Optimizing Breastfeeding

International Board Certified Lactation Consultant and outgoing NPWH Board of Directors Secretary Jamille Nagtalon-Ramos shares her tips on optimizing breastfeeding below.

WHNPs play a very important role educating and supporting pregnant women and new mothers about breastfeeding. There are many things we can do in both the critical antepartum and postpartum periods to help the mother-baby pair optimize the breastfeeding experience.

As an inpatient WHNP and an International Board Certified Lactation Consultant® (IBCLC®) here’s my guidance for clinicians. Please feel free to share your tips, as well.

Start the Conversation in the Antepartum Period

We should start providing breastfeeding education as early as possible in the pregnancy, according to the “Ten Steps to Successful Breastfeeding” guidelines from the World Health Organization and the United Nations Children’s Fund’s Baby-Friendly Hospital Initiative.

Women are interested in learning about how to best care for themselves and their babies in this period and research shows this is when mothers make their decisions about how to feed their infants. In fact, a mother’s determination to breastfeed during the prenatal period is a strong predictor of successful breastfeeding.

What we can do and say:

  • Find out what’s important to a pregnant patient
  • In my practice, I have found that getting to know my patient and opening up a conversation about what they value and what they fear helps me focus my counseling, For example women with a family history of breast cancer are very interested to know that breastfeeding is thought to decrease the incidence of breast cancer later in life.
  • It’s important to try to identify early on any breastfeeding barriers patients anticipate. You can document those and provide resources to address them at the outset. Then, revisit these barriers periodically throughout the pregnancy.
  • Use open ended questions – as a way of eliciting more comprehensive responses– versus closed questions about feeding options.
  • For example, ask the patient “What would you like to learn about breastfeeding?” rather than “Do you have any questions about breastfeeding?”.
  • Offer a strong statement of breastfeeding support to help influence a woman, while still supporting her personal choice to breastfeed, formula feed, or do both,
  • We can say things like, ”At this practice, we recommend breastfeeding exclusively for the first six months for various health reasons for the baby and for you, the mom.” Organizations like American Academy of Pediatrics recommend it, and I personally recommend breastfeeding,

Teach practice of milk expression

Immediate postpartum can be such a blur (especially with a c/s, pain, anxiety) and can be a tough time for many new moms to learn new things, acquire new skills, and believe that their bodies are capable of making milk to nourish their babies. This is why it’s important to help patients get comfortable with their bodies in the weeks and months before they deliver.

What we can do and say:

  • teach hand expression of milk antenatally. Although not evidenced based, I and other WHNP’s encourage our pregnant patients to practice beginning around 38-39 weeks if they’d like .
  • Most women are comfortable practicing in the shower, but anywhere they are comfortable would work. If they happen to express some milk, they could save it, but you can remind them that most people don’t have milk yet, and that not having expressible milk now has no significance on their body’s ability to make milk after the baby is born.
  • show them the Stanford video
  • encourage women to look in the mirror every day, and tell themselves their body is magical and will make a lot of milk for their baby.

Postpartum Period

In the immediate postpartum period, WHNP’s continue to have a vital role in helping optimize breastfeeding.

What we can do and say:

  • approach each postpartum patient as someone who will be a successful breastfeeding mother unless the patient tells us otherwise.
  • If the patient states that she has decided to formula-feed or to supplement her breastfeeding with formula, I offer the same eager support for her choices.
  • Depending upon the breastfeeding culture of your facility, and your prior knowledge of the patient history, consider asking the brief question, “Did anyone discuss the benefits of breastfeeding with you?”
  • coordinate with the nurses and lactation consultants in your unit on how to work as a team in providing the best possible support for our patients who are open to learning more about breastfeeding

Consider these steps immediately after your patient gives birth:

  • Encourage early (immediate) and unlimited skin-to-skin contact on the mother’s chest, uninterrupted for the first, golden hour
  • Early latching and suckling ??
  • Foster an environment that supports baby-led feeding instead of scheduled feedings.
    • For example, scheduling procedures such as baths, vaccinations, hearing testing around the infant’s feedings and not the other way around.
  • Provide hands-on assistance in helping position the infant especially for the first feeds
  • Teach parents about feeding cues
  • Educate and reassure about expected amounts of inputs – frequency and duration of feedings – and outputs – number of wet diapers.
  • Facilitate obtaining a breast pump through their insurance or rental of the breast pump
  • Educate on breast pump use
  • Educate women who choose to supplement with formula on the types of formula and the preparation of formula
  • Provide culturally-sensitive care for women who desire to breastfeed

Consider these steps prior to patient discharge:

  • Refer women to lactation groups within their community prior to discharge
  • Provide follow-up and telephone support

Think About Your Own Views of Breastfeeding as You Counsel Patients

It is also important for WHNP’s to examine their own personal biases for or against breastfeeding, as well as personal assumptions about cultural, racial, or ethnic influence on a woman’s breastfeeding decisions.

  • consider taking an implicit bias/racism in healthcare training course – because breastfeeding is steeped in historical context, and a person’s own implicit bias can influence their counseling,

Understand Reasons Why Moms Discontinue Breastfeeding Early

As WHNP’s it’s important for us to recognize why nearly 60% of women discontinue breastfeeding at six months and 35% stop at 1 year  – despite the fact that the American Academy of Pediatrics (AAP) recommends that infants be exclusively breastfed for about the first 6 months with continued breastfeeding alongside introduction of appropriate complementary foods for 1 year or longer. (Centers for Disease Control and Prevention, 2018).

Know these major factors that mothers identified as to why they discontinued breastfeeding early:

  • Lack of family support
  • Cultural beliefs and practices
  • Unsupportive hospital practices and policies
  • Concurrent medications while breastfeeding
  • Latching issues

Let’s Focus on Brain Health

This post is written by Jill Lesser, President of WomenAgainstAlzheimer’s

September 21 marks the seventh annual World Alzheimer’s Day – a prime opportunity to talk about where we’ve come from, where we currently stand, and where we must direct our focus for the future of those living with Alzheimer’s.

Arguably, the most significant hurdle we must address immediately is a society-wide lack of awareness for Alzheimer’s and dementia. And we’re starting with women. This disease touches everyone but it targets females. Alzheimer’s is not gender neutral. It affects women far more than me – both as people living with the disease and those that take one the role of caregiver.

Two out of every three people suffering from Alzheimer’s is a woman. And according to one survey, just 27% of women realize they are more susceptible to the disease simple because of their gender. More than two thirds of women wrongly believe that symptoms don’t start to appear until age 60. And nearly half wrongly think that Alzheimer’s is strictly genetic.

Given the scale of this disease, these numbers are particularly alarming.

We recently teamed up with HealthyWomen and participated in the WomenTalk survey to learn more about women’s attitudes towards brain health.  There was good news and bad.

The survey found that just 29% of women say they discuss the topic occasionally, and a mere 8% say they talk about it regularly.

Fewer than one in five say they’ve taken steps to protect the health of their parents, and just three in ten say they’ve taken steps to protect the brain health of their children.

That’s the bad news.

The good news is that, nearly two-thirds of women say they are worried about the health and performance of their brains. And more than two thirds are interested in learning more about the subject.

In other words, most women want to know more, and would take action if they knew what they could do.

Health data show that women over age 60 are twice as likely to develop Alzheimer’s than breast cancer. They are also far more likely to end up taking care of parents living with the disease. Women, in fact, comprise two-thirds of voluntary caregivers. For many women today, the challenge of caring for a loved one is doubled because many are trying to raise children while tending to their parents’ full-time care needs. As someone who has lived this, I can tell you that the stress can be relentless. And, as numerous studies show, caregiver’s health almost always suffers as well.

There are a number of things we can do now to see progress.

  • We need to set an example for the ones we love and get moving. Studies show that regular physical activity is good for the brain. Yet only 23% of Americans meet the national minimum physical activity guidelines. Women have the power to influence each other and their loved ones to live healthier lives and the best way to do so is to lead by example.

  • We need to start spending time educating women about the risks they face. While doing so, we need to raise awareness of the steps that women can take to improve their brains. And it’s more than just brain games and a healthy diet. Start from square one and check in on your brains at the next checkup. Get to know your baseline and start measuring changes as they happen, before memory becomes a concern.

 

  • We must advocate for a healthcare system that works for women. The public health community, led by women, has done a masterful job of raising awareness for women’s health issues such as heart disease and breast cancer. But these changes have only come when women demanded them. It’s time we come together and advocate for women’s health across the lifespan – applying the same level of dedication and enthusiasm to making women aware of the need to focus on their brains.

 

Everyone wishes for a cure for Alzheimer’s. And one day – hopefully one day soon – the cure will be discovered. Until then, we need to do everything we can to raise women’s awareness of their own risks, and what they can do to minimize them.

As a society, we need to not only direct more resources at Alzheimer’s. We need to make sure that the money we spend on research, health care, support services, and education targets the women who disproportionately carry the burden of Alzheimer’s.

On this, the 7th World Alzheimer’s Day, we need to recognize that this fight is as much about social justice for women, as it is about treatments and a cure for this relentless disease.

Preconception Diet and Supplementation

By Randee Masicola, DNP, APRN-CNP, WHNP-BC and member of the NPWH Board of Directors

Are you giving evidence-based information to your patients who are planning a pregnancy or who could become pregnant about diet that includes supplements to consider and foods to avoid?

What are the most critical things to tell them when your time with patients is limited?  What are some resources you can give them as they walk out the door?

It is particularly important to discuss food safety with all women who could become pregnant as many women do not seek care prenatal care until they are well into their first trimester.

Overall Diet: How to Eat Healthy

It is crucial that women who could become pregnant are educated on the safety of their food choices and the required nutrients needed to improve chances of a healthy pregnancy outcome.  Education starts with explaining the basics of daily fruit and vegetables and limiting high fat choices. Include background on the five food groups, healthy portion sizes, as well as any insight gathered form a 24-hour diet recall. Discuss replacing fast food with healthy convenient options to help patients make better choices within their own lifestyle.

Resource: Choicemyplate.gov, the federally funded campaign, is a great place to start

Fish – What to Eat and What to Avoid

It is important to talk with women about the benefits and risks of fish in their diet. Fish is an excellent source of low fat protein and can be help in the growth and development of the fetus.  It contains Omega-3 fatty acids which have proven to be essential for healthy fetal brain development. But women need to be counseled on the safe levels of methyl mercury in fish and warned about potential risks during pregnancy. A variety of birth defects have been linked to high levels of mercury in a pregnant woman’s diet.

  • Mercury can be found in many bottom-dwelling fish including king maceral, shark, and orange roughy.
  • Canned tuna fish has a very low mercury content and is safe but is recommend no more than 2-3 times a week. Albacore tuna has a higher mercury content.
  • Raw fish like sushi, as well as all raw and undercooked meats, should not be ingested due to the risk of parasites or bacteria.

A fabulous resource on Education of safe fish options and quantities, as well as up-to-date information for providers and patients is available on the FDA website (https://www.fda.gov/Food/ResourcesForYou/Consumers/ucm393070.htm). 

Dairy: What to Avoid

Share with your patients the value of calcium in milk and cheese, but recommend they avoid unpasteurized milk and soft cheeses including Brie, Feta, Camembert, Roquefort, and even Queso due to the risk of E coli, Listeria, and/or Salmonella contamination.

Vitamins and Minerals: When Supplements Are Needed

Folic Acid

All women who could become pregnant need to take a multivitamin with at least 400mcg of folic acid. The United States Preventative Service Task Force (USPSTF) reaffirmed its 2009 recommendation in 2017 that all women who are planning or capable of pregnancy should be recommended to take a daily supplement containing 0.4 to 0.8 mg (400-800 µg) of folic acid and received its highest recommendation (USPSTF, 2017).

Folic acid supplementation should be started at least one month prior to conception. It can significantly reduce the risks of neural tube defects, like spina bifida and anencephaly (USPSTF, 2017).

Women with a history of having a child with a neural tube defect are encouraged to take 4-5mg of folic acid daily prior to conceiving which has shown to decrease risk of defects in following pregnancies (Toriello, 2011).

Iron

The recommended daily iron allowance for reproductive age women is 27mg of iron a day (ACOG, 2015). Most women will get this in their daily diet without supplementation. However, the growing blood supply of the placenta and fetus and the increased oxygenation needs of mother and the fetus result in a woman’s need for 50% more iron while pregnant. (ACOG, 2015).  The fetus uses the mothers iron stores for growth and development, commonly leaving the mother depleted.

Women already at risk or who have been identified as anemic should be counseled on appropriate iron supplementation and foods high in iron to include in their daily diet.

Red meats, spinach and raisins are common foods high in iron which is better absorbed when consumed with vitamin C rich foods like citrus fruits and tomato sauce.

Calcium

Let your patients know that most women can increase calcium in their diet without supplementation. Supplementation of calcium is only recommended to achieve a daily uptake of 1000 mg/day in pregnant women, and if supplements are required, patients should be instructed to only take 500mg at a time at breakfast and again at dinner to increase absorption.

Calcium is an essential element for embryo growth. It is responsible for building strong bones and teeth for the fetus

Maintaining appropriate consumption can decrease risk of preeclampsia, preterm birth and low birth weight (Hofmeyr, 2010). The best source of calcium is through diet and can usually be achieved with dairy products and other foods rich in calcium; for example, calcium-fortified orange juice and cereals, sardines, green beans and sunflower seeds.

Liquids: How to Stay Hydrated

Hydration is essential for general health, however, women who could become pregnant should be advised about what beverages to avoid.

  • 6-8 glasses of water should be recommended a day.
  • Caffeine and artificial sweeteners, unfortunately, have limited evidence, so many national organizations give a blanket statement to limit or drink these beverages in moderation, recommending only 1-2 cups a day.
  • Alcohol should be completely avoided as it is a known teratogen.
  • Soda, due to the high sugar calorie count, should also be discussed and alternatives provided.

Preconception education goes beyond counseling women who are planning a pregnancy to include all women who could become pregnant. Evidence-based information about nutritional needs is an important component of this education that can occur at any office visit. This information is critical to improve health prior to pregnancy and to promote healthy pregnancies and pregnancy outcomes.

WHNPs can utilize available evidence-based web sites and written resources to streamline the information provided within the limited time we have with each patient.

 

References

American College of Obstetricians and Gynecologists. The importance of preconception care in the continuum of women’s health care. ACOG Committee Opinion No. 313, September 2005. Obstet Gynecol. 2005;106:665–6. (Reaffirmed 2017)

Hofmeyr GJLawrie TAAtallah ANDuley L. (2010). Calcium supplementation during pregnancy for preventing hypertensive disorders and related problems. Cochrane Database Syst Rev. 2010 Aug 4;(8):CD001059.

Toriello, H. V. (2011).  Policy and Practice Guideline Committee of the American College of Medical Genetics.  Policy statement on folic acid and neural tube defects.  Genet Med. 2011;13(6):593-596.

United States Preventative Services Task Force (2017). Folic Acid Supplementation for the Prevention of Neural Tube Defects: US Preventive Services Task Force Recommendation Statement. JAMA. 2017;317(2):183-189

Reflecting on the Women’s Sexual Health Course for NPs

NPWH and the International Society for the Study of Women’s Sexual Health (ISSWSH) hosted the fifth annual Women’s Sexual Health Course for NPs in June. Samantha Tojino, NP-C, FNP, DNP-s, first attended the course in 2013 and returned this year as a faculty member. She reflects on this year’s program and the need to have a course specifically focused on women’s sexual health.

Q: Why is the Women’s Sexual Health Course so important?

Before NPWH and ISSWSH developed the Sexual Health Course, there were no post-graduate education or training programs designed to keep nurse practitioners up to date on the latest practices and standards of care in women’s sexual health. Sexual health is critical to overall health and wellness throughout a woman’s life – from sexual debut and STD prevention through the childbearing years and continuing on through menopause and beyond. Unfortunately, few educational programs spend adequate time on this essential topic.

Q: Who can benefit from the Sexual Health Course?

NPs are the ideal practitioners to address sexual health needs. With their ability to have intimate conversations with patients about sometimes taboo and difficult subjects and their clinical experience with women of all ages, NPs offer a knowledgeable and caring approach to sexual health. But the Sexual Health Course isn’t just for women’s health NPs. It is a valuable complement for all nurse practitioners who deal with women’s health, including FNP, AGNPs, and CNMs.

Q: What’s unique about the instruction offered by the Women’s Sexual Health Course?

The Sexual Health Course was created by NPs recognized as sexual health experts for NPs wanting to enhance their competence in women’s sexual health. With input from both NPs and physicians, the course focuses on the knowledge and skills advanced practice nurses can include in daily practice to enhance women’s sexual health as well as specialty knowledge geared to identifying and treating women with sexual dysfunction.  The course includes content on hormone therapy specifically geared to nurse practitioner management of sexual function and dysfunction as well as training in detailed vulvar, vaginal, and pelvic examination. The vulvoscopy workshop provides a hands-on approach for providers, enabling them to evaluate epithelial dermatologic conditions during the vaginal exam. Participants are guided by experts in the field.

Q: Has interest in the Sexual Health Course changed over the years?

Yes, course offerings – and the number of participants – have grown significantly since 2013. As our program grows, more providers are taking advantage of this opportunity to better serve our patients.

Q: What were the key takeaways for participants this year?

  1. Women’s sexual health is a complex subject! Nurse practitioner education and experience lead to better patient outcomes.
  2. Sexual health is a basic human right and a vital component of overall lifelong wellness.
  3. Female sexual dysfunction can affect quality of life for a woman and her partner – but nurse practitioners can help.
  4. With the knowledge gained from this course, nurse practitioners are more confident in their ability to address, diagnose, and treat their patients’ sexual health concerns.

Spotlight on Caregivers

U.S. longevity trends are thrusting more women into caregiving roles. NPWH recently led discussions at two national summits on women’s health spotlighting how women’s health advocates must be and are increasingly focused on the roles and needs of women caregivers. For too long, caregiving has been a social and health challenge in the shadows, but as more of us age and take on the role of caregiver, there are many things to know.

Diana Drake, DNP, MSN, APRN, WHNP-BC, reflects on these efforts to put caregiving needs front and center, and shares caregiving trends health care providers should know.

Did you know? The numbers tell us we need many hands on deck and thoughtful planning.

  • The U.S. 65-and-older population is projected to nearly double over the next three decades, ballooning from 48 million, to 88 million by 2050.
  • The nation’s first wave of Baby Boomers will turn 85 twelve years from now in 2030.
  • 85 –year olds are twice as likely as 75-year-olds to need help getting through the day.
  • Increased longevity has already resulted in more than 34 million “informal” caregivers to support our aging population.
  • Family caregivers have been described as America’s other Social Security. The nation’s healthcare system would go broke if it had to pay for their work, valued at $470 billion a year in free care.2

Who are these caregivers? Many of them are our patients

  • The average caregiver is female, 49 years old and providing care for her mother that is the equivalent of a part-time job.2
  • Compared with other demographic groups, women, along with low-income workers and minorities, are more likely to reduce their work hours or leave the workforce because of their caregiving role.2
  • Female caregivers are less likely than male caregivers to see health care providers for their own preventive healthcare needs.
  • Female caregivers face increased risks for::
    • Depression and anxiety
    • A weak immune system
    • Obesity
    • Chronic disease (including heart disease)
    • Problems with short-term memory or paying attention

NPWH is pushing the issue front and center.

Through our leadership role in two coalitions, NPWH is helping drive national conversations around caregiving to increase awareness of, and support for, the female caregiver.

Coalition for Women’s Health Equity

More than three hundred women from across the country met in Washington, DC, for the Women’s Health Empowerment Summit, hosted in May by the Coalition for Women’s Health Equity.3 The summit spotlighted actions to address inequities that endanger women’s health and safety. As a member of the steering committee, NPWH helped organize a panel on Caregiving Across the Lifespan. Panel members explored the burdens and opportunities of caregiving and considered legislation to require the government to develop strategies that recognize and support family caregivers.

As a panel member, I was honored to speak as both a nurse practitioner who provides healthcare to many caregivers, and also as the daughter of two 96-year-old parents living in partially assisted care. I spoke directly to the impact of the female caregiver and the invisibility of the issue. With the profound impact that being a caregiver has on these women’s health, I also addressed the need for all health care providers to determine the caregiver status of their patients. The panel encouraged all caregivers in the room to lead by example, and to discuss their caregiver roles with their HCPs at health visits.

Healthy at Any Age Coalition

At NPWH’s second Healthy at Any Age Summit, we laid the groundwork for a coalition and began outlining the National Older Women’s Health Agenda. This agenda must include women caregivers and the adverse impact of long-term neglect of their own health.4 As we unite diverse sectors, share resources, and create strategies to advance the health and well-being of older women, NPWH will continue to draw attention to the vital role of caregivers and how to best meet their needs.

More conversations about caregiving must happen in living rooms, communities, government offices – and exam rooms. Let us know how you approach your patients to assess how caregiving may be impacting their physical health and psychological well-being.

Diana M. Drake is Clinical Associate Professor and Specialty Coordinator of the DNP WHNP Program at the University of Minnesota School of Nursing and Program Director for Integrative Women’s Health at the Women’s Health Specialists Clinic, both in Minneapolis. She is Chair of the NPWH Policy Committee and Chair Elect of the NPWH Board of Directors.

References

  1. United States Census Bureau. U.S. Population Aging Slower than Other Countries, Census Bureau Reports. March 28, 2016. gov/newsroom/press-releases/2016/cb16-54.html
  2. AARP Public Policy Institute. Understanding the Impact of Family Caregiving on Work. October 2012. org/content/dam/aarp/research/public_policy_institute/ltc/2012/understanding-impact-family-caregiving-work-AARP-ppi-ltc.pdf
  3. Coalition for Women’s Health Equity website. org/advocate/coalition-for-womens-health.html
  4. American Heart Association. Caregivers: Be Realistic, Think Positive. Last reviewed June 2017. org/HEARTORG/Support/Caregivers-Be-Realistic-Think-Positive_UCM_301771_Article.jsp#.WzlnWi2ZNhE

An Update on NPWH’s Efforts to Support Brain Health Initiatives

Julia Knox is NPWH’s Communications and Outreach Associate and represents NPWH at several legislative briefings per year. Below is information about one she attended in honor of Alzheimer’s and Brain Awareness Month and why brain health is important to NPWH and WHNPs. Julia has been at NPWH for close to two years and holds an M.S. in Public Relations and Corporate Communication. 

On Wednesday, June 20, NPWH attended an UsAgainstAlzheimer’s legislative briefing on the CHANGE Act of 2018. The CHANGE (Concentrating on High-Value Alzheimer’s Needs to Get to an End) Act is a bipartisan bill that “encourages timely and accurate assessment, detection and diagnosis of Alzheimer’s, supports innovative approaches to support family caregivers, and removes regulatory barriers to disease modifying treatments.” NPWH also signed on to an UsAgainstAlzheimer’s Congressional letter, urging all members to support the act.

IMG_8354

Sen. Shelley Moore Capito (R-WV), cosponsor of the CHANGE Act, addresses the audience

Alzheimer’s disproportionately affects women: of the approximately 5.5 million Americans with Alzheimer’s, nearly two-thirds are women[1]. In addition to the patients themselves, the disease also has a devastating effect on unpaid family caregivers, the majority of which (63%) are women. [2] NPWH believes WHNPs are an important resource for monitoring brain health. With greater awareness, knowledge and tools, providers can support earlier detection and treatment of Alzheimer’s, dementia, and other brain diseases.

Last year, NPWH partnered with WomenAgainstAlzheimer’s to survey WHNPs regarding their knowledge and treatment of brain health. The survey, Brain Health is Women’s Health, found that the vast majority of WHNPs want more knowledge, training, and tools to assess brain health. NPWH is working to provide this knowledge and training: brain health was the focus of a dedicated breakout session at the 2017 annual conference, and a topic of the second annual Healthy at Any Age Summit this April. We are also preparing to launch an updated version of our well-woman visit mobile app that includes a brain health section.

To read more about the CHANGE Act, click here. To read the full report from Brain Health is Women’s Health, click here.

[1] https://alzheimersnewstoday.com/alzheimers-disease-statistics/

[2] https://www.usagainstalzheimers.org/networks/women

Pennies for Prevention: Preeclampsia, the Leading Cause of Maternal Death

By NPWH Board Member Jennifer Hawn, MSN, WHNP-BC

Preeclampsia; the masked evader.  When does it start?  Where does it start?  Who will it effect?  How do we stop it?  These are all difficult questions that clinical providers have yet to fully understand. One thing is for sure, the staggering effects of Preeclampsia on the outcome of pregnancies impact both maternal and fetal health.  But we are also beginning to understand that one of the best prevention strategies is not some NIH developed new intervention or new pharma R&D brainchild. It’s something in most patients’ medicine cabinets that costs only pennies: low-dose Aspirin.

The Dangers of Preeclampsia:

According to evidence collected by the United States Preventative Services Task Force (USPSTF):

  • Preeclampsia is the leading cause of maternal death, effecting 3.8% of pregnancies in the U.S.
  • Twelve percent of maternal deaths are due to effects of Preeclampsia
  • 97% of preeclampsia related deaths occur in the postpartum period
  • The morbidity and mortality of preeclampsia also affects neonates causing 15% of preterm births (<37 weeks gestation)
  • Prematurity alone is responsible for 70% of neonatal mortality and 75% of neonatal morbidity in developed countries

Due to the potential lifelong effects of prematurity, the cost associated with preterm birth and other maternal complications at the time of delivery and postpartum period, it is easy to see why Preeclampsia remains such a hot topic of discussion.

The Best-Known Prevention Strategy

As Advanced Practice Nurses, it is embedded in us that prevention is the key to minimizing disease and Preeclampsia is proving to be no different.  Educating our patients is key to recognizing preeclampsia at its earliest manifestation for effective management and treatment, however, additional evidence continues to support the use of low dose Aspirin (81mg) daily after 12 weeks gestation for the prevention of Preeclampsia.  While the evidence is unclear when the most benefit of this regimen occurs, it is widely accepted based on literature review that treatment of Aspirin 75 mg or greater, sometime in the late first trimester (>12 weeks) but before approximately 16 weeks has yielded the best results.  (There are no specific recommendations on when the Aspirin should be discontinued in the third trimester.)  This strategy is supported by further evidence that suggests preeclampsia is a combination of factors that begin in the first trimester related to unusual placental development that results in placental ischemia and the release of inflammatory and oxidative stress factors into the maternal blood stream – hence the use of an “anti-inflammatory” medication – Aspirin.

What does low dose Aspirin have to offer?  It does not magically prevent preeclampsia 100%.  The risk reduction for women who are at high risk for Preeclampsia is believed to be approximately 10% and a 20% reduction in perinatal mortality.  In studies, treatment with low dose Aspirin was associated with an absolute risk reduction of 2-5% for Preeclampsia, 1-5% for Intrauterine Growth Restriction (IUGR) and 2-4% for preterm birth.  IUGR also increases the risk of neonatal respiratory distress, seizures, sepsis and long-term disability even when born at term, so a small reduction in IUGR infants can have a remarkable impact on their quality of life.  Additionally, treatment has also been associated with an average birth weight increase of 130 grams.

Given that low dose Aspirin costs somewhere around a penny or so per pill and is conveniently obtained at any retail pharmacy, it is easy to see why we should be consistent in prescribing this for our patients who are at risk for Preeclampsia.

Knowing the Risks

So, what are the risks of treatment?  A question we should continually ask ourselves when it comes to treatment of disease, regardless of the seeming innocence of the treatment.   As an Antiplatelet Aggregate Inhibitor, Aspirin inherently carries the reputation of risk, especially in the face of potential surgery and blood loss associated with delivery, which is the only known intervention for initiating resolution of Preeclampsia.  Thus far, no known complications with the use of low dose Aspirin therapy for women who are at high risk for the development of preeclampsia have been identified.  Specifically, studies have not found any adverse effects related to increased risk of maternal hemorrhage, mean blood loss, placental abruption, neonatal intracranial hemorrhage or developmental milestones at age 18 months.

Who is a Candidate for Low-Dose Aspirin Therapy?

So, now that we know what to prescribe and why, Advanced Practice Nurses need to be experts in deciding who is a candidate for the use of low dose Aspirin therapy in pregnancy.  The USPSTF identifies that this treatment is best suited for women who are considered “high risk” for the development of preeclampsia.  Answering the question of “Who is this appropriate for” can be identified easily with a comprehensive health history.

It may be beneficial to create a screening tool for your practice that can be used in the process of interviewing new patients so the opportunity to initiate low dose Aspirin at the appropriate time in pregnancy is not overlooked.

While it is impossible to predict which women will have severe features of Preeclampsia and those who will not (a topic for another blog entry), it is widely accepted that women with the following are at increased risk:

  • Histories of Preeclampsia
  • Autoimmune disease (Lupus and Antiphospholipid Syndrome)
  • Diabetes
  • Chronic Hypertension
  • Renal disease
  • Those carrying multiples

However, other moderate risk factors also include women who are nulliparous, advanced maternal age (>40 years), between pregnancy interval >10 years, Body Mass Index (BMI) >35 and a family history of preeclampsia (mother or sister).

What Does this Mean for Advanced Practice Nurses?

Given that we usually see patients several weeks before they visit a Maternal Fetal Medicine specialist, it’s important for all Advanced Practice Nurses caring for child bearing women to screen for Preeclampsia and recommend low-dose Aspirin for the appropriate patients. This simple step – for pennies on the dollar – can make a priceless difference in maternal and fetal health.

References:

  1. ACOG: Hypertension in Pregnancy (2013)
  2. USPSTF: Low-Dose Aspirin use for the Prevention of Morbidity and Mortality from Preeclampsia

Resources:

  1. ACOG Low Dose Aspirin Practice Advisory (2016)
  2. Preeclampsia Registry
  3. Preeclampsia Foundation
  4. California Maternal Quality Care Collaborative – Preeclampsia Toolkit

STD Awareness Month: I don’t think this is what they meant by ‘everything old is new again’

This month, Melanie Deal, MS, FNP-BC, WHNP-BC writes how WHNPs can teach and treat their patients for STDs. Melanie has worked as a nurse practitioner for over 20 years.  She received her Master of Science in Nursing at the University of California in San Francisco.  Melanie currently practices at UC Berkeley Health Center and is clinical faculty for the California STD Prevention Training Center.  She is a regular presenter at Contemporary Forum’s Contraceptive Technology conferences. She has served on the Board of Directors for the National Association of Nurse Practitioners in Women’s Health (NPWH). 

April is STD awareness month. We as women’s health nurse practitioners have been front and center in the fight to keep our patient’s safe from these all too common infections.

We know that:

Chlamydia and gonorrhea rates have continued to rise. We must seek all opportunities to screen our female patients < 26 years old at least on an annual basis.

Antibiotic-resistant gonorrhea remains a major concern. In the U.S., we have one remaining class of drugs that will adequately treat this infection, cephalosporins.  Around the globe, countries are reporting cases of gonorrhea with decreased susceptibility and resistance to cephalosporins.  We must be vigilant for potential antibiotic-resistant cases and know how to treat them.

But one STD has made a significant comeback in the past decade: syphilis.

I think back to a conversation I had with my mother-in-law over dinner many years ago.  We were having one of our girls’ nights.  At the time, I was directing a CDC STD program, so it was not surprising that our conversation drifted to the topic of STDs.  Cocktail in hand, she leaned in and said, “So, tell me about the herpes”.  She wanted to hear about what was new with STDs because in “my day, we only knew about syphilis.”

At the time of this conversation, syphilis was a waning concern, especially in women’s health.  Syphilis rates in the country were so low, the CDC launched a program called The Syphilis Elimination Project” through which they hoped they could rid the U.S. of syphilis completely.

Here we are 20 years later, and syphilis is once again a growing threat.  Rates of syphilis have increased 67% between 2011 and 20151; and increased another almost 18% since 20152.  While the greatest surge has been among men who have male sexual partners, rates are also increasing among heterosexual men and women.  “Rates have increased in every region, in a majority of age groups, and across almost every race/ethnicity.”3 The U.S. is also seeing a concerning growth in cases of congenital syphilis, which should be absolutely preventable.

As women’s health nurse practitioners we must prepare ourselves to address this growing epidemic in a way we have not needed to in many years.

In response, the CDC has developed many clinician resources.

To put it simply the CDC challenges us to: Talk. Test. Treat.4

Talk.

Take a complete sexual history. We as women’s health nurse practitioners are familiar with taking sexual histories.  We must redouble our efforts especially with our prenatal patients.

Test.

Screen all prenatal patients at their first visit, and for higher risk patients, rescreen in 3rd trimester and at delivery.

Treat.

Know how to identify the stage of syphilis for your patients in order to provide the appropriate treatment regimen.

Neurosyphilis can occur at any stage.  Screen all syphilis patients for signs of neurosyphilis, including ocular and otic syphilis.

Hopefully, with our vigilance, we can once again make syphilis seem like an old time disease; one for the history books.

References:

  1. CDC Call to Action: Let’s Work Together to Stem the Tide of Rising Syphilis in the United States
  2. CDC: The State of STDs
  3. The rising tide of syphilis: Coming to a patient near you
  4. Test. Treat.

Additional resources

  1. Syphilis: Pocket Guide for Clinicians
  2. Sexual Health and Your Patients: A provider’s guide
  3. Asking Essential Sexual Health Questions
  4. CDC STD Treatment Guidelines

It’s Endometriosis Awareness Month!

In honor of Endometriosis Awareness Month, NPWH Board Member Caroline Hewitt, DNS, RN, WHNP-BC, ANP-BC, explores the current standards of diagnosis and treatment.

Endometriosis is not a new condition to those of us who provide women’s health care, but it is woefully misunderstood by the public. However, it is getting increasing attention from the media and TV and film stars like Lena Dunham and women’s rights activities. This newfound attention means that our patients are learning about this condition from sources as diverse as fashion magazines, blog posts, and everywhere in between.

Occasionally, as clinicians, we can be blind-sided by what our patients are reading and hearing amongst their peers, so it helps to have an idea of what is being said outside the nurse practitioner’s office.

So, in observance of Endometriosis Awareness Month, I would like to use this occasion to briefly review the current standards of diagnosis and treatment as published by ACOG, The American Society for Reproductive Medicine (ASRM), The World Endometriosis Society (WES) as well as The Society of Obstetricians and Gynecologists of Canada.

Overview

Endometriosis affects 6 to 10 percent of women of reproductive age, and it is present in approximately 38 percent of women with infertility and in up to 87 percent of women with chronic pelvic pain. It is thought to develop from attachment and implantation of endometrial glands and stroma on the peritoneum as a result of retrograde men­struation. Endometrial lesions result from overproduction of prostaglandins and estro­gen, which leads to chronic inflammation. (AAFP, January 1, 2011 ◆ _Volume 83, Number 1)

Diagnosis

According to ASRM, “Diagnosis should be viewed as chronic disease requiring a lifelong management plan with the goal of maximizing use of medical treatment and avoiding repeated surgical procedures” (2014). Diagnosing endometriosis can take up to 10 years. This delayed diagnosis is due to the vague presenting symptoms that frequently overlap with other gynecologic and gastroenterologic processes, as well as the fact that the surgical diagnosis comes with risks.

Imaging studies like MRI and ultrasound do not provide reliable diagnosis nor does a pelvic exam adequately indicate the volume of endometriosis. There is also no positive correlation between patient symptoms and extent of disease.

Treatment

The definitive diagnosis of endometriosis can only be made by histologic examination of the lesions that have been surgically removed. That being said, initial medical treatment with combined oral contraceptive pills (OCPs) (or progesterone only pills) is the recommended first line treatment, even before a definitive diagnosis is made. If there is no response to OCPs/POPs (typically evaluated after 3 to 4 months), it is recommended to proceed with a diagnostic laparoscopy before using medications with higher risk of adverse effects (danazol or GnRH agonists).

If chronic pain doesn’t respond to medical therapy, surgery is the next option. But even after expert removal of endometriosis, recurrence is common; rates can be as high a 55%. The desire to preserve fertility will direct the extent of surgery and type (fertility preserving laparoscopy vs hysterectomy/bilateral salpingo-oophorectomy (BSO).  Laparoscopic surgical procedures require specialized training.

Link to Cancers

Endometriosis is associated with some epithelial ovarian cancers (EOC). The risk of developing an EOC is 1% for the premenopausal women with endometriosis and up to 2.5% for the post-menopausal women. It is important to note that endometriosis is not considered a pre-malignant lesion, screening for EOC is not recommended in women with endometriosis and there is no suggestion that prophylactic removal of endometriosis lesions will reduce the risk of EOC.

In summary, endometriosis is a chronic disease that can be difficult to diagnose. The first line treatment, as recommended by all the major women’s health/reproductive health organizations, remains medical. Surgical intervention, like laparoscopy and excision presents with its own risks and also requires the provider to have had specialized training. Decisions regarding extent of surgical intervention should also take into account the childbearing desires of the patient.

It’s great that more women are learning about Endometriosis. This often misunderstood and very personal condition deserves our attention. As Nurse Practitioners, we need to be prepared to listen to our patients and partner with them to ensure their diagnosis, and management, is evidence-based and safe.

Your Heart is a Lady Part

 February is Heart Health month. NPWH Chair Elect and Policy Chair, Diana Drake DNP, APRN, WHNP-BC, and Clinical Associate Professor, shares an update on the state of women’s heart health and resources for clinicians.

Connecting Heart Health and Reproductive Health, a Missed Opportunity

For many practitioners working in ob-gyn practices, you may be the only health care provider a patient sees this year.  But according to a national survey, only 13 percent of women report talking about heart health during their annual ob-gyn visit

That’s a problem, because heart disease is a leading killer of women, taking 400,000 lives in 2016. Contrary to popular belief, women have a higher risk for heart disease than men, because of higher obesity rates, rates of strokes.

The biological changes during pregnancy can also increase heart disease risk. But even in the cases of women with pregnancy complications like preeclampsia and gestational diabetes, 60 percent didn’t discuss heart health with their ob-gyn after pregnancy.

Many providers say they have limited training in assessing women’s risk for heart disease.

It’s time to change.

If we are going to do more to address the major threat that heart disease poses to women, we in the clinical community need to think of the heart as a lady part. 

Our role as a women’s health nurse practitioners is to assess and address needs of the whole woman from head to heart to toe. And good news: 80 percent of cardiovascular diseases may be prevented with education and action.

We have a huge opportunity to do more to educate ourselves and our patients.

In other words, the more we ask, the more lives we save.

8 Ways Clinicians Can Improve Heart Health:

Here are some key ways we can do more to address heart health:

  1. Start Upstream, Prevention is Key

Recommend patients get Well Woman annual visits and follow cardiovascular prevention screening guidelines.

  1. Improve Patient Education and Teach Self-Advocacy

Encourage patients to take charge of their own health. The most important personal action for the patient is to know their numbers: blood pressure, cholesterol, blood sugar and body mass index. Taking action to correct them can be lifesaving.

  1. Recognize Social Stigmas that Prevent Patient Conversation

Social stigma about body weight can keep women from discussing it with their providers, but body weight can have a profound effect on the heart. It’s up to us to ask in a way that will encourage dialogue and get our patients thinking.

  1. Utilize Risk Assessments and Recognize Health Care Disparities

Be aware that young women and ethnic minorities are often assigned a lower cardiovascular risk assessment than is appropriate for their lifelong risk.

  1. Get More Training: Use NPWH Training & Tools in Cardiovascular Assessments

NPWH provides professional continuing education for NPs and other clinicians caring for women. There are over 50 continuing education activities in our online E-Learning portal and these include heart health topics to improve your practice.

Check out the NPWH Well Woman App that includes a Cardiovascular Assessment Tool.

  1. Know the Heart Attack Signs in Women

Symptoms of heart attacks can also present differently in women. The most common heart attack symptom for women is still chest pain or discomfort. But women are more likely to experience some of the other common symptoms, including the following:

  • Uncomfortable pressure, squeezing, fullness or pain in the center of the chest that either lasts more than a few minutes or goes away and comes back.
  • Pain or discomfort in one or both arms, the back, neck, jaw or stomach.
  • Shortness of breath with or without chest discomfort.
  • Other signs such as breaking out in a cold sweat, nausea or lightheadedness.
  1. Know the General Risk Factors for Heart Disease

High blood pressure, high LDL cholesterol, and smoking are key risk factors for heart disease. About half of Americans (49%) have at least one of these three risk factors. Several other medical conditions and lifestyle choices can also put people at a higher risk for heart disease, including:

  • Diabetes
  • Being overweight or obese
  • Poor diet
  • Physical inactivity
  • Excessive alcohol use
  1. Advocate for Better Clinical Trials & More Research
  • When it comes to developing a research base, only one-third of heart research subjects are women even though women make up 51 percent of the population. NPWH encourages representation of women in clinical trials to help increase data for accurate clinical decision making that is gender specific.

Our mission is to ensure high quality health care to women by women’s health nurse practitioners and other nurse practitioners who focus on women’s health. And we know that’s your mission, too. We hope you will take advantage of our online resources or join us at our conferences this year!  And we remind you: your patient’s heart is a lady part!

Here are a few more great heart health resources for clinicians and patients:

American Heart Association (AHA)

Center for Disease Control and Prevention, Women’s Heart Health

US Department of Health and Human Services, Womenshealth.gov

Managing hyperlipidemia

2017 hypertension Clinical Practice Guidelines Released

2017 New Stroke Prevention Guidelines (AHA)

Patient Education