Oregon AWHONN

Promoting the Health of Women and Newborns

September 2018 Vol. 5 No. 3

In This Issue

Join Us at Oregon AWHONN's Premier Event

Oceans of Knowledge & Inspiration…that’s what your Oregon AWHONN Fall Conference Committee has in store for you this year! From how to work as a better team, to what’s the latest on marijuana use in pregnancy, to how interventional radiology procedures save lives (and uterus). From female sexuality (things you never knew!), to updates on all things newborn, to how to survive feeling “swamped” at work. And much more!


Expert nurses, physicians and other clinicians will bring the latest evidence-based practice & research that you can add to your clinical practice. Some of our speakers you may know. Like Pat Scheans, NNP extraordinaire. And Dr. Lishiana Shaffer from OHSU. But we’ve kicked it up a notch by bringing in AWHONN Board members (past & present) Cheryl Roth from AZ and Helen Hurst from LA. They bring new perspective and insights to both clinical practice and clinical leadership.


We also want you to have a little fun and relaxation. We have a networking/vendor fair Sunday evening, so you can mingle and meet new friends. On Monday eve, Hester Carr, CNS for Legacy Women’s Services, will entertain us in the Attic Lounge at Salishan. Did you know Hester is an amazing singer & guitar player? Hope you will join us. And, of course, the grounds of Salishan are beautiful and only a short walk from the beach.


Don’t forget to bring red to wear on Tuesday to support the American Heart Association’s Go Red for Women campaign. And we are having a Diaper Drive to benefit local charity Family Promise of Lincoln City. Would love to give them a years’ worth of diapers! Bring any size diapers.


You still have time to register at a discounted price until September 16. Go to oregonawhonn.org/registration.


We look forward to seeing familiar faces and meeting new AWHONN members! See you at the beach!

We are expecting a full turnout!
On-site registrations may not
be available due to limited capacity.

Women's Health Update

Severe Hypertension Treatment in Pregnancy: Making a Difference in Maternal Outcomes

by Kara Johnson, DNP, RNC-OB, CNS


Hypertensive disorders of pregnancy are one of the leading causes of preventable maternal morbidity and mortality. Hypertensive related complications can be significantly reduced with timely recognition and appropriate treatment. ACOG’s Task Force on Hypertension report was released in November of 2013 with severe hypertension treatment recommendations. Are we making a difference in decreasing maternal morbidity and mortality related to severe hypertension treatment?


Multiple studies have demonstrated that almost half of pregnancy-related deaths are preventable (Ozimek & Kilpatrick, 2018). Preeclampsia related deaths have been deemed one of the most preventable with high rates of delayed response to symptoms and vital signs, ineffective control of hypertension, inadequate staff knowledge around blood pressure management, misdiagnosis, and lack of continuity of care (Main, McCain, Morton, Holtby, & Lawton, 2015). 


Severe range blood pressure (particularly systolic blood pressure of 160 mmHg or higher) may be associated with pregnancy-associated stroke (ACOG, 2013). ACOG supports administration of antihypertensive agents with a sustained systolic blood pressure of 160 mmHg or higher, or diastolic 110 mmHg or higher. First line treatment agents for severe hypertension include intravenous labetalol, intravenous hydralazine, and oral nifedipine. 


A retrospective study in patients with severe preeclampsia admitted for delivery between 2006 to 2014 demonstrated that intravenous labetalol use increased 11.1%, oral labetalol 10.1%, hydralazine 4.0%, nifedipine 3.9%, and more than one medication 10.7%. Individual hospital rates of antihypertensive administration to patients with severe preeclampsia differed significantly. The median hospital-level rate of antihypertensive administration to patients with severe preeclampsia was 60.0% with the 25th and 75th percentiles 52.7% and 67.9%, respectively (Cleary et al, 2018). 

Cleary et al, Obstet Gynecol 2018

Protocols and timely administration of antihypertensive medication decreases the risk for hypertension-related fatal intracranial hemorrhage. Antihypertensive treatment also prevents renal injury and cardiovascular complications, specifically congestive heart failure and myocardial ischemia. Increases in antihypertensive medication use has been associated with a decreased risk of stroke in patients with severe preeclampsia from 13.5 cases per 10,000 deliveries from 2006-2008 to 9.7 cases per 10,000 deliveries from 2009-2011 to 6.0 cases per 10,000 from 2012-2014 (Cleary et al, 2018). 


Although we have seen a significant increase in antihypertensive medication treatment and a decrease in stroke risk for patients with severe preeclampsia, many hospitals continue to have opportunities to improve severe hypertension treatment. In a retrospective study the majority of 301 hospitals, with 50 or more patients with severe preeclampsia, had lower than 80% antihypertensive administration treatment rates (Cleary et al, 2018). 


How nurses can continue to make a difference:

  • Standardize practices on blood pressure measurement to ensure accuracy.
  • Advocate for patient treatment to improve outcomes. Follow acute hypertension treatment orders and facility protocols. Escalate concerns through chain of command if needed.
  • Identify and report barriers to treatment such as medication access.
  • Provide education and share learnings with peers.
  • Ask if your facility tracks antihypertensive treatment rates for severe hypertension. 
  • Develop a quality improvement project that will increase rates at your hospital.

Thank you for your commitment to maternal patient safety!

References


American College of Obstetricians and Gynecologists Task Force on Hypertension in Pregnancy. (2013). Hypertension in pregnancy. Retrieved September 3, 2018 from https://www.acog.org/Clinical-Guidance-and-Publications/Task-Force-and-Work-Group-Reports/Hypertension-in-Pregnancy


Bernstein, P.S., Martin, J.N., Barton, J.R., Shields, L.E., Druzin, M.L., Scavone, B.M., Frost, J., Morton, C.H., Ruhl, C., Slager, J., Tsigas, E.Z., Jaffer, S., & Menard, M.K. (2017). National Partnership for Maternal Safety: Consensus bundle on severe hypertension during pregnancy and the postpartum period. Obstetrics & Gynecology, 130, 347-357. doi: 10.1097/AOG.0000000000002115

Cleary, K.L., Siddiq, Z., Ananth, C.V., Wright, J.D., Too, G., D’Alton, M.E., & Friedman, A.M. (2018). Use of antihypertensive medications during hospitalizations complicated by preeclampsia. Obstetrics & Gynecology, 131, 441-450. doi: 10.1097/AOG.0000000000002479


Main, E.K., McCain, C.L., Morton, C.H., Holtby, S. & Lawton, E.S. (2015). Pregnancy-related mortality in California: Causes, characteristics, and improvement opportunities. Obstetrics & Gynecology, 125, 938-947. doi: 10.1097/AOG.0000000000000746


Ozimek, J.A., & Kilpatrick, S.J. (2018). Maternal mortality in the twenty-first century. Obstetrics Gynecology Clinics North America, 45, 175-186. doi: 10.1016/j.ogc.2018.01.0040889-8545

Neonatal Update

News about NOWS: Neonatal Opioid Withdrawal Syndrome

by Pat Scheans, DNP, NNP-BC


Test your knowledge - true or false:

  1. Opioid use by pregnant women in the United States has doubled in the past decade.
  2. Babies of narcotic using mothers are born addicted due to prenatal exposure.
  3. The severity of withdrawal is predictable based on maternal drug or dose. 
  4. Symptoms of withdrawal include hypertonia and poor feeding.
  5. Annual hospital costs for treatment of NAS is over a billion dollars nationally.

Read on for the answers…


Opioid use by pregnant women in the United States has tripled in the past decade. This has led to an increase in Neonatal Opioid Withdrawal Syndrome (NOWS) from 1.2 per 1000 births in 2000 to 5.8 per 1000 births in 2012 (Grossman, et al, 2018). You may be more familiar with the term Neonatal Abstinence Syndrome (NAS). It has been used to describe withdrawal from opioids, but it is not specific, and may refer to withdrawal from other substances such as alcohol or nicotine. 


Affected babies are opioid dependent -- not addicted -- as addiction is behavioral with psychological components. Withdrawal symptoms are the body’s physical response to the absence of substances that opioid receptors have become dependent on. These receptors are concentrated in the central nervous system and the gastrointestinal tract. Opioid withdrawal may therefore manifest as altered sleep, increased muscle tone, tremors, irritability, high-pitched cry, poor feeding, vomiting and diarrhea.


Not all opioid-exposed infants will experience NOWS, nor is the severity of withdrawal predictable based on maternal drug or dose. Symptoms may appear 24-72 hours after birth/last maternal use depending in the half-life of the drug, which is why the AAP recommends that intrauterine drug exposed (IUDE) babies be observed in the hospital for 5-7 days (Kocherlakota, 2014).


There is wide variation in management of NOWS by region, inpatient unit and provider preference. Approximately 70% of NOWS is treated pharmacologically to ease withdrawal symptoms (Wachman, Schiff, Silverstein, 2018). This greatly prolongs the length of stay and associated cost of care. The average length of stay (ALOS) is 17 to 22 days for pharmacologically treated  NOWS. The average cost of care for these babies is over $40,000…an estimated $1.5 billion in hospital charges in 2012 (Grossman, et al., 2018).


It can be difficult to assess withdrawal symptoms and decide on treatment. Many hospitals use the Finnegan tool, which uses over 20 symptoms to assess withdrawal and guide management. Recently, Grossman, Lipshaw, Osborn and Berkwitt (2017) described a new “common sense” approach to NOWS called the Eat, Sleep, Console (ESC) model. This simple tool is based on functional well-being: is the baby acting like a baby? The ESC approach asks three questions to assess whether the NOWS baby requires treatment for opioid withdrawal:

E – Eat: can the baby feed 1 ounce or more, or breastfeed well?

S – Sleep: can the baby sleep undisturbed for an hour or longer? 

C – Console: can the baby be consoled, if crying, in 10 minutes or less?

If all three criteria are met, the baby is well-managed and does not need additional treatment.  Treatment emphasizes non-pharmacologic measures which are considered medicine and are the first line to control symptoms.  These interventions include a dark, quiet environment avoiding excess stimulation (no TV), rooming-in and increased family integration, on-demand feeding, breastfeeding (for mothers maintained on methadone or buprenorphine), kangaroo care, swaddling and aggressive skin care for the diaper area (Wachman, Schoff, Silverstein, 2018; Holmes, Atwood, Whalen, 2016; Boucher, 2017; Macmillan, Rendon, Verna, et al., 2018). Nonpharmacologic interventions are maximized before adding pharmacologic treatment with oral morphine or methadone.


There are emerging reports of the success of the ESC approach. In general, pharmacologic treatment was cut in half, and length of hospitalization fell by a third (Wachman, Grossman, Schiff, et al, 2018).  This is a win-win for all, as well as healthcare utilization. 


One last question for you:

When’s the last time a change at your hospital made patient care simpler, easier and less expensive?

Resources


1. Grossman MR, Lipshaw MJ, Osborn RR, Berkwitt AK. A novel approach to assessing infants with neonatal abstinence syndrome. Hospital Pediatrics. 2017; 8 (1): doi: 10.1542/hpeds.2017-0128


2. Kocherlakota P. Neonatal abstinence syndrome. Pediatrics. 2014; 134 (2): e547-e561; doi: 10.1542/peds.2013-3524


3. Wachman EM, Schiff DM, Silverstein M. Neonatal abstinence syndrome: Advances in diagnosis and treatment. JAMA. 2018; 319(13): 1362-1374. doi: 10.1001/jama.2018.2640


4. Holmes AV, Atwood EC, Whalen B, et al. Rooming-in to treat neonatal abstinence syndrome: improved family-centered care at lower cost. Pediatrics. 2016; 137(6): e20152929.doi: 10.1542/peds.2015-2929


5. Boucher AM. Nonopioid management of neonatal abstinence syndrome. Advances in Neonatal Care. 2017; 17(2): 84-90. doi: 10.1097/ANC.0000000000000371


6. MacMillan K, Rendon C, Verma K, et al. Association of rooming-in with outcomes for neonatal abstinence syndrome: A systematic review and meta-analysis. JAMA Pediatrics. 2018; 172(4): 345-351. doi: 10.1001/jamapediatrics.2017.5195


7. Wachman EM, Grossman M, Schiff DM, et al. Quality improvement initiative to improve inpatient outcomes for neonatal abstinence syndrome. Journal of Perinatology. 2018; 1: doi: 10.1038/s41372-018-0109-8

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Success is no accident. It is hard work, perseverance, learning, studying, sacrifice and most of all, love of what you are doing or learning to do.

Pele