WHAT IS ADDICTION? - UAB · WHAT IS ADDICTION? Sandra L. Frazier, ... esp. knees lower than hips •Squatting ... Obstetric, and Neonatal Nurses

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WHAT IS ADDICTION?

Sandra L. Frazier, MD, FASAM

Assistant Dean of Professional Development

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ADDICTION

• 3 C’s

Reduction of Control

Compulsive use

Use in spite of negative Consequences

PROFESSIONAL DEVELOPMENT OFFICE

Sandra Frazier, MD

(205)731-9799

[email protected]

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Sheila Lopez, MSN,CNM

DON’T HOLD YOUR BREATH-

EVIDENCED BASED PUSHING

No conflict of interest

• I have no financial or other conflicts of interests related to this presentation.

Objectives: At the end of the course participants will be able to:

• Identify benefits to un-directed, open-glottis pushing for both mother and fetus.

• Identify strategies to facilitate patient education of open-glottis pushing techniques for the RN or other care provider at the bedside.

• Define labor dystocia and factors that contribute to slowed labor progress.

• Identify techniques, including optimal positioning, that promote labor progress and prevent or treat labor dystocia.

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Supporting Physiologic Birth

“Nature does not hurry, yet everything is accomplished.”

~Lao Tzu

Normal Physiology of Second Stage of Labor:

• Latent phase:

• “Resting phase”

• Lull in contractions for 20-30 minutes

• Not experienced by all laboring women

• Active phase:

• Contractions resume

• Often more intense

• Involuntary urge to push

• Fetal descent

(Simkin & Ancheta, 2011)

Ferguson Reflex • Involuntary pushing

• Caused by positive feedback loop: • Cervical and vaginal stretching

• Increased oxytocin release

• Occurs when fetal head is at 0 to +1 station

http://intranet.tdmu.edu.ua/data/kafedra/internal/ginecology2/classes_stud/en/nurse/bsn/ptn/4/Nursing%20Care%20of%20Childbearing%20Family_Practicum/16.%20Labor%20and%20birth%20process..files/image006.gif

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Physiology of closed-glottis (Valsalva) pushing

• Venous return and CO decreases

• Maternal arterial BP decreases then elevates suddenly

• Maternal O2 saturation and placental blood flow decreases

• Maternal CO2 increases

• Lactic acidosis begins to develop

• Vaginal canal and pelvic musculature is distended rapidly

• Oxygen available to the fetus is decreased

Maternal-

• Increased perineal trauma

• Structural and/or neurologic injury to the pelvic floor

Fetal-

• Increased non-reassuring fetal heart rate patterns

• Lower APGAR scores

• Fetal acidemia

With prolonged breath holding and straining: May lead to:

(Roberts & Hanson, 2007; Simkin & Ancheta, 2011)

Spontaneous Undirected Pushing

• AWHONN Perinatal Nursing Quality Measure B:

• Goal: 100%

• Documentation

Definition:

• AWHONN defines spontaneous pushing as “a mother’s response to a natural urge to push or a bearing down effort that comes and goes several times during each contraction. It does not involve timed breath holding or counting to 10.”

(AWHONN,2014)

Spontaneous Undirected Pushing • Woman experiences several urges

to bear down, that last for 5-7 seconds each and breathes several times between pushes.

Benefits:

• Duration, force, and timing of bearing down efforts are directed by the mother.

• Decreases maternal fatigue, active pushing time, and operative delivery, and perineal trauma

Potential Risks:

• Increases second stage total length

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EBP Pushing

LITERATURE REVIEW

Pushing/ Bearing down methods for the second stage of labour by Lemos et al, 2015. • Cochrane review:

• 20 studies with total N= 815 of spontaneous vs directed pushing

• 13 studies with total N= 2879 comparing delayed pushing vs immediate pushing with epidural anesthesia.

• Spontaneous vs. Directed:

• No difference in second stage length

• No difference in perineal lacerations and episiotomy

• No difference in neonatal outcomes- APGAR scores, NICU admissions

• Active pushing time lessened by 5 mins for spontaneous pushing group

• Delayed vs. Immediate pushing:

• Second stage increased by 54 min for delayed pushing

• Active pushing decreased by 20 min in delayed pushing group

• Increased intrapartum care cost

• Neonatal outcomes similar except one study reported increased risk of low umbilical cord pH in delayed pushing group

A randomized trial of the effects of coached vs uncoached maternal pushing during the second stage of labor on postpartum pelvic floor structure and function; Schaffer et al, 2004 • Coached N= 67 nulliparous women

• Uncoached N=61 nulliparous women

• Urodynamic indices were negatively affected in the coached group

• First urge to void significantly decreased

• Bladder capacity decreased

• Trend towards detrusor over-activity

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A randomized controlled trial comparing the physiological and directed pushing on the duration of the second stage of labor, the mode of delivery and Apgar score; Jahdi et al, 2011

• Spontaneous and undirected N=100

• Second stage was shortened 10 min for nulliparas and 7 mins for multiparas

• Closed-glottis, supine, coached immediate pushing (Control) N=91

• No differences in mode of delivery or Apgar scores

Evidence Based Pushing

NURSING IMPLICATIONS

How should we teach pushing?

• Best practices show that we actually shouldn’t “teach” it at all.

“Do what comes naturally.”

• Best maternal and fetal outcomes occur when pushing efforts are:

• Spontaneous

• Un-Directed

• Open-glottis

(AWHONN, 2014;Roberts & Hanson, 2007; Simkin & Ancheta, 2011)

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Nursing Implications • Wait for woman’s report of sensation of pressure or need to push

prior to initiation of active pushing

• Assist woman to remain up-right, gravity-neutral positions

• Encourage grunting, groaning, or vocalization during pushing

• Provide information and feedback as encouragement

• “ You’re moving the baby.”

• “That’s it. That’s the right spot.”

• “Good job.”

• “I see her/his head.”

• Avoid directing pushing efforts if fetal descent is evident

• Do not say:

• “Harder.” “Longer.” “Mas forte” or “Forte”

• “Hold your breath and bear down.”

• “Push here.” (AWHONN, 2014;Roberts & Hanson, 2007; Simkin & Ancheta, 2011)

ACOG Recommendations to Reduce Intervention • When not coached to breathe in a

specific way, women push with an open glottis. In consideration of the limited data regarding outcomes of spontaneous versus Valsalva pushing, each woman should be encouraged to use the technique that she prefers and is most effective for her.

• In the absence of an indication for expeditious delivery, women (particularly those who are nulliparous with epidural analgesia) may be offered a period of rest of 1–2 hours (unless the woman has an urge to bear down sooner) at the onset of the second stage of labor.

https://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Approaches-to-Limit-Intervention-During-Labor-and-Birth

Spontaneous vaginal birth

Effective pushing and improved progress

Directed pushing

Ineffective pushing for 20 mins

Change position (try several)

No improvement in 4 to 6 contractions

No improvement in 4 to 6 contractions

Open eyes and look downward: “self-directed

pushing”


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Additional Learning: • Labor Progress Handbook by Penny Simkin

• ACOG Committee Opinion 687 Approaches to Limit Intervention During Labor and Birth

• www.evidencebasedbirth.org

To resolve or prevent labor dystocia

POSITIONING TECHNIQUES

Labor Progress

• 6 ways to progress in labor:

• Cervix moves from posterior to anterior

• Ripening

• Effacement

• Dilation

• Fetal rotation, and molding

• Fetal descent

• 4 “Ps” that affect labor:

• Passageway

• Passenger

• Powers

• Psyche


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Causes of prolonged labor • Passenger: • CPD/ macrosomia

• Malpositioning

• Asynclitism

• OP

• Deflexed head

• Passageway: • CPD

• Powers: • Inadequate uterine intensity or

frequency

• Psyche: • Fear

• Exhaustion

• Iatrogenic:

• Dehydration

• Restriction of movement

• Epidural anesthesia

• Relaxation of pelvic floor

• Inhibition of Ferguson Reflex


CPD, macrosomia, or “poor fit”

• Utilize positions that alter force of gravity, pelvic dimensions, and pressures on pelvic joints

• Sitting upright, esp. knees lower than hips

• Squatting

• Increases intertuberous diameter

• Encourages descent

• Forward-leaning positions

• Open-knee chest

• Kneeling, leaning on partner, ball, or bed/chair

• Hands and knees

• Standing, leaning on bed

• Straddling and chair or toilet

• Enlarges pelvic inlet

• Aligns fetus with pelvis

• Some also utilize gravity

• May relieve cord compression


Asynclitism • One parietal bone enter the pelvis first

• Slows labor if persists at a low station

• Suspect if:

• PROM at term

• Irregular contractions

• Coupling or grouping of contractions

• Ctx space out in active labor

• Rate of progression plateaus in active labor

• C/O back pain

• Uncontrollable urge to push prior to complete dilation


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http://intranet.tdmu.edu.ua/data/kafedra/internal/ginecology2/classes_stud/en/nurse/adn/ptn/2/Nursing%20Care%20of%20Childbearing%20Family/02.%20Unit%20test%20II.htm

Frontal suture

https://classconnection.s3.amazonaws.com/20/flashcards/573020/jpg/fotosearch_cog120441321414422442.jpg

Occiput Posterior & Occiput Transverse OP: 15-30%

• ROP 5x’s > LOP

• Flexion of the fetal head is imperfect

• Results in longer presenting diameter

• Delivery can occur with:

• Rotation to OA

• Rotation to direct OP

• Arrest can occur

• High in pelvis- usually poor fit

• Midpelvis- no rotation or partial rotation to direct OP or OT

• Arrest at the outlet

OT: Most babies begin labor in LOT and rotate to LOA/OA

• Arrest can occur:

• No rotation

• Posterior rotation

• Partial rotation to OA without completion to LOA

(Oxorn, 1986)

Strategies to correct malpositioning: Trial and error of:

• Asymmetric positions • Walking on un-even surface/stair

climbing

• Kneeling

• Lunge

• Peanut ball

• alternate sides every few contractions

• Forward leaning positions:

• Open knee-chest

• Hands and knees

• Leaning on a ball

• Sitting leaning forward

• Kneeling leaning forward

• combine with pelvic rocking


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Side lying techniques

Baby’s back towards bed

• Encourages head to rotate to OT

Baby’s back toward the ceiling

• Gravity pulls head to OT then OA

Side-lying lunge

• Widens the pelvis to improve chances of fetal rotation

Pure side lying Semi-prone

https://www.scienceandsensibility.org/positioning-during-second-stage-of-labor-dorsal-lithotomy-vs-lateral-lying/

http://media-cache-ec0.pinimg.com/236x/66/44/3f/66443fd531c0b49432da9fe4c9fa8908.jpg

https://birthowl.wordpress.com/2008/02/15/positions-for-labor-and-birth/


Walking and stair-climbing: Walking:

• Shortens labor

• Reduces risk of Cesarean section

• Slight but repeated changes in alignment of pelvic joints encourage fetal rotation and descent

• Use gravity to advantage

• Often improves morale

Stair climbing:

• Continue climbing through contractions, if possible

• Can pause with legs spread wide on stairs in a lunge

• Can face the rail and move up and down stairs laterally

• May be tiring


Positions to avoid : • Squatting

• May decrease space available for fetal head to correct asynclitism

• Semi-sitting & Supine

• Gravity pushes fetal head against spine

• Prevents rotation

• Increases back pain

• May increase risk of supine hypotension

http://img.webmd.com/dtmcms/live/webmd/consumer_assets/site_images/tools/fetal-positions-slideshow/tool_occiput_cephalic_posterior.gif (Simkin & Ancheta, 2011)

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Immobility and ineffective contractions: Ineffective contractions: • Walking and upright positions

• Upright positions with knees lower than hips

• Consider exhaustion

Immobility: • Rollover sequence: if no malposition is suspected

• Avoid positions not tolerated by woman or fetus

• Move every 20-30 mins through: • Semi-sitting

• Left side-lying • Left semi-prone

• Hands and knees

• Right semi-prone • Right side-lying

• Repeat (Simkin & Ancheta, 2011)

Exhaustion: • May cause ineffective contractions through lactic acid accumulation

in myometrial cells.

• Positions to allow rest and progression:

• Hydrotherapy

• Hands & knees

• Kneeling

• Side-lying

• Semi-prone

• Supported leaning- sitting, kneeling or standing

• Semi-sitting


Reducing length of labor and cesarean surgery rate using a peanut ball for women laboring with an epidural; Tussey et al, 2015

• Randomized Controlled Trial

• Standard care: n= 94

• Positioned in semi or high Fowler’s

• Turned every 1-2 hours

• Peanut ball intervention: n= 107

• Ball placed between knees after epidural placed

• Removed when completely dilated and effaced

• Results:

• Shorter first stage: 29 mins shorter, adjusted

• Shorter second stage: 11 mins shorter

• Fewer cesareans: 21% vs 10%

• Well received by women

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Peanut ball variations:

Persistent Anterior Lip • Side-lying lunge, or peanut ball

• Releases “trapped” cervix

• Hands and Knees

• Closed knee chest position

• Antigravity

• Spreads ischia, enlarging pelvic outlet

References: • Association of Women's Health, Obstetric, and Neonatal Nurses. (2014). Women's Health and Perinatal Nursing Care

Quality Refined Draft Measures Specifications. Retrieved February 2, 2016, from http://c.ymcdn.com/sites/www.awhonn.org/resource/resmgr/Downloadables/perinatalquality measures_ref.pdf

• Bloom, S. L., Casey, B. M., Schaffer, J. I., McIntire, D. D., & Leveno, K. J. (2006). A randomized trial of coached versus uncoached maternal pushing during the second stage of labor. American Journal of Obstetrics and Gynecology, 194(10-3), 124-324.

• Jahdi, F., Shahnazari, M., Kashanian, M., Farahani, M. A., & Haghani, H. (2011, May). A randomized controlled trial comparing the physiological and directed pushing on the duration of the second stage of labor, the mode of delivery and Apgar score. International Journal of Nursing and Midwifery, 3(5). Retrieved from http://www.academicjournals.org/ijnm

• Lawrence, A., Lewis, L., Justus Hofmeyr, G., & Styles, C. (2013, October 9). Maternal positions and mobility during first stage labour. The Cochrane Library. doi:10.1002/14651858.CD003934.pub4

• Lemos, A., Amorim, M., de Andrade, D., de Souza, A., & Cabral, F. J. (2015, October 9). Pushing/ bearing down methods for the second stage of labour. Cochrane Database. doi:10.1002/14651858.CD009124

• Lythgoe, A. (2014, April 8). Peanut Balls for Labor – A Valuable Tool for Promoting Progress?. In Science and Senisbility. Retrieved from https://www.scienceandsensibility.org/peanut-balls-for-labor/

• Oxorn, H. (1986). Human Labor & Birth (5th ed.). New Delhi, India: Tata McGraw-Hill.

• Roberts, J., & Hanson, L. (2007, May). Best Practices in Second Stage Labor Care: Maternal Bearing Down and Positioning. Journal of Midwifery and Women's Health, 52(3), 238-245. doi:10.1016/j.jmwh.2006.12.011

• Schaffer, J. I., Bloom, S. L., Casey, B. M., McIntire, D. D., Nihira, M. A., & Leveno, K. J. (2005). A randomized trial of the effects of coached vs uncoached maternal pushing during the second sage of labor on postpartum pelvic floor structure and function. American Journal of Obstetrics and Gynecology, 192, 1692-1696. doi:10.1016/j.ajog.2004.11.043

• Simkin, P., & Ancheta, i. (2011). The Labor Progress Handbook: Early Techniques to Prevent and Treat Dystocia (3rd ed., pp. 124-324). Oxford, UK: Wiley-Blackwell.

• Tussey, C. M., Botsios, E., Gerkin, R. D., Kelly, L. A., Gamez, J., & Mensik, J. (2015). Reducing Length of Labor and Cesarean Surgery Rate Using a Peanut Ball for Women Laboring With an Epidural. Journal Of Perinatal Education, 24(1), 16-24 9p. doi:10.1891/1058-1243.24.1.16

http://c.ymcdn.com/sites/www.awhonn.org/resource/resmgr/Downloadables/perinatalquality

http://www.academicjournals.org/ijnm

https://www.scienceandsensibility.org/peanut-balls-for-labor/







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2017 Update: HIV & Pregnancy

2017 Progress in OB/GYN Conference

Jodie Dionne-Odom, MD, 1917 HIV Clinic, Division of Infectious Diseases

Mickey Parks, FNP-BC, Center for Women’s Reproductive Health

University of Alabama at Birmingham

10 February 2017

Disclosures

• Dr. Dionne-Odom receives funding from:

• NIH/NICHD (1K23HD090993)

• CDC Division of STD Prevention

• Mickey Parks, FNP-BC, has no financial disclosures.

Outline

• Part 1:

• Epidemiology (United States and Alabama)

• Vertical Transmission

• Treatment Recommendations

• PReP and Pregnancy

• Part 2:

• HIV Screening

• Approach to Care

• Intrapartum and Post Partum Care

• Resources

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US HIV Epidemiology

Rates of Persons Living with Diagnosed HIV, by County, 2013

Living with Diagnosed HIV, by County, 2013

Aidsvu.org

Diagnoses of HIV Infection among Adults and Adolescents, by Sex and

Transmission Category, 2015—United States and 6 Dependent Areas

CDC.gov

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Adults and Adolescents Living with Diagnosed HIV Infection, by Sex and Race/Ethnicity, Year-end

2014—United States and 6 Dependent Areas

Note. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. a Includes Asian/Pacific Islander legacy cases. b Hispanics/Latinos can be of any race.

CDC.gov

Alabama HIV Epidemiology

http://www.adph.org/aids/assets/2014_HIVSurveillance_AnnualUpdate_FINAL_reEditedVersion.pdf

2014 Alabama HIV Annual Surveillance Report

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Fundamentals of HIV

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Natural History of HIV

Vertical transmission of HIV

• 1) Transplacental

• 2) Labor and Delivery

• 3) Breast Feeding

• Maternal Viral Load is always a key predictor of transmission

HIV in Pregnancy

0

5

10

15

20

25

Tra

nsm

issi

on

Rate

(%)

none AZT mono dual

therapy

HAART

Antenatal Treatment & MTCT

Cooper JAIDS 2002;29

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Duration, timing & complexity of ART regimens impact

effectiveness to reduce MTCT

Maternal ART prophylaxis

sd-NVP

sc AZT + Sd-NVP Daily Infant NVP

Maternal therapeutic ART

Courtesy of Lynne Mofenson, NICHD

• 8075 mother-infant pairs

• Followed prospectively in France 2000-2011.

• Cohort analyzed according to maternal viral load at delivery and timing of ART initiation.

• 56/8075 vertical transmissions (0.7%).

• None among 2651 women with VL <50 before conception

Retention in HIV Medical Care and Viral Suppression among Persons Aged ≥13 Years Living

with Diagnosed HIV Infection, by Sex, 2013—32 States and the District of Columbia

Note. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. Retained in medical care was defined as ≥2 tests (CD4 or VL) ≥3 months apart in 2013. Viral suppression was defined as <200 copies/mL on the most recent VL test in 2013.

CDC.gov

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Case #1

• 24 year old G2P1 is 16.3 weeks pregnant and presenting for routine follow up care (visit #2).

• Her intake medical labs are notable for newly diagnosed HIV infection (4th generation screen, confirmatory test positive).

• CD4 is 455 cells/mm3, CD4 % is 38

• HIV Viral Load is 95,000 copies/mL

• Remainder of labs and STI screen are unremarkable

• She feels well and has no complaints. M partner is being tested.

• What additional labwork do you need to order today?

• Does she need to start antiretroviral therapy? PCP prophylaxis?

• Urgently?

• Which medications do you want to begin ?

Antiretroviral Drugs by Class NRTI

Abacavir (ABC) Didanosine (ddI) Emtricitabine (FTC) Lamivudine (3TC) Stavudine (d4T) Tenofovir DF (TDF) Zidovudine (AZT, ZDV)

NNRTI

Efavirenz (EFV) Etravirine (ETR) Nevirapine (NVP) Rilpivirine (RPV) Delavirdine (DLV)

PI

Atazanavir (ATV) Darunavir (DRV) Fosamprenavir (FPV) Indinavir (IDV) Lopinavir (LPV) Nelfinavir (NFV) Saquinavir (SQV) Tipranavir (TPV) Pharmacokinetic

Enhancers

Ritonavir (RTV, /r) Cobicistat (COBI)

Fusion Inhibitor

Enfuvirtide (ENF, T-20)

CCR5

Antagonist

Maraviroc (MVC)

INSTI

Raltegravir (RAL) Elvitegravir (EVG) Dolutegravir (DTG)

General Principles of Drug Selection Guidelines for use of ART for maternal health during pregnancy generally are

the same as for women who are not pregnant

Some modifications based on concerns about specific ARVs during pregnancy

Consider benefits vs risks of ARV drug use during pregnancy

Ensure that at least 1 NRTI with high placental transfer is included in cART regimen for sufficient infant preexposure prophylaxis

Counsel women on the importance of close adherence to ARV regimen

Offer support services, mental health services, smoking cessation, and drug abuse treatment plans as indicated

Coordinate care between OB/GYN, ID/HIV and Pediatric specialists.

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Initial ART for ARV-Naive Pregnant Women

Comments

ABC/3TC • Potential HSR: ABC should not be used in patients who test positive for HLA-B*5701

• Available as FDC, can be given once daily

TDF/FTC or TDF + 3TC

• Can be administered once daily • TDF has potential renal toxicity, use with caution

in patients with renal insufficiency

ZDV/3TC • Most experience for use during pregnancy • Twice-daily administration • Higher risk of hematologic toxicity

Preferred 2-NRTI Backbone Regimens

Initial ART for ARV-Naive Pregnant Women

Comments

ATV/r + preferred 2-NRTI backbone

• Once daily

LPV/r + preferred 2-NRTI backbone

• Twice-daily administration. • Once-daily LPV/r not recommended

during pregnancy

Preferred PI Regimens

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PReP: pre-conception and pregnancy

2016 HIV Perinatal Guidelines: https://aidsinfo.nih.gov/guidelines/html/3/perinatal-guidelines/0

Heffron Curr HIV/AIDS Reports 2016

Summary for Part I

• HIV infection rates are high in the southeastern US.

• More than 3500 women in Alabama have HIV.

• Vertical HIV transmission can be prevented with early diagnosis and treatment in women.

• More work is needed to improve retention in care, particularly postpartum.

• One recommended ART regimen during pregnancy is atazanavir/ritonavir and tenofovir/emtricitabine.

• Women at risk of acquiring HIV during pregnancy are expected to benefit from PReP with tdf/ftc. Studies are ongoing.

• Care coordination between OB/GYN, ID/HIV and Pediatrics is necessary.

https://aidsinfo.nih.gov/guidelines/html/3/perinatal-guidelines/0



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HIV Screening

1. Opt-out HIV test as early as possible during routine prenatal care 2. Repeat HIV in 3rd trimester (ideally before 36 weeks) for women “at risk”

or in high HIV prevalence/incidence area 3. Opt out rapid screen at delivery if not tested previously (or not

documented)

Testing and Diagnosis

• 15% of adults with HIV in the US are unaware of their infection

• In past - 3rd generation HIV testing

• Tests for antibodies (IgM/IgG)

• 3-4 week window period

• Currently – 4th generation HIV-1/2 Testing

• Tests for antibodies and HIV P24 antigen.

• 2 week window period.

• Sensitivity and specificity approach 100%

• Molecular virologic testing - HIV RNA PCR

• Not recommended for screening

• Useful if acute HIV infection is suspected

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Testing and Diagnosis

• All currently available tests look for HIV-1 and HIV-2 Ab.

• False positive screening tests can occur with autoantibodies of pregnancy.

• Reactive 3rd/4th generation test without confirmation is a “reactive test”, but not a “positive test”.

• Confirmatory testing via a different method is needed.

• Many labs have reflex confirmatory testing.

• ie - HIV differentiation assay

• Western blot is no longer recommended for confirmatory testing (longer window period for detection).

• Once HIV infection has been confirmed, follow up testing includes HIV viral load, CD4 and CBC with differential.

• If HIV diagnosis is confirmed, discuss results in person instead of over the phone.

Approach to Care

Care Basics

• New diagnosis: discuss disease and treatment, risk of transmission to the baby, partner status, support system. Initiate medication treatment, and link with an HIV care provider.

• Existing diagnosis: determine disease history, current meds (may need to initiate or change meds), HIV care provider. Discuss risk of transmission to baby, partner status, support system.

• Complete initial prenatal exam, ultrasound and labs. Also obtain: HIV viral load; CD4; CBC with diff; Basic metabolic profile; Hepatic Function Profile.

• Start conversation about birth control, safe sex with condoms and need to bottle feed.

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Intrapartum and Postpartum Care

Prenatal Care in HIV

• Monitor for medication compliance: confirm meds and doses.

• Monitor for medication side effects: nausea/vomiting and diarrhea tend to be the most common. Treat proactively.

• Monitor for candidiasis: for severe/recurrent guidelines suggest Diflucan 150 mg.

Prenatal Care – Labs and Meds

• HIV viral load and CD4 every trimester or sooner if compliance an issue.

• Viral load: “Target not detected” is undetectable.

• If VL trending up, assess adherence and consider resistance

• Obtain BMP and Hepatic Function Panel

• Prophylaxis

• CD4<200: add Bactrim DS 1 daily for PCP prophylaxis

• CD4<50: continue Bactrim and add azithromycin 1200 mg/wk for MAC

• Standard STI screening at first visit and repeat in 3rd trimester.

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Intrapartum Care

• Delivery:

• May deliver vaginally at term if HIV viral load is <1,000

• Cesarean at 38 weeks if HIV viral load >1,000

• With either mode, AZT IV for 3 hours prior until the cord is clamped.

• Dose based on admission weight: 2 mg/kg bolus, then 1 mg/kg/hr

• Bottle feeding is strongly encouraged.

Postpartum Care

• Continue ART medications.

• AZT BID for HIV-exposed infant x 6 weeks.

• Schedule follow up visit with HIV provider for mother and with pediatrician aware of HIV-exposure for baby.

• Postpartum Birth Control:

BTL if eligible and consented

Long Acting Reversible Contraceptives (LARCS)

Injections

Oral Contraceptives

Other hormonal contraceptives: patch, ring

Condoms: always recommended for STI prevention

Summary Part 2

• Ensure testing accuracy

• Provide diagnosis in person

• Confidentiality very important

• Determine med regimen

• Determine HIV care provider

• Determine support system

• Monitor labs

• Delivery plans

• Bottlefeeding

• Postpartum birth control

• HIV follow up

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Resources

• National Perinatal HIV Consultation Service (UCSF):

1-888-448-8765

• Alabama Department of Public Health HIV/AIDS Hotline:

1-800-592-2437

• AIDS Alabama Confidential State Helpline: 1-800-592-2437

• National Institutes of Health:

AIDS INFO. http://aids info.nih.gov

a. HIV Pregnancy Treatment Guidelines

b. Pediatric HIV Treatment Guidelines

c. Adult HIV Treatment Guidelines

Resources (cont)

• Centers for Disease Control (CDC)

a. www.cdc.gov/hiv/

• American Congress of Obstetricians and Gynecologists (ACOG)

a. http://www.acog.org/About-ACOG/ACOG-Departments/HIV

• Alabama Department of Public Health

a. www.adph.org

b. www.adph.org/aids

• Alabama Perinatal Excellence Collaborative (APEC)

www.apecguidelines.org

Thank You

Questions?

http://www.cdc.gov/hiv/

http://www.acog.org/About-ACOG/ACOG-Departments/HIV





http://www.adph.org/

http://www.adph.org/aids

http://www.apecguidelines.org/

Jan-17

1

The Journey

to

Baby Friendly

Where are we Now?

February 10, 2017

Elicia Jacob, DNP, RN, PHCNS-BC

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Speaker Disclosures

I have no relevant financial relationships to disclose.

There are no known conflicts of interest.

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Declines in Breastfeeding

Early 1900’s, 90% US mothers breastfed.

Shifts in technology, advertising, attitudes lead to rapid declines

1946: 38% newborns breastfed (Bain 1948)

1966: 18% newborns breastfed (Mayer, 1968)

Dramatic declines coincide with economic factors resulting in major migrations from rural to urban areas

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The Aftermath

1972 – WIC established

Largest purchaser and distributor of manufactured milk, $600 million/year (2006)

Considered one reason for decline of breastfeeding

Twice as much cost to support non breastfeeding babies

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Action Planning

Stakeholders engaged in consciousness raising published policy statements on breastfeeding:

American Academy of Pediatrics - AAP

American Congress of Obstetricians and Gynecologist - ACOG

Association of Women’s Health Obstetric and Neonatal Nurses - AWHONN

The United Nations Children’s Fund - UNICEF

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The Baby Friendly Hospital Initiative

WHO and UNICEF

1991 launched the BFHI

Program to encourage & recognize hospitals and birthing centers when successful implementation of the Ten Steps to Successful Breastfeeding is achieved.

Baby-Friendly USA is the national authority in the United States.

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ACTIONS

1978 - National health objectives formally defined with goals of 45% initiation and 21% duration at 6 months:

TODAY

U.S. Public Health Services for Healthy People 2020 set goals to increase breastfeeding initiation and duration rates. 81.9% of mothers will initiate breastfeeding in early

postpartum period

60.6% of mothers will continue to breastfeed at 6 months

34.1% of mothers will continue to breastfeed at 12 months.

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Healthy People 2020

Objectives address maternity care practices Reduce formula supplementation within the first

two days of life. The CDC reports that 25.4% of breastfed

infants receive formula before two days of age, despite medical recommendations against routine supplementation with formula, glucose water, or water.

Early supplementation decreases a mother’s milk production and can lead to negative health outcomes for the infant.

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The Grade

CDC Breastfeeding Report Card Goal National 2014 HP 2020 Ever Breastfed 79.2% 81.9%

Breastfeeding @ 6 months 49.4% 60.6%

Breastfeeding @ 12 months 26.7% 34.1%

Exclusive Breastfeeding 3 months 40.7% 46.2%

Exclusive Breastfeeding 6 months 18.8% 25.5%

Formula before 2 days old 19.4% 14.2%

Live births in BF facilities 7.79% 8.1%

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The Disparities

Cultures:

Native

African

Mexican

Vietnamese

Understand the health benefits

Pumping

Formula access

Painful

Spoil baby

Violation

Constricting

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UAB’s Baby Friendly Journey

Our Story

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Who Are We

Assessment

What are our values?

What is our data?

How does our culture influence our outcomes?

Who are our stakeholders?

What are the driving forces for change?

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The Assessment

What and where are the driving and restraining forces?

Internal systems – facilities and operations

External partners – WIC, Physician practices, Health Department, local/state/national agencies.

Vendors and business partners

People – mothers, families, staff (multidisciplines), community

Cultural norms

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Obstacles to Breastfeeding

Lack of spousal or partner, family support Short term maternity leave Full time employment Inflexible work hours/ lack of workplace support

programs Unfriendly social environment making it difficult to

breastfeed in public Media portrayal of bottle feeding as normative Commercial promotion of infant formula

Source: AAP Policy Statement & ACOG Clinical Review

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Short term hospital stays Disruptive hospital practices and policies Inappropriate interruption of breastfeeding

Lack of guidance & encouragement by health care professionals

Source: AAP Policy Statement & ACOG Clinical Review

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The sharpest decrease in breastfeeding occurs within

the first month after discharge & is attributed to:

Insufficient milk supply

Difficulty with latch-on and infant sucking

Lack of maternal confidence

Each of these obstacles is preventable with breastfeeding promotion, support, and protection strategies by health care providers.

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Knowledge

• Lack of experience or understanding among family members of how best to support mothers and babies.

• Not enough opportunities to communicate with other breastfeeding mothers.

• Lack of up-to-date instruction and information from health care professionals.

• Hospital practices that make it hard to get started with successful breastfeeding.

• Lack of accommodation to breastfeed or express milk at the workplace.

U.S. Department of Health and Human Services

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The Ten Steps

Have a written breastfeeding policy that is routinely communicated to all health care staff.

Train all health care staff in the skills necessary to implement this policy.

Inform all pregnant women about the benefits and management of breastfeeding.

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The Ten Steps

Help mothers initiate breastfeeding within one hour of birth.

Show mothers how to breastfeed and how to maintain lactation, even if they are separated from their infants.

Give infants no food or drink other than breast-milk, unless medically indicated.

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The Ten Steps

Practice rooming in - allow mothers and infants to remain together 24 hours a day.

Encourage breastfeeding on demand.

Give no pacifiers or artificial nipples to breastfeeding infants.

Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or birth center.

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Groundwork

WIS leaders engaged with community partners:

Alabama Breastfeeding Committee (ABC)

Breastfeeding Education Support Team (BEST)

Alabama Lactation Consultant Association (ALCA)

International Lactation Consultant Association (ILCA)

United States Breastfeeding Committee (USBC)

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Groundwork

Community Transformation Grant (CTG)

Interstate Baby Friendly Collaborative (North Carolina Global Breastfeeding Institute)

Co-sponsor conferences with national speakers

AWHONN

Healthy Children

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Groundwork

The Business Care For Breastfeeding

Commission on the Status of Women

Established lactation rooms throughout UAB campus.

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The Buy In

Administration

Patient satisfaction

Quality Care

Evidence based practice

Cost effective

Healthier Community

Prestige

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The Buy In

Physicians

Evidence based practice


Quality Care

Leaders in healthcare

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The Buy In

Front Line-Staff


Staff satisfaction

Quality Care

Improved patient outcomes

Praise and recognition

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The Buy In

Patient/Families

Quality Care

Patient centered care

Improved health outcomes

Recognition for providing change for the better

Feels good

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The Buy In

Community

Healthier outcomes

Celebration

Recognition

Partners

Recognition

Support

Innovation

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Why?

Why Participate in the US Baby-Friendly Hospital Initiative?

Benefits for maternity care facilities: Quality improvement: It is evidence based care -

easily adaptable as QI projects. Cost containment: impact on health care costs from

postpartum hemorrhage, to decreased ear infections. Public relations/marketing: families who feel

adequately supported during the vulnerable postpartum days can speak powerfully for a birth facility.

Prestige: The receipt of this WHO/UNICEF international award is an achievement to celebrate!

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One Step at a time

Follow the 4D pathway

Establish a Leadership Committee:

Start with the Policy

Make it evidence based

Get buy-in

Train

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The policy

Step 1: Have a written breastfeeding policy that is routinely communicated to all health care staff.

The facility will have a detailed breastfeeding policy that is inclusive of the Ten Steps to Successful Breastfeeding, and is routinely communicated to all health care staff.

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Breastfeeding policy

The 10 steps to successful breastfeeding

An institutional ban on acceptance of free or low cost supplies of breast-milk substitutes, bottles, and teats and its distribution to mothers

A framework for assisting HIV positive mothers to make informed infant feeding decisions that meet their individual circumstances and then support for this decision

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Breastfeeding Policy

How should it be presented?

It should be:

Written in the most common languages understood by patients and staff

Available to all staff caring for mothers and babies

Posted or displayed in areas where mothers and babies are cared for

Include a mechanism for evaluating it’s effectiveness

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Policy

All Nursing policies and procedures reviewed and updated to be compliant with the Ten Steps.

Hospital wide policy training started with the nursing staff orientation in Women and Infants Services.

Hospital wide –

Use Hospital on-line training system - over 8,000 employees trained

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What Does being “Baby Friendly”

mean?

UAB Medicine will not receive free gifts, non-scientific literature, materials, equipment, money or support for breastfeeding education/events from manufacturers of breast milk substitutes, bottles, nipples, and pacifiers.

UAB Hospital will not distribute infant formula, formula coupons, and/or literature with formula company logos.

UAB Hospital will not provide/promote marketing materials, samples/gift packs, that include breast milk substitutes, bottles, nipples, pacifiers or other feeding equipment.

Educational materials will not include messages that promote or advertise any infant food and/or drink other than breast milk.

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Baby Friendly Step 1

The University of Alabama Medical Center will promote, protect, and support breastfeeding as the preferred method of providing nutrition to infants.

The “Baby Friendly Breastfeeding Management and Care” policy will be communicated to all healthcare staff.

Electronically available @ UAB Medicine clinical standards and resources.

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Step 2: Staff Training

All staff with primary responsibility for the care of breastfeeding mothers and babies: a minimum 20 hours of training inclusive of 5 hours of supervised clinical experience & competency verification.

15 categories of training have been outlined for educational sessions.

Physicians caring for mothers and infants: complete 3 hours of training on care of breastfeeding mothers and babies.

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Step 2: Staff Training

Training for other staff members tailored to their job description and degree of exposure to breastfeeding.

Completed within 6 months of hire

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Staff Education Strategies

In-house training

15 Module Breastfeeding Workshop

Physician Training – resident rotations

Clinic and doctor’s office personnel training

Competency skills training and checks - superusers

Shadowing experience with IBCLC

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Staff Training

Health Stream on-line modules for policy and update training

Grand rounds, huddles, staff meetings, orientation class, flyers, poster presentations, “Tips of the Week”, pocket guides, communication books

Superuser training , RNICU/CCN, L&D, HRO, ongoing new orientees.

WellStart International

University of Virginia

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Challenges

How to resolve breastfeeding difficulties Hospital breastfeeding policies and practices Focus on changing negative attitudes which set up

barriers

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Step 3 Informing Pregnant Women

Inform all pregnant women about the benefits and management of breastfeeding.

Criteria: All women delivering in the facility receive

consistent, positive messages about breastfeeding. All prenatal educational media free of messages

that promote artificial feeding. Prenatal records indicate discussion of

breastfeeding

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Antenatal education should include:

Benefits of breastfeeding

Early initiation/ skin to skin

Rooming-in

Feeding on demand – No schedules

Exclusive breastfeeding

Position and latch

How to express milk

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Strategies

Focus groups for prenatal and postpartum women and their support persons

Focus group for health professionals

Patient education task force: multidisciplinary representing hospital staff and community agencies.

Focus on consistent messaging across the continuum of pregnancy through postpartum and follow up

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Websites for Support Persons

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Patient Education

Your Birth Experience

What to expect and how to make it

memorable

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Step 4 – Initiation of Breastfeeding

Criteria

All healthy, full term babies skin-to-skin (S2S) within 5 minutes of a vaginal delivery for 1 hour or until the first feeding is complete.

Cesarean birth, placed skin-to-skin as soon as mother and infant stable and able to respond to each other.

Staff offer assistance & help with learning feeding cues.

Father or significant other encouraged to do S2S if mother unable and agrees.

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Early Initiation

Why?

• Increases duration of breastfeeding • Allows skin-to-skin contact for warmth and colonization of baby with maternal organisms • Provides colostrum as the baby’s first immunization • Takes advantage of the first hour of alertness • Babies learn to suckle more effectively • Imprints feeding instincts • Improved developmental and cognitive/neural outcomes

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Early initiation - How?

• Keep mother and baby together •Place baby on mother’s chest naked except for diaper and hat. Covered with warm blanket. •Do not hurry or interrupt the 9 instinctive stages of recovery from birth to first feeding.

•Let baby start suckling when ready •Delay non-urgent medical routines until after the first feeding complete.

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Skin-to-skin is easy

When a mother holds her baby skin-to-skin:

Baby: • cries less and is calmer • breastfeeds better • stays warmer • has better blood sugar levels

Mother: • breastfeeds more easily • learns when baby is getting

hungry • bonds more with baby

Enjoy the closeness and bonding

with your baby.

Daddy can skin to skin too!

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Step 5 Access to Assistance

Show mothers how to breastfeed and how to maintain lactation even if they should be separated from their infants.

Criteria: All mothers receive additional assistance within six

hours after birth and are able to demonstrate correct positioning and latch of their own baby.

Staff able to describe and demonstrate teaching of patients

Mothers of preterm or ill babies report assistance within 6 hours of delivery to express milk by hand or other method and can demonstrate how they were taught.

Mothers report they were told to express milk 8 times a day

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When baby comes early or is separated

• Hand expressing or

pumping your breast

milk within 2 to 6 hours

of delivery starts to

establish your milk

supply.

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Access to Assistance

Criteria: Staff can describe assistance for non-breastfeeding

mothers on how to: Provide counseling and informed consent Teach safe formula preparation and feeding

techniques. Mothers who choose to feed formula will report

someone: Discussed their feeding choice with them and the

risk associated with formula feeding, Provided education on safe preparation and giving

feedings, Are able to describe the advice given.

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Step 6 Breast-milk only

Give newborn infants no food or drink others than breastmilk, unless medically indicated.

Purpose: To assure that healthy breastfeeding babies are

not routinely supplemented with any food or drink other than human milk (unless medical indications exist for supplementation).

Furthermore, to protect parents from formula marketing.

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Breast Milk Only

Criteria: All breastfed infants will be exclusively breastfed

except when a) acceptable medical indications exist for

supplementation; or b) parents request supplementation after

receiving education regarding the possible consequences of non-indicated supplementation.

Parents of breastfed infants will receive no free samples, items bearing formula company names or logos, coupons for formula, etc.

This step also requires that the facility purchase infant formula and feeding devices in the same manner as is used to procure other food and supplies.

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Exclusive Breast Feeding

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Medical Indications for Supplementation

UNICEF, revised BFHI course and assessment tools, 2006

Infant conditions: very weak, sucking difficulties oral abnormalities separated from their mothers. Infants who may need other nutrition in addition to

BM include: very low birth weight or preterm infants, infants at risk of hypoglycemia, dehydrated or malnourished

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Supplementation Challenge

● Early Tracking ● Share the Data

● Identify barriers ● Change Care Practices

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Supplementation

Evidence Based

Maternal Factors

• Anti-metabolites, radioactive iodine and some medications used to treat thyroid conditions.

• IV drug abuse

• Maternal herpes lesions on breasts refrain from BF until active lesions resolved.

• BF continued if hepatitis B, TB and mastitis, with appropriate treatments undertaken.

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Supplementation

Maternal conditions (continued): Maternal breast abscess, use EBM and BF

resumed once the breast is drained and antibiotics have commenced. BF can continue on the unaffected breast

Maternal weakness: may be assisted with positioning so she can BF.

Human T-cell leukaemia virus, if safe and feasible options are available.

BF is best choice for babies even if mother uses tobacco, non-IV drugs or ETOH.

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Step 7 Rooming-In

Practice rooming-in allow mothers and infants to remain together – 24 hours a day.

Purpose: To assure that healthy mothers and babies have

ample opportunities for skin-to-skin contact and early learning of baby’s feeding cues.

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Rooming-In

We will make sure your baby stays with you as much as possible.

• We recommend you and your baby be together unless there is a need for medical intervention in our observation nursery.

• Rooming in helps you learn your baby’s feeding cues so you can feed him at his first sign of hunger.

• Mom and baby actually sleep better when together in the same room.

• Babies who are with mom breastfed better.

• Babies cry less if they stay with their mom.

• When it is time for sleep – Mom and baby each have their own bed.

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Breastfeeding on Demand

Step 8. Encourage breastfeeding on demand. Purpose: To assure that mothers are encouraged to feed

their babies in response to the baby’s signs of feeding readiness.

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Step 9 Pacifiers

Give no artificial teats or pacifiers. Purpose: To assure that breastfed babies are not deterred

from learning how to suckle at the breast, and thereby from maximizing mothers’ milk supply.

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Baby Friendly Step 9

Pacifiers will not be given to normal, full-term infants

Mothers bringing pacifiers from home will be educated on how pacifier use impacts feeding within the first month.

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UAB Mother Baby Unit Pacifier Policy

Pacifiers used for comfort during painful procedures (heel sticks, IM injections, IV placement, venipuncture, arterial puncture, lumbar puncture, circumcision).

Discarded at the end of the procedure.

Other Medical Indications for pacifier use include:

Phototherapy infant can’t be consoled .

Withdrawal syndrome difficult to console.

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Step 10 Community Support

. Foster the establishment of breast-feeding support groups and refer mothers to them on discharge from the hospital or clinic.

Purpose: To assure that mothers are linked to ongoing

breastfeeding support resources.

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Community Support

Criteria: Facilities should assess the available community

breastfeeding support resources and foster the development of breastfeeding support networks.

All mothers should receive referral to appropriate resources prior to their discharge.

Staff should develop individual care plans for the follow-up of mothers and babies who have identified breastfeeding risk factors.

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Support

Early postnatal or clinic checkup Home visits Telephone calls Community services Outpatient breastfeeding clinics Peer counselling programmes

Mother support groups Help set up new groups Establish working relationships with those already

in existence Family support system

Slide 4.10.3

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Community Support Group

www.nurturingmotherssupport.com

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Community Support

WIC Partnership

Nurturing Mothers Support Group sponsor

WIC Nutrition Counselor on-site

Pre-discharge teaching

Sign up for WIC

Follow up Instructions

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FULLY Breastfeeding

Mom – Up to 1 year

MOSTLY Breastfeeding

Mom – Up to 1 year

SOME or NO Breastfeeding Mom – 0 to 6 months

Mom – 7 to 12 months

Baby – 6 to 12 months

http://www.cdph.ca.gov/programs/wicworks/Documents/NE/WIC-NE-EdMaterials-PantryForMomAndBabyComparisonSheetsForIndividualEd.pdf

Baby – 6to 12 months

WIC

Baby – 6to 12 months

Images from California WIC & Public Health

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TJC

The measure is reported as an overall rate which includes all newborns that were exclusively fed breast milk during the entire hospitalization, and a second rate, a subset of the first, which includes only those newborns that were exclusively fed breast milk during the entire hospitalization excluding those whose mothers chose not to exclusively breast feed.

http://manual.jointcommission.org/releases/TJC2014A/MIF0170.html

Performance Measure Name: Exclusive Breast Milk Feeding Description •PC-05 Exclusive breast milk feeding during the newborn's entire hospitalization

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The Joint Commission

The measure is reported as an overall rate which includes all newborns that were exclusively fed breast milk during the entire hospitalization, and a second rate, a subset of the first, which includes only those newborns that were exclusively fed breast milk during the entire hospitalization excluding those whose mothers chose not to exclusively breast feed.

http://manual.jointcommission.org/releases/TJC2014A/MIF0170.html

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Cost to Consider

Collaborative

Surveyors

Signage

Literature

Training

Formula

Supplies

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Sustainability

• Hardwiring

• Accountability

• Report the data

• Dashboards

• Huddles

• Celebrate Successes

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Thank You