal data.
  • Share best practices from the CDC how to best identify, review and prevent maternal mortality. The data will help with this.
  • Establish a grant program to help ensure widespread adoption and implementation of best practices.
  • Expand Medicaid and CHIP coverage from 60 days to 1 year after birth. Can you believe coverage is only for 60 days….when postpartum risk is officially a year?
  • Provide specialized training for health care professionals related to implicit bias and cultural competency.
  • Extend WIC to 2 years after birth (currently 6 months for bottle fed babies and 1 year if they are breastfeeding).

AWHONN believes the MOMMA’s act is the next step to the Preventing Maternal Deaths Act that was signed into law December 2018, that is intended to establish and support maternal mortality review committees at the state level.


S. 463 and H.R. 1185 the Family and Medical Insurance Leave (FAMILY) Act

This bill would provide paid leave for 12 weeks for any person using any family-related medical leave. By minimizing the loss of income, the hope is Mothers would have increased ability to establish and sustain breast feeding, resulting in improved health for children.


H.R. 728 Title VIII Nurse Workforce Development Reauthorization Act of 2019

This bill is complicated and easy. Title VIII addresses the education, practice, recruitment, and retention of the nursing workforce. This bill was enacted into law in the 1970’s I think. It is expiring and needs to be renewed. This is more complex than it sounds. Right now, money continues to be allocated for the bill, but that could change with the next budget approval unless it is renewed.


I was so impressed with several things about this legislative day. Oregon legislator assistants are smart and informed and passionate (and young). Senators Merkley and Wyden and Representative Schrader are generally in support of these issues (especially Merkley). AWHONN prepared us thoroughly with speakers to inform us on the issues and bills we were discussing, and written material to enhance our communication with legislators. By participating in this AWHONN Day on the Hill, I made a difference for women, children, families and nurses. What an amazing privilege. Thank you AWHONN!

Registration is Open!

Don't miss out on Oregon AWHONN's premier event! Register now for early bird savings and save your seat for what's sure to be another spectacular event.

Grow Your Practice Rooted in Excellence
September 29 - October 1
Oregon Garden Resort, Silverton, OR

Upcoming Events

Southern Willamette Valley Chapter Meeting

Join International birth worker, Speaker & Spinning Babies® Approved Trainer Tammy Ryan for a Labor and Birth with Spinning Babies® Workshop!


Workshop is open to:
Midwives
Labor & Delivery Nurses
Physicians


Cost:

$175.00 until Sept 10, 2019, then $200 Regular price, $225 at the door.


Details:
Lunch Break from 12:30-1:30 pm
Please bring a pillow. If you have a yoga mat and/or a rebozo please bring those also.
We will work in pairs so if you don’t have the above we will put you with someone who does.
Babies in arms welcome.


Local host: 

Kathy Nice, kathy.adelman@gmail.com


Cancellation Policy:

100% if you miss for a birth, if I am contacted by 7am the day of the workshop


Email Approved Trainer Tammy Ryan at ServantHands123@aol.com

Questions? Approved Trainer Tammy Ryan at ServantHands123@aol.com


Register at  https://www.eventbrite.com/e/springfield-or-labor-and-birth-with-spinning-babies-w-tammy-ryan-oct-24-registration-62952309051

Oregon AWHONN Elections

Elections for the 2020-2022 Oregon AWHONN Chair and Secretary/Treasurer are coming up. Stay tuned for details. Now's the time to start considering how you want to make an impact on the future of the care of women and newborns. Get involved! Lead a team of amazing volunteers who are dedicated to the best care of the population we serve.

Tuesday, Aug 27 at 8:00 AM - Friday, Aug 30 4:30 PM
Thursday, Sep 5 at 7:30 AM - Friday, Sep 6 4:00 PM
Tuesday, Sep 10 at 8:00 AM - Thursday, Sep 12 4:30 PM
Thursday, Oct 17 at 7:30 AM - Friday, Oct 18 3:45 PM

The best way to cheer yourself up is to try to cheer somebody else up.

Mark Twain