Oregon AWHONN

Promoting the Health of Women and Newborns

March 2015 Vol. 2 No. 1

In This Issue

Volunteer Opportunities Abound with Oregon AWHONN

by Deb Castile, MN, RNC, CNS, NE


Happy 2015! Have you gotten used to writing "2015" yet? I do fine with “2015” until I write a check. My pen does not want to embrace “2015.” Regardless of what my pen is doing, your Oregon AWHONN Leadership team has fully welcomed 2015.


At the end of January, your Oregon AWHONN leadership team met in Portland to identify our 2015 goals. Within one day, we approved our 2015 budget, determined membership goals, established plans for Chapter meetings, discussed Oregon activities for Convention in Long Beach, CA, began planning for the Oregon Fall Conference and approved a new Oregon website design. We also welcomed Trish Alexander as our new Northeast Oregon Chapter Leader. We met Trish in Orlando last summer during the 2014 AWHONN Convention. It was evident to me and others around that Trish has a passion for obstetric care. As a result of Trish’s passion, she graciously accepted the leadership position.


Do you have a passion for women’s health, obstetric or neonatal care? Would you like to join a group of fun loving women who share your passion? Oregon AWHONN is looking for

a few people like you. We are looking to fill two open Chapter Leader roles (Mid-Willamette and Southern Willamette Valley), two Legislation positions and two members to participate on the Nomination Committee for our fall elections. There are many other ways we can get you engaged in Oregon AWHONN as well. Don’t be like my pen. If you have a passion and want to become involved with Oregon AWHONN, reach out to me at chair@oregonawhonn.org to discuss how you can become more active with your professional organization – AWHONN. 


May 2015 be Oregon AWHONN’s best year yet.

Join Us in the Fun in Long Beach, California

by Donna Talain, RNC-OB, BSN, MBA


This year’s AWHONN National Convention is in sunny Long Beach, California. Come to The Urban Waterfront Playground to get inspired to transform your quality of care and integrate innovations into your nursing practice.


But you know what they say about all work and no play. Join your fellow Oregon AWHONN members in all the fun! Register now and save $100. You’re sure to have a good time... and learn a thing or two also. 


www.awhonnconvention.org 

From the Editor's Desk

If you know me, it’s no secret that I’m a gadget person. I like technology and modern things. I like Oregon AWHONN too. But our website was so old and not so useful — definitely not modern.


So I joined my interests and created a brand new Oregon AWHONN website. I think you’ll find the site easy to navigate and easy on the eyes. You’ll even find it easy to contact us if you need to. 


I invite you to go play on the website. If you’re an active Oregon AWHONN member, register to join and you’ll get access to the entire On-Demand AWHONN Webinar Series. Start a discussion on the discussion board and you just might learn something new. 


Donna Talain

www.oregonawhonn.org

Spotlighting Best Practice: Catch the Show

We are so excited to share preliminary news about this year’s Oregon AWHONN Fall Conference! This year we will enjoy the warmth, beauty & ambiance of our own Southern Oregon. The conference facility is located at Inn at the Commons in Medford, just minutes away from several fun activities including Ashland and all its offerings! You’ll likely be able to add some fun onto a full agenda of clinically relevant and engaging conference content!


This year, our keynote speakers are Lisa Miller, CNM, JD & Roger Freeman, MD. This is an exceptional opportunity to hear and learn from this team. We will also be including content relevant for nurses caring for moms and babies with engaging and insightful presenters. Additionally, this year, we will again be hosting a simulation event for pre-conference on September 9th. Always a hit and always great learning!


We can’t wait to see you this fall in Medford.


Conference registration and hotel information will be posted this spring!

Vitamin K Refusal: Answers to your Patient’s Questions

by Pat Scheans, DNP, NNP-BC


If it seems like more parents are questioning or refusing vitamin K for their babies, you’re right. They are. The leading reasons for refusal appear to be desire for a natural birthing process, and believing prophylaxis is unnecessary. The refusal rate has been reported to be as high as 3.7% (Novella, 2013).


A Canadian retrospective study found that midwife-assisted deliveries were more likely to be associated with vitamin K refusal compared with physician-attended delivery. The study also found that planned home delivery or delivery in a birth center was more likely to result in decline of vitamin K compared with hospital delivery. No surprise that vitamin K refusal was associated with a higher risk of having no recommended childhood vaccines at 15 months (Sahni, Lai, & MacDonald, 2014). 


You can be prepared to provide answers to questions about vitamin K. There are many great resources available to help us. Yes, the incidence of bleeding is low, but it exists. It most commonly occurs in the brain and can be severe, even fatal. There have been reports of clusters of vitamin K deficiency bleeding (VKDB), including 4 cases recently in Tennessee. Reported incidence of VKDB in the first week of life is 0.25 - 1.7%. There is also a late VKDB that is more severe but has a lower incidence of 4.4 - 7.2 per 100,000 live births (Novella, 2013).


Here are some common questions you might hear from your patients and what you can say to encourage vitamin K administration.


Why does my baby need a shot of vitamin K?

Vitamin K helps blood clot. Bleeding in the brain and other places in the body can occur when the body does not have enough vitamin K. This is called Vitamin K Deficiency Bleeding, previously called Hemorrhagic Disease of the Newborn (HDN). Half of babies with VKDB have bleeding in their brains.


Vitamin K does not go from mom to the baby very well, leaving baby with too little to protect from bleeding. Vitamin K is undetectable in cord blood.


Breast milk does not provide enough Vitamin K.


We get Vitamin K when we eat green leafy vegetables, babies don’t eat these.


Bacteria in the bowel make vitamin K for us. A newborn’s bowel does not have these bacteria at birth. 


If it is a rare problem why worry about it and make my baby have a painful shot?

It may be rare, but it can be devastating when it happens. There is no way to predict whether your baby will have a bleeding problem. It is safest for baby to have a shot of Vitamin K to tide her over until she starts making her own. That is why it is required by law, and you must sign a paper saying you do not want your baby to have this protection.


Why must it be a shot, not by mouth?

There is no FDA-approved oral form of vitamin K. One small shot (injection) is all a newborn needs.


It takes several doses of the unapproved forms (like giving the IV medicine by mouth), but no one knows for sure that this works. There have been failures with oral vitamin K.


Where is the shot given?

The shot is given in the big muscle in the leg. Even though it is very quick, whenever we do something that might be painful to baby, we give something sweet to suck on to help minimize the pain. This sucking and sweet taste has been shown to help soothe babies, and keep their heartbeat from going as high as it would without it.


Can the medicine cause autism or other problems?

There is no correlation between vitamin K and autism, cancer, jaundice or any other side effect besides the brief pain from the injection. Allergic reaction is very rare.


Helpful resources:

Provider Information

http://newborns.stanford.edu/VitaminK.html


Parent Handout

http://www.cdc.gov/ncbddd/blooddisorders/documents/vitamin-k.pdf

Resources


Novella, S. (2013). Vitamin K refusal – The new anti-vax. Retrieved February 13, 2014. http://www.sciencebasedmedicine.org/vitamin-k-refusal-the-new-anti-vax/


Sahni, V., Lai, F., & MacDonald, S. (2014). Neonatal vitamin K refusal and nonimmunization. Pediatrics, 134(3), 497-503. doi:10.1542/peds.2014-1092

Six is the New Four: Here’s Why!

by Nancy Irland, DNP, RN, CNM


The Way We Were

Any nurse worth her salt knows she should be following “evidence-based practice.” Yet we haven’t really been doing that in labor and delivery management. For years, we thought the timeframes on the Friedman curve were evidence-based. For years, if a patient fell off “the curve,” we would start oxytocin or do a c-section after she pushed for two hours because it was “evidence-based.” Everything seemed very cut and dried. We loosened the timeframes for second stage a little bit once epidurals were common, but still, nursing and medical schools have taught the progress of labor primarily by Friedman’s curve since the 1950’s.


The Way We Are

As a result, however, our c-section rate has gone haywire and the CDC reports that one out of every three pregnant women in the U.S. is delivered by c-section. This involves all races and all gestational ages (CDC/NCHS, 2014), so a provider can’t hide behind the excuse that “I see high risk women who must deliver early, so that’s why my c-section rate is so high.” Related factors include fewer VBACs, a decreased number of instrumented deliveries (forceps and vacuum), and the latest Aha! Moment: Friedman’s curve does not include outliers. It has led to unnecessary c-sections for “failure to progress.”


Friedman’s Research Mistake

So, what did Friedman do wrong? First, let me say in his defense, that he was a resident when he did his amazing research. For the first time, he provided a visual graph of labor progress by studying and graphing the labors of 500 nullips in one hospital. His mistake was that his curve was based on only 200 “ideal labors” (his words, per Dr. Katharine Wenstrom, co-author of Spong, et al., 2012, during webinar on 2/25/2015). He sorted through the 500 patients and put together a graph based on the most common curve, without including the outliers that were one and two standard deviations away. Without questioning his methods, everyone followed his lead.


Correcting Our Practice

Only recently, as the c-section rate has risen, revealing associated conditions such as placenta previa and accreta (along with its cousins increta and percreta), the experts have begun to question Friedman’s curve. They went back to the drawing board to see how to prevent that very first c-section. Their work led them to review Friedman’s work in detail (NPIC, 2015). 


As noted above, Friedman’s original work in 1954 included just 500 nullips in one OB service. He must have added the multips later. In contrast, Zhang, et al. (2010) reviewed the charts of 228,668 multips and nullips in 19 hospitals in the U.S. as reported by The Consortium on Safe Labor. Zhang and colleagues discovered that our current patient population is older, heavier, have more epidurals, and labor longer than their mothers and grandmothers did in the 1950’s (data on which Friedman’s curve was based). But still they wondered why we were doing so many primary cesarean sections for first- and second-stage arrest, and failed induction, in the presence of reassuring fetal heart rates. Since these c-sections were based on how one defined “arrest,” it seemed like a place to start, by defining the terms, based on broader research. It seemed as though the Friedman curve was driving the decision-making. So, they asked, “Was Friedman’s curve reliable?”


With 15-20% of primary c-sections being for first-stage arrest, 10-25% for second-stage arrest, and 10% for failed induction, doctors Spong and Wenstrom along with their colleagues, set out to define true labor arrest and failed induction. They reviewed Dr. Zhang’s findings and compared it with Dr. Friedman’s data. 


Friedman wasn’t all wrong; the problem was that his curve was based on selected data, instead of all the data. When Spong and colleagues (2012) reviewed Friedman’s work more closely and included the data of two standard deviations above Friedman’s “ideal labor,” they found similarities with Zhang’s report in 2010 (adapted from NPIC, 2015). See Table 1.

Most patients are in latent phase for around 15 hours. That was also true for Friedman, if you include two standard deviations above “ideal labor.” For most patients, first stage is around 20 hours long; it’s also been that way since it was mapped out in the 1950’s at two standard deviations above “ideal labor.”


A New Definition of Labor Arrest

Nothing has really changed. Spong, et al. (2012) found that until 6 cm, both nullips and multips dilate at approximately the same rate. Normal early labor (before 6 cm) sometimes includes a phase where there is no change in dilation for several hours. In fact, it can take 17 hours for a nullip to go from 3 to 6 cm. For both multips and nullips, it can take more than six hours to progress from 4 to 5 cm. No longer can we say the average progression is about one centimeter per hour after four centimeters. Only after six centimeters do the labors of all patients (both multips and nullips) take off in different directions (see Spong, et al., 2012, for details). And that is why “6 is the new 4.” In general, active labor begins at 6 cm for both nullips and multips alike. This is supported by Friedman’s complete database, and by the more recent work by the Consortium on Safe Labor. If a c-section is done before 6 cm, it’s probably not true labor arrest and the intervention is too soon. Friedman’s curve has driven c-sections before their time.


Recommendations for Second Stage

The work of Spong, et al. (2012) was endorsed by the American Congress of Obstetrics & Gynecology (ACOG) and the Society for Maternal Fetal Medicine (SMFM, 2014). A review of both articles clearly defines second stage arrest and guidelines around management of second stage. 


Second stage arrest

No progress in descent or rotation after the following timeframes:

Nullipara

  • 4 hours or more with epidural
  • 3 hours or more without epidural

Multipara

  • 3 hours or more with epidural
  • 2 hours or more without epidural


Neither of these guidelines mandates a cesarean section after these timeframes, but that should certainly be kept in mind, per Dr. Wenstrom (NPIC, 2015).


Summary 

Very little about the physiology of birth has changed since Friedman’s curve. We simply got ourselves in a jam by using incomplete data. That’s the value of our current, more sophisticated approaches to research. What was considered slow labor in Dr. Friedman’s day is actually the normal rate of dilation for the majority of women. If we continue to use Friedman’s curve, we are saying that half of all women have abnormally slow labors. This means there is something very wrong with our definition of abnormal. Instead of “failure to progress,” perhaps the majority of our c-sections are a result of “failure to wait.”

References


ACOG and the Society of Maternal-Fetal Medicine, (2014). Obstetric Care Consensus, Safe Prevention of the Primary Cesarean Delivery. Number 1.


CDC/NCHS. (2014). Retrieved March 1, 2015. http://www.cdc.gov/nchs/data/databriefs/db155.htm


National Perinatal Information Center (NPIC), (2015). Comparing Data, Improving Quality, Driving Value. Presenter, Dr. Katharine Wenstrom. education@npic.org


Spong, C. Y., Berghella, V., Wenstrom, K. D., Mercer, B. M., & Saade, G. R. (2012). Preventing the first cesarean delivery. Summary of a joint Eunice kennedy Shriver National Institute of Child Health and human Development, Society for Maternal-Fetal Medicine, and American College of Obstetricians and gynecologists Workshop. Obstet Gynecol, 120:1181-1193.

Member Spotlight: Trish Alexander, RNC, BSN

Introducing the Northeast Oregon AWHONN Chapter

Greetings from Eastern Oregon! My name is Trish Alexander. I graduated from Oregon Health Science University with a Bachelor’s degree in Nursing in 1998. I have worked in various areas of nursing throughout my career, my favorite being Labor and Delivery. Currently, I am the Family Birthing Center Manager at Grande Ronde Hospital in La Grande, Oregon. This is a new role for me (it was a year in January), and boy has it been a learning experience! I am blessed to be able to work with some of the best nurses in Oregon. They have been patient with me as I have learned what my new role entails and have inspired me to become more involved in professional organizations like AWHONN.


I have been a member of AWHONN for one year now and I can honestly say it has been one of the most rewarding years of my life. As a member, I have immersed myself in taking advantage of the many features this organization has to offer. From the webinars, to the journal subscriptions, to attending the National Conference in Orlando, Florida last year; I have learned about the endless resources that are available to nurses from AWHONN in this field. I have been able to meet and network with other healthcare professionals which have helped to strengthen my own practice. As a nurse manager, I have utilized resources to develop policies and protocols to provide the most up-to-date, safe patient care to the women and newborns in our community. 


I am very excited for the opportunity to become a chapter leader and re-engage Northeastern Oregon in AWHONN. My goal for the upcoming year is to increase membership in Northeastern Oregon and to educate and encourage current members to get involved in the activities AWHONN has to offer. I encourage you to contact me at neoregon@oregonawhonn.org if you or one of your colleagues is curious about AWHONN and the opportunities that come with membership. I am looking forward to meeting you all at the Fall Conference in Medford!


Know an Oregon AWHONN member

 that deserves to be in the spotlight?

Send us your story

www.oregonawhonn.org/contact

AWHONN National Recruiter of the Year 2014!

Congratulations to Oregon’s own

Kendra Crawford


Thanks to Kendra’s recruiting efforts, she was named this year’s AWHONN National Recruiter of the Year! She introduced a total of 17 new members to the many benefits of AWHONN membership. When asked about tips and tricks for recruiting new members, she says, “Be genuine and look for opportunities to recruit new members... Recruiting is a collaborative effort. I wouldn’t have been this successful without the help of the Oregon Section.” Congratulations Kendra! Read More

Oregon AWHONN Wins Again

by Deb Castile, MN, RNC, CNS, NE


Oregon ROCKS!!!!!

I just had to tell you, in case you didn’t know. If it’s proof you want, I have some for you.....

For the second year in a row, Oregon AWHONN won the Every Women, Every Baby (EWEB) campaign for participation. 


To determine the Section winner of the national EWEB campaign, AWHONN headquarters looks at the total number of members within each section (state) and the total number of donors who reside within that section to determine participation percentages. This means that members and non-members alike impact participation in the EWEB campaign. Oregon AWHONN had a 9.63% participation rate for 2014. This number was actually down from 13.2% in 2013, however it was enough to keep us ahead of the next closest section by greater than 1% participation. 


Our total contribution went up in 2014 from 2013. Oregon donated a total of $1,892 in 2013 and $3,009 in 2014. Oregon was 9th overall for total dollar contribution. Total dollar contribution goes to California this year.


Oregon’s reward from AWHONN headquarters is one free convention registration to the 2015 Convention in Long Beach, CA. An award like this belongs in the hands of the donors. So, from the list of Oregon Section donor names, Sharon Baker's name was drawn and will have her 2015 AWHONN Convention registration fee covered by AWHONN. Congratulations Sharon!


Oregon, you all have much to be proud of. Pat yourself on the back for a job well done. Your contributions support our work to improve care for late preterm infants, increase breastfeeding, champion spontaneous labor and encourage healthier habits for women at every stage of life. I am so proud to represent all of you. 


Can we do three years in a row? Donate today at www.awhonn.org/donate.

Chapter News

Southern Oregon

by Linda Veltri, PhD, RN


Greetings from Southern Oregon! Thanks to Ginnie Kim and Dawn Varney for their excellent presentation on Helping Babies Breathe at our November chapter meeting. We had a record attendance at this meeting! Just a few short weeks following the meeting, Ginnie, Dawn, Linda Veltri, and other nurses from across the United States traveled to Southern India to train 98 nursing students and their instructors how to Help Babies Breathe. As a bonus we were able to leave seven baby manikins, ambu bags and bulb syringes on the maternity unit of a local hospital. 


We are so pleased to welcome you all to Southern Oregon for the 2015 fall conference. Hope a trip down the Rouge River, attending the Ashland Shakespeare festival or ziplining is on your to do list while in the area.

Central Oregon

by Mara Kerr, MN, RN


The Central Oregon section will be meeting on April 14th at 6:00 pm in the Health Careers Center at Central Oregon Community College. There will be a brief section meeting followed by the presentation of an AWHONN webinar titled “The Myths and Truths of Amniotic Fluid Embolism/Anaphylactoid Syndrome of Pregnancy.” All are welcome to attend and learn more about AWHONN. Contact Mara Kerr at 541-383-7265.

Call for Oregon Section Elected Position Nominations

by Robin Cothrell-Tubbs, MN, RN


Every two years, each AWHONN Section holds elections for its respective Section. This year marks another election year for our Oregon Section. Elected positions open for nominations are: 


  • Section Chair
  • Section Secretary/Treasurer


Elected positions in these roles serve two-year terms.  


National AWHONN will be posting MUCH MORE information on or by April 1, 2015, including position descriptions and expectations, and the instructions, requirements, and deadlines for the application process.


Be sure to visit the AWHONN website www.awhonn.org for that information on or after April 1!


As the chair of the Oregon Section Nominating Committee, I am happy to answer any questions you might have.  Feel free to email me at conference2@oregonawhonn.org.

Welcome Oregon AWHONN New Members

Trisha D. Alexander

Patricia Ann Berdan

Molly M. Burtchaell

Tamara Calkum

Katey Card

Danielle Contreras

Allison Drew

Susan Farthing

Jennifer Marie Grinde

Lisa Hindman

Margo K. Huntsman

Cara M. Johnson

Olivia Kestle Kaufman

Ginnie L. Kim

Bernadette Lisac

Helen Louise Parker

Trisha Marie Parshall

Maribeth Roberts

Chris Schneekloth

Holli Tuss


Oregon AWHONN finished the year strong in regards to new members! In 2013, we had a total of 32 new members. This past calendar year, we welcomed 102 new members into the Oregon section. We’re so glad to have you all as part of our professional organization. We are doing and will continue to do great things for the health and well being of women and neonates. Don’t forget! Recruit three new members and receive a free membership!