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July 2011 Issue for Perinatal Post

In this issue...

• Healthy North Carolina 2020 and Prenatal Priorities
• Antibiotics and Cesarean Delivery
• STABLE Update
• Newborn Falls in the Hospital
• Lamaze in 2011
• Breastfeeding Focus
• Hepatitis B Infection in Newborns
• Upcoming Northwest AHEC Perinatal CE Events

Healthy North Carolina 2020 and Prenatal Priorities

North Carolina ranks 35th among U.S. states in terms of our overall health, and for most of the past 20 years, our rank has been even lower. NC ranks poorly on other health measures as well, including health outcomes, health behaviors, access to care and socioeconomic factors (America's Health Rankings). Racial and ethnic disparities strongly correlate with health disparities, as racial and ethnic minorities have increased prevalence of chronic diseases. This burden of premature morbidity and mortality in our state signifies a need for dramatic improvements in population health.

Every 10 years since 1990, North Carolina has set decennial health objectives with the goal of making NC a healthier state. The primary aim is to mobilize the state to achieve a common set of health objectives. Healthy North Carolina 2020 (HNC2020) consists of 40 objectives within 13 specific focus areas, including tobacco use, physical activity and nutrition, injury and violence, maternal and infant health, sexually transmitted disease and unintended pregnancy, Others include substance abuse, mental health, oral health, environmental health, infectious disease and foodborne illness, social determinants of health, chronic disease and cross-cutting objectives.

Over the course of the next decade, HNC2020 will help drive state and local-level activities to improve population health. HNC2020 will provide a basis for monitoring population health status to identify community health problems while informing, educating, and empowering people about health issues; mobilizing community partnerships to identify and solve health problems; linking people to needed health services; and researching new insights and innovative solutions to health problems. The Healthy NC 2020 program seeks to improve the health of all North Carolinians by implementing the NC Prevention Action Plan, disseminating the Healthy North Carolina 2020 objectives, and building capacity in communities to develop sustainable initiatives implementing evidence based strategies to improve population health and move North Carolina to "A Better State of Health."

Several of the HNC2020 objectives are of specific interest and related to perinatal health, specifically: health disparities in infant mortality, overall infant mortality, smoking during pregnancy and unintended pregnancy. These objectives were chosen as maternal health is an important predictor of newborn health and is critical to reducing poor birth outcomes. Preconception health and the woman's health during pregnancy are important. With NC's high rate of unintended pregnancies, preconception care is essential to ensure women are as healthy as possible before pregnancy occurs. Age, poverty, and access to appropriate preconception and interconception care affect pregnancy and childbirth, and maternal behaviors such as smoking, substance abuse, and poor nutrition are behavioral risk factors that increase the risk for poor birth outcomes. The health challenges faced by mothers and infants can help forecast the public health challenges that families, the health care system, and communities will face in the future. Maternal and infant health measures, such as the infant mortality rate and mortality rate disparities, are also good measures of general population health because they are associated with maternal health, quality of and access to medical care, socioeconomic conditions, and public health practices (Healthy North Carolina 2020 Technical Report).

Please visit the Healthy North Carolina 2020 website at http://www.publichealth.nc.gov/hnc2020/ to read more about the objectives and targets and "sign" a resolution in support of making North Carolina a healthier state. For further information, please contact Laura Edwards at 919-707-5376 or laura.edwards@dhhs.nc.gov.

-- Laura Edwards, RN, MPA, Healthy NC 2020 Director

Antibiotics and Cesarean Delivery

The American College of Obstetricians and Gynecologists (ACOG) recommends that all pregnant women be given antibiotics before having a cesarean delivery in an effort to help prevent infections. Infection is the most frequent complication of cesarean births and may occur in 10 to 40% of women with a cesarean, compared to 1 to 3% of women who give birth vaginally. The Committee Opinion # 465 was published in the September 2010 issue of Obstetrics and Gynecology. Antibiotics should be given within 1 hour of the start of surgery for maximum effectiveness.

Antibiotics have long been given to women having cesareans in an effort to minimize postoperative infections, but they have generally been administered after delivery of the baby and cord clamping. ACOG states that prophylactic antibiotics given to women before a cesarean significantly reduce maternal infection but do not appear to harm the newborn babies. Exceptions to this recommendation are pregnant women already receiving antibiotics for other conditions such as chorioamnionitis. The College also recommends that women needing an emergency cesarean be given antibiotics as soon as possible.

-- AWHONN, 2011. Antibiotics and Cesarean Delivery. Nursing for Women's Health, 14 (6), 452.

STABLE Update

The S.T.A.B.L.E Program was developed to meet the educational needs of health care providers who must deliver this important stabilization care. S.T.A.B.L.E. education is critical to the mission to reduce infant mortality and morbidity and to improve the future health of children and their families. S.T.A.B.L.E. is the most widely distributed and implemented neonatal education program to focus exclusively on the post-resuscitation/pre-transport stabilization care of sick infants. Based on a mnemonic to optimize learning, retention and recall of information, S.T.A.B.L.E. stands for the six assessment and care modules in the program: Sugar, Temperature, Airway, Blood pressure, Lab work, and Emotional support. A seventh module, Quality Improvement stresses the professional responsibility of improving and evaluating care provided to sick infants. Any health caregiver involved with post-resuscitation and/or pre-transport care of sick newborns would benefit from the S.T.A.B.L.E. Program Learner/Provider course. Students who complete the S.T.A.B.L.E. Learner Course are awarded a course completion card. The S.T.A.B.L.E. Program is offered by the Brenner Children's Hospital Critical Care Transport Team in conjunction with Northwest AHEC.

A STABLE workshop will be offered on August 12, 2011 at Northwest AHEC in Winston-Salem. You may access registration information at the following: www.northwestahec.org. Registration is limited to 20 participants to allow for greater interaction and personal instruction, so register early.

-- Heather M. Furlong, MD, Assistant Professor of Pediatrics, Neonatal-Perinatal Medicine, Wake Forest Medical Center; Medical Director, Neonatal Critical Care Transport Services, Brenner Children's Hospital, Winston-Salem, NC.

Newborn Falls in the Hospital - Update

Inpatient falls in the adult population have been well-studied, and many hospitals have established programs in place to increase patient safety in this area. However, much less attention has been devoted to falls in the newborn population. Limited information is available in this area, but reports on the incidence of newborn falls in studies have ranged from 600 to 1,600 per year in this country. Injuries from falls reported in the literature include minor injury such as a bump or bruise to more severe injury such as a depressed skull fracture. Parents can be reluctant to report newborn falls due to shame or anxiety.

One hospital in the northeast was concerned about harm to both newborn babies and their families associated with new postpartum mothers dropping their infants, since they had experienced falls in their facility. The characteristics of moms of babies who fell in their hospital included: breastfeeding or combination of breast and bottle feeding, cesarean birth, second or third postoperative night, receiving opioid pain relief medication, and 18 to 28 years old. The most common scenario was an exhausted new mother, attempting to feed her baby and dropping the baby from the bed as she fell asleep.

As part of a fall prevention strategy, the hospital team developed a contract pledge for infant safety including commitments from both the mother and nursing staff. Signs were placed in postpartum rooms, and new parents were educated about the need for newborn safety. In addition, they continued hourly patient rounds with a particular emphasis on safety aspects. Maternal rest was also strongly promoted as a prevention practice. As a result of these measures, the hospital experienced a long period of time without any falls at all. Additional study is recommended in this area of risk management.

-- Galuska, L. (2011). Prevention of In-Hospital Newborn Falls. Nursing for Women's Health, 15 (1) 59-61.

Lamaze Supports Evidence-Based Childbirth Practices and Your Patient Relationship

Today, the challenge for every provider and every health system is to offer care based on quality evidence. Lamaze supports your work in improving quality outcomes for your patients and enhancing their satisfaction with you and their care setting. Lamaze can be a valuable partner in your efforts to help women achieve good clinical outcomes and satisfying birth experiences.

• Simplify Birth. Everyone knows that childbirth can be demanding on a woman's body and mind, but Lamaze can help simplify the process of childbirth for your patients. It promotes a natural approach that alleviates a woman's fears and helps her manage pain - all with the goal of a safe and healthy birth, based on current evidence.
  • The Lamaze approach to birth can help reduce the use of unnecessary interventions, reducing costs and associated medical complications, while improving outcomes for all.
  • Lamaze reinforces your relationships with your patients, helping them to better understand what to expect during pregnancy and childbirth, providing information to help answer their questions and, in the end, facilitating patients are satisfied and they understand the medical care they receive.
• Use a Proven Approach. Lamaze practices are based on the best medical evidence available and are designed to promote safe and healthy pregnancies and births.
  • Lamaze's firm grounding in quality evidence reinforces your efforts to support optimal care for women and babies. Compared with non-evidence-based interventions, Lamaze can more significantly reduce the risk of adverse outcomes and the unnecessary use of resources.
• Improve Childbirth Understanding. The best start for your patients includes safe and healthy pregnancies and births, with practices based on current evidence. Lamaze can help your patients achieve this - and feel confident about giving birth - by serving as a resource for information about what to expect and the options available during the childbirth process.
  • When you support Lamaze, it becomes easier to successfully work with your patients to achieve healthy and satisfying outcomes.
  • Lamaze increases your patients' "childbirth literacy" by helping them become better educated about pregnancy and childbirth. Lamaze presents them with clinically sound, easy-to-understand information.
  • Lamaze can help you communicate more effectively with your patients. It serves as a critical information resource and reinforces your patients' responsibility to be a good partner with you in achieving healthy outcomes.
• Work as a Team. Women, families, providers and Lamaze educators each have an important role in the process of pregnancy, childbirth and early parenting. Together, all of you make up a community that works to help women and babies achieve safe and healthy outcomes.
  • Lamaze reinforces your efforts to support optimal care for women and babies. Compared with non-evidence-based interventions, Lamaze can more significantly reduce the risk of adverse outcomes and the unnecessary use of resources.

-- For more information about how Lamaze healthy birth practices can support you in your practice or how you can participate in an upcoming Lamaze Childbirth Educator seminar, please call Tara Owens Shuler at 919-684-2648 or tara.owens@duke.edu or visit http://dukeahec.mc.duke.edu

Breastfeeding Focus

August 1-7 has been designated each year as World Breastfeeding Week (WBW) by the World Alliance for Breastfeeding Action. The theme for WBW 2011 chosen by WABA is "Talk to me! Breastfeeding - A 3D Experience". You can access resources and materials via the WABA website at: http://www.worldbreastfeedingweek.org.

The International Lactation Consultant Association (ILCA) has further refined the theme to a simple message, "Breastfeeding Support-Stay Connected". The theme is focused on helping mothers build strong networks of support for success. Mothers should link with mother-to-mother support groups, trained health care providers, peer counselors, parent groups, and with social media. In the digital age using the internet through computers and smart phones, is another way for mothers to stay connected through texting, websites, forums and blogs. The connection between mom and her surrounding support system can be the key to her success. ILCA is offering a WBW toolkit through their website: http://www.ilca.org. The Nutrition Services Branch of the NC Division of Public Health has provided the ILCA WBW toolkit to local health departments statewide.

The WBW theme is very complementary to the Surgeon General's Call to Action to Support Breastfeeding which was released in January 2011. The document emphasizes the need to build a circle of support around the mother-baby dyad enabling them to break down barriers and reach their breastfeeding goals. It calls on communities, health care systems, employers, families and researchers to assist in improving breastfeeding initiation, duration and exclusivity rates. There are key strategies and action steps outlined for each target audience. The Call to Action can be found on the Surgeon General's website at: http://www.surgeongeneral.gov/topics/breastfeeding/index.html.

To stay connected with what is happening in North Carolina, visit the North Carolina Breastfeeding Coalition website at: http://www.ncbfc.org.

--Catherine Sullivan, MPH, RD, LDN, IBCLC, North Carolina Breastfeeding Coordinator, Nutrition Services Branch, North Carolina Division of Public Health, Greenville, NC.

Newborns Most Vulnerable to Hepatitis B Infection

Hepatitis B virus (HBV) infection in a pregnant woman poses a serious risk to her infant at birth. Without post-exposure immunoprophylaxis, approximately 40 percent of infants born to HBV-infected mothers in the United States will develop HBV infection. Approximately one-fourth of those infants eventually die from liver-related disease such as cirrhosis, liver failure, hepatocellular carcinoma or premature death.

Perinatal HBV transmission can be prevented by identifying HBV-infected (i.e., Hepatitis B surface antigen [HBsAg]-positive) pregnant women and providing Hepatitis B immune globulin and Hepatitis B vaccine to their infants within 12 hours of birth.

Preventing perinatal HBV transmission is an integral part of the national strategy to eliminate Hepatitis B in the United States. National guidelines include:

• Universal screening of pregnant women for HBsAg during each pregnancy
• Case management of HBsAg-positive mothers and their infants (Report to LHDs)
• Provision of immunoprophylaxis for infants born to infected mothers, including Hepatitis B vaccine and Hepatitis B immune globulin
• Routine vaccination of all infants with the Hepatitis B vaccine series, with the first dose administered at birth

The U.S. Centers for Disease Control and Prevention (CDC) estimates that North Carolina should identify up to 600 children born to HBsAg-positive women each year. In 2009, only 229 (38%) cases were detected by the North Carolina Immunization Branch and local health departments.

The Perinatal Hepatitis B Prevention Program, part of the North Carolina Immunization Program, along with local health departments provide individualized case management to hepatitis B infected mothers and infants to assure completion of vital post-exposure immunoprophylaxis at birth, hepatitis B series completion by 6-8 months of age and post- vaccination serology by 9-12 months of age to confirm immunity or infection.

Please do your part by reporting all HBsAg positive women to your local health department or the Perinatal Hepatitis B Prevention Program at (919) 707-5552 and learn more about your role to prevent Perinatal-Acquired Hepatitis infection by visiting the web sites below:

CDC Perinatal Hepatitis B: http://www.cdc.gov/hepatitis/HBV/PerinatalXmtn.htm

Policies and Procedures for Prenatal Care and Delivery Hospital: Prenatal Care - Prenatal Care Provider Policies and Procedures [PDF - 1 page]

Delivery Hospitals: Delivery Hospital Policies and Procedures to Prevent Perinatal HBV Transmission [PDF - 1 page] Guidelines for Standing Orders in Labor & Delivery & Nursery Units to Prevent Hepatitis B Virus (HBV) Transmission to Newborns [PDF - 2 pages]

Hep B Mom Resource: http://www.hepbmoms.org/projects.html

If you have questions, please contact Sheree Smith, RN at 919-707-5552/ or sheree.smith@dhhs.nc.gov or Mara Larson at 919-707-5577 or mara.larson@dhhs.nc.gov in the Perinatal Hepatitis B Prevention Program in the North Carolina Immunization Branch.