Implementing Patient-Centered Trauma-Informed Care for the Perinatal Nurse.

Adverse childhood experiences and trauma significantly impact physical and mental health. Increased maternal perinatal depression/anxiety, preterm labor, and low birth weight, as well as infant morbidity and mortality, are some examples of the impact of trauma on perinatal health. Trauma-informed care begins with knowledge about trauma, the ability to recognize signs of a trauma response, responding to patients effectively, and resisting retraumatization. As holistic providers, perinatal nurses can create safe care environments, establish collaborative patient relationships based on trust, demonstrate compassion, offer patients options when possible to support patient autonomy, and provide resources for trauma survivors. This can prevent or reduce the negative impact of trauma and improve the health and well-being of infants, mothers, and future generations. This clinical article outlines key strategies for implementation of patient-centered trauma-informed perinatal nursing care.

[Midwives' feelings about the post-partum care of women with severe mental illness: A qualitative analysis]. / Ressenti des sages-femmes dans la prise en charge en suites de couche des patientes avec troubles psychiques sévères : une analyse qualitative.

BACKGROUND: A significant proportion of women with Severe Mental Illness (SMI) will become mothers during their reproductive life. These pregnancies are, however, more at risk of psychiatric, obstetrical and neonatal complications (increased risks of post-partum depression, relapse, suicide, gestational diabetes, placental abnormalities or low birth weight). Midwives often feel isolated and resourceless when taking care of these women. Specialized units such as mother-infant psychiatric units or the Transversal Unit of Perinatal Care (UTAP) in the Grenoble Alpes University Hospital (CHUGA) enhance the coordination between psychiatric and obstetrical teams and have shown effectiveness in improving maternal and child outcomes. OBJECTIVES: i) to assess midwives' feelings about the postpartum care of women with SMI; ii) to determine UTAP's impact on this feeling and its determinants; iii) to look for unmet needs. METHODS: This study is a prospective, exploratory, qualitative analysis. Twenty midwives from Grenoble Alpes University Hospital who took care of one of the selected patients participated in this study. Two women had schizophrenia and one bipolar disorder. Interviews realized with a semi-structured guide were fully transcribed, anonymized and thematically analyzed. Topics have been structured according to the number of occurrences to build a thematic tree. RESULTS: Midwives felt insecure and resourceless when the postpartum care was unclear, insufficiently anticipated and in case of a danger for the women or the children. They felt uneasy when not feeling able to provide usual care to these patients (due to lack of specific knowledge about SMI and to the impossibility to consider their patient otherwise than through their pathology). Midwives felt at ease and secure when the postpartum care was anticipated. UTAP was identified as a resource for midwives. Specific training and improvements in the organization of the pre and post-natal care could improve midwives' feelings when taking care of women with SMI.

"Sos vos con el pensamiento": La experiencia vivida de la hospitalización de mujeres con embarazos de alto riesgo / "Are your voices with thought": The lived experience of the hospitalization of women with high-risk pregnancies

Objetivo: Develar el significado de la experiencia vivida de la hospitalización de mujeres con gestaciones de alto riesgo en una institución de salud en la ciudad de Medellín. Metodología: Esta es una investigación cualitativa realizada con el enfoque fenomenológico hermenéutico. La muestra fue definida por el criterio único de saturación a través de un muestreo de tipo intencional. Las participantes fueron cuatro mujeres que cumplieron con los criterios de inclusión. La recolección de la información se hizo mediante entrevista en profundidad, realizada en dos sesiones por participante, para un total de 8 entrevistas. De manera previa, se hizo un estudio exploratorio con una mujer que estuvo hospitalizada en otra institución, pero estos datos no forman parte de los resultados. El análisis de la información recopilada fue guiado por los cinco existenciales de Max Van Manen: cuerpo vivido, relación vivida, espacio vivido, tiempo vivido y cosas vividas. Resultados: Por medio de tres aproximaciones (holística, selectiva y línea a línea) se logró develar el mundo de cada una de las participantes a través de los cinco existenciales de Van Manen. En la experiencia cuerpo vivido, "Sos vos con el pensamiento", las mujeres relatan una lucha interna entre lo que sienten y lo que expresan. El significado de la relación vivida, Los tres otros, estuvo mediada por una conexión con un ser superior, ayudada por las relaciones con sus familiares y con el apoyo y la tranquilidad que les brindaba el personal de salud. Por su parte, el espacio vivido, transitando por los diferentes servicios, fue significativo ya que tuvo en cuenta el lugar y los sucesos ocurridos en el espacio, y estos permitieron percibir vivencias con diferentes matices. En cuanto a la experiencia tiempo vivido, el pasado que anticipa el futuro, se refiere a experiencias pasadas que influyen los sentimientos, pensamientos y las emociones del presente. Por último, las cosas vividas, (como, cuando me lo quitaban en la noche, que no me hacían monitoreo, sentía como una paz) expresan, en este caso, la molestia por el uso de los dispositivos médicos, pero entendiendo que eran necesarios para su cuidado. Conclusiones: El significado de la experiencia vivida de la hospitalización es relatado por las participantes como una lucha interna con sus pensamientos; esto desencadena en ellas una cascada de emociones en la que los acontecimientos hacen que, de manera abrupta, pasen de una emoción a otra. La incertidumbre se siente a lo largo de la experiencia, es parte del proceso y se expresa de diferentes formas. A su vez, el paso del tiempo les permite percibir, de forma corporal, las implicaciones de las situaciones, y altera la experiencia del espacio que están habitando. Las mujeres quieren ser reconocidas por la complejidad de su enfermedad y por su proceso de embarazo, reclaman que las hagan sentir únicas y especiales a través de un cuidado humanizado. (AU)

Objective: To reveal lived experience meaning from women at Inpatient care high-risk pregnancies in Healthcare Facility at Medellin city. Methodology: Qualitative research with a hermeneutical phenomenological approach proposed by Max Van Manen. The sample was defined by a single criterion of saturation and through intentional sampling. Our participants were four women who met the inclusion criteria. The information was collected through an in-depth interview, carried out in two sessions by each participant for a total of 8 interviews, these were carried out after the exploratory study was done, which included the participation of a woman who was hospitalized in another institution but she isn´t part of the data. The information analysis was guided by Max Van Manen's five existentialist, lived body, lived relationship, lived space, lived time and lived things. Results: Through three holistic, selective and line by line approaches it was possible to unveil the life's world from each one participants by means of the five existential's comprehension In the experience of the lived body, the women relate "Are you with voices with thought "an internal struggle between what they feel and express. The meaning lived relationship: "The three others" were mediated by a connection with a higher being aided by family relationships and the support and tranquility provided by health personnel, for their part, the lived space: Transiting through the different services It was significant according to the place and the events that occurred within the space that made this experience perceived with different nuances. The time lived: The past that anticipates the future, the past experiences influenced their feelings, thoughts and emotions of the present and the other part the things lived "When they took it off me at night, they didn't monitor me, it felt like a peace" meant feeling discomfort for the use of the devices but understanding that they were necessary for their care. Conclusions: Their lived experience meaning from inpatient setting is lived and related by the participants as an internal struggle with their thoughts which triggers a cascade of emotions where events make them abruptly transition from one emotion to another. Uncertainty is felt throughout the experience, it is part of the process and is expressed in different ways. In turn, the passage of time allows them to perceive the implications of situations in a bodily way, altering the experience of the space they are inhabiting. Women want to be recognized for the complexity of their disease and their pregnancy process, they demand that they make them feel unique and special through humanized care. (AU)

Midwifery Management of Pregnant Women Who Are Obese.

INTRODUCTION: Obesity is associated with increased risks for adverse health outcomes during and after pregnancy in both the woman with obesity and her infant. This study was designed to investigate midwifery management of pregnant women with obesity. METHODS: Certified midwives and certified nurse-midwives who were members of the American College of Nurse-Midwives were sent a survey. The survey instrument was divided into 4 sections: demographic characteristics; practice guidelines and protocols; the role of the 2015 Levels of Maternal Care guidelines for referral, including transfer to a higher level of care; and factors that influence management of pregnant women with obesity. Descriptive statistics were used to analyze data. RESULTS: In a sample of 546 midwives, 87% of respondents reported observing an increase in perinatal complications associated with obesity. Midwives reported increasing discomfort with the care of pregnant women with obesity as body mass index (BMI) increased. For pregnant women with extreme obesity, the respondents reported less frequent use of physiologic birth guidelines only and increased use of interventions, referral to physician care, and transfer to a higher level of care. Approximately half (270, 49.5%) reported having a guideline that addressed the care of women with obesity. Of these, 145 midwives (53.7%) reported that extreme obesity was the BMI threshold for identifying an increased or high risk for perinatal complications. Sixty percent (339) of midwives who participated requested guidance for management of laboring women who are obese. DISCUSSION: This study provides a greater understanding of midwifery management practices when caring for women with obesity and opportunities to improve care. The results suggest that midwifery management alters with increased BMI, specifically in the care of women with extreme obesity. Suggestions for future study include research on management of pregnant women with obesity and extreme obesity with outcome data examining management strategies that provide safe, satisfying care.

Improving the utilization of health services among high-risk pregnant women through community health nurse assistance

Objective: The objective of this study was to identify the impact of implementing community health nurse assistance for high-risk pregnant women on utilization of health services. Method: The study was quasi experimental with a control group design. The sample included high-risk pregnant women in 10 community health centers in Indonesia who were selected by consecutive sampling. The total sample included 66 women in both the intervention and the control groups. The high-risk pregnant women in the intervention group received nurses' assistance during the third trimester and until giving birth. Before and after the intervention, the knowledge, attitudes, and behavior of the women were measured. Results: The average scores for the knowledge, attitudes, and behavior of women in the intervention group increased. Differences were found in health care utilization between the two groups. All women in the intervention group received antenatal care during the third trimester more than once and were assisted by skilled health personnel during childbirth, while in the control group 10.6% of respondents were assisted by a paraji shaman (traditional birth attendant). All women in the intervention group accepted family planning, and the contraceptive choice varied. Conclusions: The assistance of community health nurses improves the knowledge, attitudes, and behavior of high-risk pregnant women and positively impacts the rate of health care utilization

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Assessing the Mental Health Needs of Pregnant Adolescents: Health Literacy Frameworks to Guide Research and Practice.

BACKGROUND: Psychological distress negatively impacts fetal development and may result in complications such as preterm delivery, low infant birth weight, and poor maternal-infant attachment during the postpartum period. Female adolescents may be experiencing environmental and psychosocial stressors during the pre- and postnatal periods that may predispose them to psychological distress. Health literacy has been used to assess the needs of individuals who have chronic illnesses. Mental health literacy however has not been assessed as extensively, particularly among pregnant adolescents. PURPOSE: Analysis of 2 health literacy frameworks for assessment of relevancy for use among adolescents experiencing psychological distress. METHODS: Systematic analyses of health literacy frameworks by Anthony Jorm and that of Paasche-Orlow and Wolf are provided in this article. RESULTS: Paasche-Orlow and Wolf's frameworks both provide useful approaches for assessing pregnant adolescent needs. A modified holistic health literacy conceptual model based on Paasche-Orlow and Wolf's and Jorm's framework is proposed. IMPLICATIONS FOR PRACTICE: Assessing the mental health needs of pregnant adolescents requires a holistic approach. The modified conceptual model provides a basis for research and practice addressing health literacy and psychological distress among pregnant adolescents.

Spiritual Darkness: Reflections on a Medical Mission.

This is a reflective analysis on the lived experience of a medical mission in a third world country, where young women are abused and trafficked for sex. Practices of Scripture study, Lectio Divina, and contemplative prayer enabled me to deal with the spiritual darkness we encountered. Opening a dialogue with community members to view males and females in a different manner and battling alongside the local mission and ministers against sex trafficking, are not easy tasks. The perseverance found in the Bible gives us hope to be witnesses and healers in our broken world, and a small part in change that can take root with prayer.

Australian midwives' perspectives on managing obstetric care of women living with female genital circumcision/mutilation.

Female genital mutilation (FGM) or female circumcision is a global health issue with increasing international migration of affected women and girls to countries unfamiliar with the practice. Western health care providers are unfamiliar with FGM, and managing obstetric care presents challenges to midwives who are in the forefront of care provision for the women. The participants in this Heideggerian qualitative interpretive study elucidated the strategies they used in overcoming the particular physical, emotional, and gynecological health issues with which mutilated women present. Ongoing emphases on women-centered, culturally competent maternity care are germane to optimal maternity care of circumcised women.

Using acupressure to minimize discomforts during pregnancy. / Uso da acupressão para minimizar desconfortos na gestação.

OBJECTIVE: To describe responses issued by pregnant women, and the improvement of the gravidic discomforts after the use of the acupressure technique. METHOD: Qualitative and descriptive study conducted with 15 pregnant women between November 2013 and February 2014 in a Basic Health Unit in Natal, RN, Brazil. The data were collected through unstructured interviews and depositions that were then transcribed and treated according to Minayo's operative proposal, carefully read, compared and organized into two groups. RESULTS: The categories that resulted were: Positive effects of acupressure, and the recommended use of acupressure. According to pregnant women, the discomforts of pregnancy cramps, fatigue in the legs, lower back pain and headaches decreased with the use of acupressure. CONCLUSIONS: Based on the results, acupressure should be introduced by the nurse in pre-natal care as a therapeutic resource for the pregnant woman's well-being.

A systematic review: Are herbal and homeopathic remedies used during pregnancy safe?

BACKGROUND: Herbal and homeopathic remedies have been used to assist with child bearing and pregnancy for centuries. Allopathic ('Western') medicine is traditionally avoided during pregnancy because of limited drug trials and the suspected teratogenic effects of these medications. This has led to an increase in the use of herbal and homeopathic remedies, asthey are viewed to have no teratogenic effect on the developing foetus. Health providers are faced with questions from their clients regarding the safety of these remedies, but much of the evidence about these herbal and homeopathic remedies is anecdotal and few remedies havebeen tested scientifically. OBJECTIVES: By conducting a systematic review, the primary objective was to evaluate maternal and neonatal outcomes of ingested herbal and homeopathic remedies during pregnancy. METHOD: A systematic review was conducted to synthesise all the evidence with the purpose of evaluating the safety of herbal and homeopathic remedies based on adverse maternal and neonatal outcomes. Only randomised and quasi-randomised controlled trials that met allinclusion criteria were included in the review. RESULTS: The ingestion of ginger for nausea and vomiting during pregnancy was shown to have no harmful maternal or neonatal effects. Ingestion of castor oil for induction of labour showed a tendency towards an increase in the incidence of caesarean section and meconiumstained liquor, warranting further research into its safety issues. CONCLUSION: Larger randomised controlled trials need to be conducted, especially in South Africa, to establish the safety and efficacy of commonly-used remedies.

MBRRACE - Confidential enquiries into maternal death.

Guideline commentary takes its place alongside Cochrane corner and Research unwrapped as part of our evidence series. The aim of Guideline commentary is to support you to critique and utilise newly published guidelines, enabling translation of appropriate recommendations to practice. The objective is to scrutinise recent guidelines to encourage an understanding of the key issues, recommendations and midwifery practice implications. This month, Hannah Rogers looks at the new MBRRACE report and is struck by the addition of mental health disorders as a cause of death. She also considers the proportion of women who suffer morbidity.

Comfort over Pain in Pregnancy.

Pregnancy is often a time when chronic pain is exacerbated, or when acute pain appears. Frequently the easiest intervention within reach, for both chronic and acute pain, is a prescription. However, medication cannot correct the cause of the pain; instead it alters the person's experiential perception of the pain. In addition, medication exposes both mother and fetus to risks. To provide simple, evidence-based, holistic/alternative remedies for women who experienced nonemergent pain during pregnancy. Holistic/alternative techniques for increasing comfort were taught to the participants and individualized during three sessions. Levels of pain and comfort were measured before and after the treatment, using the validated General Comfort Questionnaire and Pain Outcomes Profile. Pain scores decreased from an average of 5.8/10 to 3.5/10 (p = .00). Comfort scores increased from an average of 17.5 to 30 (p = .00).

Midwives' perception of their role in providing antenatal asthma management in Australia--a qualitative study.

UNLABELLED: International guidelines recommend a collaborative approach to the care of pregnant women with asthma. Midwives, as the primary health care provider for childbearing women should be viewed as collaborative partners in the provision of antenatal asthma management. However, the role of the midwife in providing antenatal asthma management has not been widely reported. METHOD: Australian midwives' perceived role in antenatal asthma management was studied using a qualitative descriptive method. Semi-structured in-depth interviews were conducted with 13 midwives working in a regional tertiary hospital. Morse and Field's four-stage process was used to analyse the data. FINDINGS: the perceived role of the midwife in antenatal asthma management varied among participants. Some midwives stated their role was to refer women on to other health professionals. Other midwives stated that they should provide education to the women regarding their asthma management during their pregnancy. CONCLUSION: participants were uncertain about their role and lacked confidence in antenatal asthma management. The midwifery context in which they worked and the resources available to them at this health care facility appeared to influence the perception of their role.

Midwives and women's views on using UK recommended depression case finding questions in antenatal care.

OBJECTIVE: detecting and treating depression early on in pregnancy can improve health outcomes for women and their children. UK guidelines recommend that Midwives screen for antenatal depression (AND) at the woman's first Midwife appointment using recommended depression case finding questions. This is the first qualitative study to explore Midwives' and women's views of using these questions in the context of antenatal care. DESIGN: Semi-structured interviews with Midwives and pregnant women exploring their views and experiences of screening for AND, conducted alongside a validation study of the depression case finding questions. SETTING: the initial appointment with the Midwife when the woman is 10-12 weeks pregnant. Interviewees were working or living in Bristol, England. PARTICIPANTS: maximum variation samples of 15 Midwives and 20 pregnant women. MEASUREMENTS AND FINDINGS: Midwives and pregnant women viewed the depression case finding questions as a useful way of introducing mental health issues. Midwives often adapted the questions rather than using the phrasing specified in the UK guideline. Sometimes Midwives chose not to use the questions, for example if a partner was present. Both Midwives and women struggled to differentiate symptoms of early pregnancy from antenatal depression; yet thought that detecting depression early on in pregnancy was important. Women were unsure about the kind of help that was available; some women reported this as a reason for withholding their true feelings. There was a general lack of awareness among Midwives about the range of non-drug treatments potentially available to women and referral pathways to access them. KEY CONCLUSION: both Midwives and women regard screening for AND as acceptable and important but reported shortcomings with the recommended depression case finding questions. IMPLICATIONS FOR PRACTICE: providing training for Midwives on how to frame the questions and increase their knowledge and application of the referral pathways suggested by UK guidelines will help address some of the issues raised by Midwives and women in our study.

Certified Nurse-Midwives' Experiences with Gestational Weight Management.

Excessive gestational weight gain is associated with fetal metabolic reprogramming and subsequent childhood obesity, as well as maternal recalcitrant obesity and its successive morbidities. We conducted a review of the literature and an explorative, descriptive study of the techniques and strategies used by a subset of certified nurse-midwives to help women achieve optimal gestational weight gain. We also identified barriers to this outcome. With more effective management approaches to gestational weight gain, adverse maternal and neonatal health outcomes could potentially be prevented. http://dx.doi.org/10.1016/j.nwh.2015.12.007.

The effect of gestational weight gain on likelihood of referral to obstetric care for women eligible for primary, midwife-led care after antenatal booking.

OBJECTIVE: to examine the effect of gestational weight gain (GWG) on likelihood of referral from midwife-led to obstetrician-led care during pregnancy and childbirth for women in primary care at the outset of their pregnancy. DESIGN: secondary analysis of data from a prospective cohort study. SETTING: Dutch midwife-led practices. PARTICIPANTS: a cohort of 1288 women of Northern European descent, with uncomplicated, singleton pregnancy at antenatal booking who consequently were eligible for primary, midwife-led care. MEASUREMENTS: because of the absence of an established GWG guideline in the Netherlands, we compared the effect of inadequate and excessive GWG according to two GWG guidelines: the criterion traditionally used, which is based on knowledge of the physiological components of GWG, advising 10-15kg as a normal GWG irrespective of a woman׳s BMI category, and the 2009 Institute of Medicine recommendations (IOMr) on GWG, which provide BMI related advice. Outcome measures were: number of women referred from midwife-led to obstetrician-led care during pregnancy and during childbirth; indications of referral and birth outcomes. FINDINGS: GWG above traditional criteria (Tc; >15kg between 12 and 36 weeks) was associated with increased odds for referral during childbirth (adjusted odds ratio (aOR) 1.88; 95% confidence interval (CI) 1.22-2.90), but had no effect on referral during pregnancy (aOR .86; 95% CI .57-1.30). No associations were established between GWG below Tc (<10kg) and referral during pregnancy (aOR 1.08; 95% CI .78-1.50) or childbirth (aOR 1.08; 95% CI .74-1.56). No associations were found between GWG below and above the IOMr and referral during pregnancy (below IOMr: aOR 1.01; 95% CI .71-1.45; above IOMr: aOR .89; 95% CI .61-1.28) or childbirth (below IOMr: aOR .85; 95% CI .57-1.25; above IOMr: aOR 1.09; 95% CI .73-1.63). With regard to the effect of GWG according to both recommendations on indications for referral and birth outcomes, GWG above Tc was associated with higher rates of referral for hypertensive disorders (aOR 1.91; 95% CI 1.04-3.50) and for meconium stained liquor (aOR 2.22; CI 1.33-3.71) after adjusting for BMI and parity. CONCLUSIONS: GWG above Tc - irrespective of BMI category - was associated with doubled odds of referral to specialist care during childbirth. GWG below or above IOMR and GWG below TC were not associated with adverse obstetric outcomes in women who were eligible for primary care at the outset of their pregnancy. IMPLICATIONS FOR PRACTICE: weight gain <15kg between 12 and 36 weeks is advised for women in all BMI categories in this population. It is important to validate GWG guidelines in a target population before implementing them.

Analysis of qualitative data from the investigation study in pregnancy of the ASSIST Version 3.0 (the Alcohol, Smoking and Substance Involvement Screening Test).

OBJECTIVE: to utilise qualitative data from investigation of the screening tool ASSIST Version 3.0 with pregnant women to help determine its appropriateness for this cohort, thus informing potential innovations to enhance the questionnaire׳s utility. DESIGN: pregnant women were co-administered the ASSIST Version 3.0 and three established substance use questionnaires (the T-ACE for alcohol, the Timeline FollowBack for cannabis and the Revised Fagerstrom Questionnaire for tobacco). SETTING: antenatal clinics and the antenatal ward of the Women׳s and Children׳s Hospital, Adelaide, South Australia. PARTICIPANTS: 104 pregnant substance-users. MEASUREMENTS AND FINDINGS: as well as the quantitative date (reported elsewhere), rich qualitative data documenting participants' perspectives and experiences in antenatal care were thematically analysed. Women constantly reported friends and family urging them to stop use. Although care providers also advocated cessation or curtailment of use, this advice was reported as unpredictable, with only some providers strongly attuned to such recommendations. Some women voiced suggestions for the appropriate level of provider advice. While pregnancy was often reported as a motivator for changing substance-using behaviour, others reported continued attachment to use which was clearly linked to dependence. Those who reported successful control of use were in contrast to others who were more pragmatic, sceptical in relation to attributable harms, and disinterested in change. There were limited reports of experiences of discrimination directed to pregnant substance users. However, those instances were clearly linked with subsequent lack of honest discussions with care providers, resulting in an absence of appropriate support. KEY CONCLUSIONS: current absence of universal screening for substance use has the potential for less than optimal consequences for both mother and baby. IMPLICATIONS FOR PRACTICE: appropriate screening accompanied by honest, non-judgmental dialogue can guide the necessary interventions to achieve better outcomes. The recent development of the more concise and easier to administer ASSIST-LITE was partly informed by this investigation.